1 Introduction

Personality is a broad and complex construct that is difficult to conceptualize, and it is considerably more than what it is possible to observe if we consider only behaviors and symptoms. How can we approach personality though?

Personality is more related to what one is and to what one experiences consciously and unconsciously in relation to the internal world and to the external reality, a sense of subjectivity that we can call self and/or identity.

This emphasis on the subjective experience and on the balance between the internal and external experiences caused many discussions during the last years regarding how to scientifically propose a model for personality disorders (PDs) in DSM-5.

Indeed at the beginning of the DSM-5 revision process, it was widely expected that personality disorders would have a dimensional component, but during the closing weeks, it was decided that the categorical personality model contained in DSM-4 would be reprinted in DSM-5 with no essential changes in the criteria (Zachar et al. 2016).

Thus the DSM-5 contains a hybrid model of categories and dimensions, which is extended in Section III “Emerging Measures and Models” and proposed as the alternative model for PDs (AMPD) .

Here in this chapter our attempt is to propose a neuropsychodynamic model of personality and personality disorders considering the centrality of the self for DSM-oriented assessment, for psychodynamic understanding, and for neuroscience. We will first focus on the categorigal classification of personality disorders of the DSM-5, emphasizing the psychodynamic aspects that are characteristic of each disorder. In the subsequent section, we will underline the necessity of a neuropsychodynamic model for personality disorders starting from the novel emphasis given to the construct of self and relatedness in clinical psychology, in the long-standing psychodynamic organization of personality, and last but not least in neuroscience and research on the brain structure and functionality.

2 Categorical Classification of Personality Disorder

DSM-5 conceptualized a personality disorder as an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, which is pervasive and inflexible, which has an onset in adolescence or early adulthood, and which is stable over time, and leads to distress or impairment.

Personality disorders are grouped into three clusters based on descriptive similarities. Cluster A includes paranoid, schizoid, and schizotypal personality disorders. Individuals with these disorders often appear odd or eccentric. Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders. Individuals with these disorders often appear dramatic, emotional, or erratic. Cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders. Individuals with these disorders often appear anxious or fearful. It should be noted that this clustering system, although useful in some research and educational situations, has serious limitations and has not been consistently validated (American Psychiatric Association 2013).

3 Cluster A

3.1 Paranoid Personality Disorder (PPD)

Definition

Paranoid personality disorder represents a pattern of distrust and suspiciousness such that others’ motives are interpreted as malevolent.

3.1.1 Psychodynamic Aspects

The lack of trust in others seems to be the core feature of paranoid personality disorder (PPD) , and, following Kernberg’s classification , this disorder takes place in the low-level borderline personality organization. They occupy the introjective, self-definition end of Blatt’s continuum from relatedness to self-definition (Blatt and Blass 1992).

Primitive and persecutory introjects determine the presence of an accusatory and violent moral instance (primitive and harsh superego). The individual cannot tolerate the bad aspects of the self; thus the bad characteristics are split and projected onto others. The PPD individual works to make his or her projection “fit” the projective target.

Along with an image of self and of other devalued and damaged, there is another one of the opposite polarity, grandiose and violent. For the subject it is impossible to integrate the dyads and ends up in attributing the negative aspects to external figures, perceiving himself as a victim of a persecutor.

The key defense mechanisms are splitting and projective identification; representations of self and others are “totally good” and not integrated with “totally bad” characteristic or vice versa.

For the paranoid individual, anyone is a potential enemy, and everyone is watched with distrust, waiting for a false step to confirm their representation of reality. It gives rise to circumspection, coldness, tension, and control; reality testing is maintained even though there may be psychotic episodes.

From a psychodynamic point of view, the central problem of the paranoid subject is therefore the inability to deal with depressive feelings caused by the awareness of the coexistence, both in them and in others of good parts and bad parts. This scenario can be either caused by an excessive degree of aggressiveness as well as an empathically deficient maternal environment that does not provide a sufficient management of depressive anxiety and the ability to worry about the others.

From an affective point of view, paranoid personality is characterized by the feeling of anger and desire for revenge but also suffers from overwhelming fears as a combination of shame and fear. McWilliams (2011) underlines that shame is considered a threat for both paranoid personality disorder and narcissistic personality disorder. The narcissistic personality is ashamed if certain aspects of the self (fragile and devaluated) are exposed to others, so that all the efforts are in the direction to impress the others so that they cannot find out. PPD individuals instead spend their own energies to overturn the intention of the other persons (according to their mental representation) to humiliate them. An obstacle in the therapy is that the therapist as well can be considered as a bad and a persecutory object.

To our knowledge there are no published laboratory studies that investigated specifically at PPD. Instead, such studies have been done in samples that include patients with Schizophrenia spectrum disorder and/or other personality disorders, which have included patients with PPD.

It has been highlighted that cognitive impairment similar to, but usually less severe than, the deficits found in schizophrenia is one of the hallmarks of the prototypical cluster A disorder, SZPD (Siever et al. 2002). No studies have examined these parameters in PPD itself, but degradations in information acquisition and processing appear to be a risk factor for dimensional paranoia.

3.2 Schizoid Personality Disorder (SPD)

Definition

Schizoid personality disorder indicates a pattern of detachment from social relationships and a restricted range of emotional expression.

3.2.1 Psychodynamic Aspects

The main problem in schizoid individuals is a deficit in the ability to relate with the others. Bowlby (1980) and Winnicott (1960) propose that the etiology of the disorder is given by a severe deprivation in a context of early attachment, particularly in regard to the avoidance of the attachment and maternal care severely inadequate.

From this early relational scenario comes the choice of retreat (from emotion, from affects, from feelings) and of the false self as protection for the true self. This results in a split of the self in unintegrated images: internally the subject is sensitive and emotionally dependent, while externally he/she appears self-sufficient and distant. According to Winnicott (1960) it is possible to hypothesize a sense of inauthenticity of schizoid life: “if the mother/caregiver failed in giving what he/she needed no one else would succeed.” Their isolated superiority could result from the defense of possible relational delusions but also by their insatiability, moreover may have its origin in rejecting the incursions of an overcontrolling or overintrusive other (caregiver).

On the other side Klein (1946) believes that the schizoid defense is used to avoid the persecutory anxiety that derives from the projection of the own aggression onto objects. The schizoid defends him/herself from the anxiety of destroying the loved object by withdrawal. The characteristic defense mechanisms of the schizoid individual are splitting retreat, autistic fantasy. Once they have constructed their own fantasy world, they do not seem to be shaken to get gratification or even commit themselves to avoid punishment. In this regard Clarkin et al. (1997) argue that there is a deficit in the capacity to discriminate pleasure and pain.

They may appear notably detached, or they may behave in a socially appropriate way while privately attending more to their inner world than to the surrounding world of human beings (Fairbairn 1952).

As suggested by McWilliams (2011), working with schizoid patients implies that the therapist is open enough to a certain degree of authenticity and a level of awareness of emotions and imagery. It also requires to leave a certain degree of emotional space in order not to repeat the role of the overintrusive or abandoning object.

3.3 Schizotypal Personality Disorder (SZDP)

Definition

Schizotypal personality disorder represents a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior.

3.3.1 Psychodynamic Aspects

The schizotypal personality disorder (SZDP) individual appears strange and eccentric and, in addition, psychotic features and symptoms are emphasized in comparison with schizoid personality. There are problems in the ideation and in communication, detachment from the consensually accepted representation of reality, ideas of reference, and unusual perceptual experiences.

Schizotypal individual uses a very particular language, often incomprehensible to the listener, characterized by digressions, dizzying, loosening associative links, and inconsistency. As with schizoid disorder, schizotypal disorder involves a temperamental genesis and early relational deficits. Choice of retreat in an imaginary world can be considered as a solution to the conflict.

This disorder belongs to the dimension of schizotypy and shares with schizophrenia genetic-phenomenological characteristics in response to treatment.

Psychodynamically, in line with Psychodynamic Diagnostic Manual 2 (PDM-2), schizotypy is considered as a trait common in schizoid psychologies (the most severe trait in a continuum) and not as a type of personality. Indeed, Westen and colleagues (2012) empirically identified a grouping of patients in a clinical sample that they labeled “schizoid-schizotypal,” characterized by “pervasive impoverishments, and peculiarities in, interpersonal relationships, emotional experience, and thought processes” (p. 280).

Cognitive deficits, together with social/interpersonal and affective processes impairments, represent functionally, clinically, and neurobiologically significant manifestations of SZDP and schizotypy in general.

Prefrontal-dependent cognitive processes, specifically working memory and context processing, have been studied in SZDP. The intense focus on cognitive dysfunction in SZDP has been largely driven by the critical role of working memory impairments on functional outcomes in schizophrenia.

The caudate, which receives input primarily from dorsolateral prefrontal regions and has been implicated in higher-order cognitive processes, appears to be involved in the cognitive abnormalities of SZDP. Specifically, caudate volumes have been shown to be smaller in patients with SZDP, and greater volume reduction was related to poorer cognitive performance (Levitt et al. 2002); in addition it has been found that greater aberrant morphology of the right caudate in patients with SPD was also related to cognitive impairment (Levitt et al. 2004, 2009).

Functional imaging studies have also begun to reveal the neural substrates associated with working memory impairments: patients with SPD, compared to healthy control participants, showed attenuated working memory-associated activation of the left ventral prefrontal cortex, superior frontal gyrus, intraparietal cortex, and posterior inferior gyrus (Koenigsberg et al. 2005). In another study, activation of the left posterior cingulate gyrus and deactivation of the superior temporal gyrus, insula, and middle frontal gyrus were both attenuated during a working memory task in patients with SPD compared to healthy controls (Vu et al. 2013).

In regard to the neural underpinnings of social/interpersonal and affective processes, brain imaging studies have recently showed that schizotypal patients exhibit exaggerated habituation of amygdala response to affectively valenced social visual stimuli compared to healthy control participants (Hazlett et al. 2012). Premkumar and colleagues have characterized differences in neural activity patterns in response to social rejection in low- vs. high-schizotypy, nonclinical participants. Specifically, they found a significant difference in response to social rejection in the dorsal anterior cingulate cortex (dACC), right superior frontal gyrus, and left ventral prefrontal cortex in the low- vs. high-schizotypy group (Premkumar et al. 2012).

4 Cluster B

4.1 Antisocial Personality Disorder (ASPD)

Definition

Antisocial personality disorder indicates a pattern of disregard for, and violation of, the rights of others.

4.1.1 Psychodynamic Aspects

Antisocial individuals seem to live in a pre-social affective world where emotions and feelings are experiences exclusively in relation to oneself but not to others. Antisocial subjects do not experience gratitude and remorse and often feel anger and contempt; as narcissistic subjects they can assume devaluing and denigrating attitudes toward others, but in addition they inflict consciously psychic or physical pain.

Many authors emphasize the disinhibition features as a key component of this disorder (e.g., Siever and Davis 1991). In addition we may find early relation and familiar histories of very severe abuse and deprivation. Often the attachment is totally compromised, and the child perceives the parent as a stranger, bad, and unworthy of trust and builds up a grandiose self that can give him some sense of self-sufficiency; it can be considered a precursor of the omnipotent control. Relationally they can refuse any affective bond, or they can attempt to bind with others through manipulation of power and destruction

These individuals are characterized by lack of empathy and humanity, inability to see others as individuals with their own feelings and needs. There is no remorse for what their injurious actions produce on other people, and there is no possibility to have feeling about that. It needs to be taken into account the superego , whose compromise is at the basis of the moral deficit.

The antisocial subject disclaims all responsibility and attributes to the outside world all the problems and responsibility. According to Winnicott, antisocial personality develops around serious maternal mirroring failures and can be paradoxically interpreted as a hope of obtaining what has not happened and what has not offered to them. Kernberg (1984) places ASPD at the low level of borderline personality organization at the extreme pole of a narcissistic continuum, before the so-called malignant narcissism , constituted by individuals with a narcissistic personality disorder characterized in addition by paranoid and antisocial features and ego-syntonic aggressiveness.

The prognosis for these individuals is very scarce, and, as proposed by PDM-2, any therapeutic influence are better if antisocial or psychopath individual has reached midlife or later and thus felt a decline in physical power and encountered limits to omnipotent strivings.

The experimental literature defined two subgroups, one constituted by antisocial reactive individuals and the other constituted by antisocial psychopathic individual . The review written by Blair (2010) reveals that individuals who present with an increased risk for reactive, but not instrumental, aggression show increased amygdala responses to emotionally evocative stimuli. This suggests that such individuals are primed to respond strongly to an inappropriate extent to threatening or frustrating events. In contrast, individuals with psychopathic tendencies show decreased amygdala and orbitofrontal cortex responses to emotionally provocative stimuli or during emotional learning paradigms. This suggests that such individuals face difficulties with basic forms of emotional learning and decision-making.

fMRI research also strongly support the hypothesis that amygdala and orbitofrontal cortex (OFC) functioning is disrupted in individuals with psychopathic tendencies and that neural circuit is strongly relevant for the moral system (Blair, 2007). Other systems may also be affected, but there is a paucity of studies.

For example a recent resting-state fMRI study (Tang et al. 2013) showed abnormal resting-state connectivity in ASPD patient in default mode network (DMN) and the attention network.

Interestingly decreased functioning of the DMN may manifest as difficulties in self-relatedness functions such as adaptively regulating emotions, future planning, or self-inspection.

Individuals with ASPD demonstrated decreased functional connectivity between regions of the default mode and attention networks. Moreover decreased functioning between the attention network, together with the DMN, with cerebellar network may result in deficits of transmission in the implementation of cognitive control and self-regulation. These results could be interpreted as inefficient transmission between DMN, which detects conflict, and the attention network, which implements increased cognitive control to resolve conflict in future trials.

A person with ASPD, characterized by these resting-state features may act impulsively and inappropriately, resulting in antisocial behaviors.

4.2 Borderline Personality Disorder (BPD)

Definition

Borderline personality disorder is a pattern of instability in interpersonal relationships, self-image, and affects and marked impulsivity.

4.2.1 Psychodynamic Aspects

There are several psychodynamic theorizations of the borderline personality disorder. Kernberg (1975) focuses on the rapprochement phase (18–24 months) as theorized by Mahler (1971), during which the child, after moving away from his/her mother and starting to acquire self-consciousness as a separate entity and after exploring the environment and enjoying the skills concerning the new acquired autonomy, returns to the caregiver driven by the fear of losing her but doesn’t find the response he/she expected because of the ambivalence of the mother-caregiver. It results in confusion at the identity level, extremely vulnerable to separation events, unable to tolerate loneliness and to live without the anxiety connected to the relational distance or to the relational intimacy.

According to Kernberg, these individuals are unable, due to the innate quote of aggressiveness, to integrate into a single representation the “totally good” and the “totally bad” images of the self and of the object, to modulate their affects, or sublimate their impulses, to plan and to finalize their behavior. At a conflict level, the child would not be able to cope with the anxiety and guilt associated with such integration that endangers the self and object representations.

There is a severe oscillation between the times when the subject feels good and surrounded by good people and others where he considers himself worthless and frustrating (identity diffusion, feeling of emptiness, suicidal impulses) and tends to see who is close to him as wicked, enemy, and abandoning (rage and hostility).

This way of functioning is supported by defensive mechanisms such as splitting and projective identification. Theories focusing primarily on relational deficit, trauma, and attachment (Fonagy and Target, 1997) show that most of BPD patients have insecure attachment styles associated with traumatic experiences; specifically scholars have identified a relevant disorganized/disoriented or “type D” insecure attachment style (e.g., Liotti 2004; Holmes 2014; Main and Solomon 1986).

This attachment pattern results in chronic and long-term difficulties in tolerance and affects regulation (Fonagy et al. 1995) with compromised mentalization ability (to recognize internal states in self and others that underlie behaviors) and inability to experience continuity of the self and others (Bromberg 2000; Chefetz 2015; Meares 2012). These relational features are particularly active with people who trigger the attachment system (therapist included), causing them to be treated with confusing state of minds and dissociative states in case of BPD individuals with history of human trauma (Mucci 2013, 2017; Scalabrini et al. 2017a).

In regard to etiology, there is evidence for a genetic vulnerability (Kernberg and Caligor 2005; Paris 1993; Siever and Davis 1991; Stone 1980; Torgersen 2000), for origins in an early attachment disorder (Guidano and Liotti 1983), for developmental arrest (Bateman and Fonagy 2004; Fonagy and Target 2002; Masterson 2013), and for the effects of severe relational trauma (Meares 2012; Mucci 2013).

The relative weight of each of these factors varies from person to person. It’s quiet clear that within the same BPD levels we have a large variability of different types of BPD patients. These individuals are notoriously difficult patients, partly because they may challenge ordinary therapeutic limits and evoke intense countertransference reactions and partly because they require specific treatment models (e.g., as mentalization-based treatment; transference-focused psychotherapy, or dialectical behavior therapy).

Supporting the psychodynamic understanding of BPD, fMRI research reported consistent results over years regarding the affective system and the processing of anxiety in BPD; particularly it has been showed how BPD, compared with healthy control, is characterized by increased amygdala activation when viewing aversive emotion-inducing slides (Koenigsberg et al. 2009a, b) or when viewing pictures of human emotional facial expressions (Minzenberg et al. 2007). Moreover during the recall of an unresolved life event, BPD patients showed bilateral activations of the amygdala (Beblo et al. 2006).

Other studies reported the involvement of the prefrontal cortex in BPD in the attempt to control intensive emotions elicited by negative stimuli (Herpertz et al. 2001) or the minor involvement of the anterior cingulate cortex (ACC) in cognitive coping strategies (Koenigsberg et al. 2009a, b). Thus, patients with borderline personality disorder do not seem to engage the cognitive control regions to the extent that healthy individuals do, which might contribute to the affective instability of this disorder. Other studies indicate the existence of different neural networks in BPD with or without comorbid PTSD syndrome (Driessen et al. 2004; Kraus et al. 2009). Altogether this research indicates a dysfunctional frontolimbic network , which involves the anterior cingulate cortex, the orbitofrontal cortex , the dorsolateral prefrontal cortex, the hippocampus, and the amygdala, in BPD individuals.

4.3 Histrionic Personality Disorder (HDP)

Definition

Histrionic personality disorder is a pattern of excessive emotionality and attention seeking.

4.3.1 Psychodynamic Aspects

Kernberg (1984) differentiates the histrionic personality disorder (borderline personality organization) from the hysteric personality disorder (neurotic personality organization): the unintegration of the representation of the self and of the object and related affects takes into account the affective instability , the precariousness of relationships, and the impulse control associated with HPD. Usually hysteric-histrionic individuals are preoccupied with gender, sexuality, and their relation to power. As pointed out by McWillaims (2011), HPD patients unconsciously consider their own sex as weak, defective, or inferior and the opposite sex as powerful, exciting, frightening, and enviable, and as a consequence their behavior is primarily focused on seductiveness and attention seeking.

While hysteric disorder reveals a prevalence of Oedipal conflicts (seductiveness that results in the impossibility of satisfying sexual relations) expressed in a very regressive way, in the histrionic disorder sexual behavior is a means to satisfy the drive desires and the most primitive self and ego needs.

Often histrionic patients cannot keep in mind of being in a person’s important thought, and the only way to maintain a closeness to these people is to use their seductiveness in search of a sensory contact as a substitute for the mental and psychic proximity they need.

In their story it is possible to find serious deficit in maternal care along a continuum constituted by real inadequacy of the caregiver and excessive pressing child needs. In addition it is possible to find a kind of cultural/familiar devaluation of their gender. The defensive structure is organized around the mechanisms of splitting, projective identification, dissociation, denial, acting out with a cognitive style impressionistic, poor in details, and unspecific.

To our knowledge there are no studies that investigated solely the neurobiological underpinnings of the HPD; however there are several studies on the affective instability that can be considered one of the core features of HPD individuals. Indeed, while BPD is the personality disorder most closely associated with affective instability, the DSM-4 and the DSM-5 criteria for histrionic personality disorder also include two criteria related to affective instability : “rapidly shifting and shallow expressions of emotions” and “ …exaggerated expression of emotion” (APA 1994, p. 658).

Affective instability is not a unitary construct and encompasses shifts in affective valence, rapidity of mood shifts, short risetime, delayed time to return to baseline, and reactivity to internal and external stimuli (Koenigsberg 2010). It could arise from an increased sensitivity of neural systems involved in the generation of an emotional state or an impairment in emotional control mechanisms. The former includes the amygdala, the insula, the pregenual and subgenual anterior cingulate cortices, the orbitofrontal cortex, and the ventromedial and ventrolateral prefrontal cortices (Phillips et al. 2003).

It can be hypothesized that HPD patients have an impairment in top-down control that could also contribute to affective instability (Dillon and Pizzagalli 2007). Specifically, the dorsal anterior cingulate, dorsomedial, dorsolateral prefrontal, orbitomedial prefrontal cortices and hippocampus have been implicated in the conscious control of emotion (Dillon and Pizzagalli 2007; Phillips et al. 2003), and these regions downregulate amygdala activity.

4.4 Narcissistic Personality Disorder (NPD)

Definition

Narcissistic personality disorder is a pattern of grandiosity, need for admiration, and lack of empathy.

4.4.1 Psychodynamic Aspects

Narcissistic individuals show difficulties in regulating self-esteem, ambitions, and ideals that are the fundamental core of narcissistic personality disorder.

According to Kohut (1971), the basis of the subjective experience of these subjects is the empathic failure of parents who have failed to respond adequately to the natural demands and needs of the child’s self. Personality remains locked in that phase, and the infant self becomes an omnipotent grandiose self.

Inversely, Kernberg (1984) emphasizes the development of a pathological grandiose self that is characterized by the condensation of ideal aspects of self and others with the real self. These constellations inevitably lead to the inflation of the ego and the impoverishment of the superego which remain somewhat primitively organized, leading to mild to moderate antisocial features (Kernberg 1984). The individual believes of being self-sufficient, does not recognize the other’s needs, consider him/herself with special abilities and special powers, and devalue constantly the external reality and the others. Kernberg (1984) characterizes the most problematic type of narcissistic individual long a continuum with “malignant narcissism ” (i.e., narcissism blended with sadistic aggression, antisocial and paranoid features, and ego-syntonic aggressivity), a condition that he places on a continuum with the antisocial personality disorder (Rosenfeld 1964, 1987).

The difference in the psychodynamic theory between the two authors can be explained by the different patients they treated in their career: Kohut worked principally with outpatient higher-level personality organization individuals, while Kernberg was more exposed to inpatient low-level personality organization subjects, more aggressive and more primitive.

The DSMs’ narcissistic personality disorder describes the more grandiose or arrogant version of narcissistic personality (first described by Reich 1933, as the “phallic narcissistic character”) but doesn’t consider the other face of the coin: there are many individuals who look for psychological help feeling ashamed , avoiding relationships with others, with difficulty in engaging in activities in a long run, looking a bit suspicious and diffident, but, internally, they are preoccupied with grandiose fantasies. Rosenfeld (1987) distinguished between the “thick-skinned” and “thin-skinned” narcissist; Akhtar (1989) between the “overt” and “covert” (shy) patient; Gabbard (1989) between the “oblivious” and the “hypervigilant” types; Masterson (1993) between the “exhibitionistic” and “closet” types; and Pincus et al. (Pincus et al. 2014; Pincus and Roche 2011) between the “grandiose” and “vulnerable” ones.

In all theories there is an agreement in considering narcissism as a problem in self-regulation, where the individuals are disengaged from the social/empathic processing toward the other and are constantly worried about their selves, trying to get the admiration from the other to not show their inner aspects of the self. Thus, contemporary clinicians adopt an integrated approach working with NPD individuals, being more confrontative with defense mechanisms when they are salient and being more empathically attuned when the vulnerability is more accessible.

In neuroscience little research has been done with narcissism to directly measure the neural mechanisms behind the trait or the disorder.

A recent structural diffusion tensor imaging study found that narcissism goes along with weakened frontostriatal connectivity of white matter tracts (Chester et al. 2015). The authors interpret their findings in terms of a neural disconnect between brain regions responsible for self-representation (medial frontal cortex) and reward (ventral striatum) suggesting that narcissistic individuals lack an intrinsic system for self-rewarding activity and at the same time strive from external reward.

Cascio et al. (2014) reported that narcissistic individuals display increased activation in the “social pain network ” (dorsal ACC , subgenual ACC, and anterior insula) following social exclusion in a cyberball paradigm. It has to be noted that highly narcissistic individuals did not report elevated feelings of social exclusion in self-report measure, which lead the authors to conclude that “narcissists’ social pain [is] seen only in the brain” (p. 335).

In a recent fMRI study pictures of emotional faces were presented and participants were asked to empathize with the person in the picture. Participants high on narcissistic traits displayed decreased deactivation of right anterior insula during processing of emotional faces (Fan et al. 2011) suggesting a lack in empathizing process that the authors interpreted as indicative of an increased self-focus among narcissistic individuals. These results are confirmed and extended by another study that directly investigated the relationship between the resting-state spontaneous activity and task-evoked activity in social processing (Scalabrini et al. 2017 b). Narcissism has been found to be associated with right anterior insula positively in resting state while negatively associated during social processing. These results suggest an increased preoccupation for the self, more specifically the bodily and interoceptive self (Craig 2009; Gu et al. 2013) during a rest/mind-wandering period (Smallwood and Schooler 2006) while a disengagement in regard to activity that involves the “other.”

5 Cluster C

5.1 Avoidant Personality Disorder (APD)

Definition

Avoidant personality disorder is a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.

5.1.1 Psychodynamic Aspects

The main feature of subjects with avoidant personality disorder is the extreme sensitivity to rejection, which determines their pathological behavior. Shame is the main emotion in this disorder and is expressed in several ways such as feeling of being unable to compete with others, feeling of being defeated physically or mentally, feeling of being disgusting, etc.

The subject is afraid of all those situations in which he/she’s forced to be revealed or where he/she can be noticed. From this phenomenology depends all the typical symptoms characterizing these patients: social anxiety, rejection of relationship, fear of criticism, and extreme shyness. They live in a state of mind believing that “if I retire nothing will hurt me.” Extremely high ideal aspects accompanied by inflexible and severe stances characterize the superego . Internal saboteurs of these patients are constituted by fear of the judgment of the others and sense of self-defeating.

APD can be reserved and introverted, with a tendency to feel inferior and inadequate, indecisive, and inhibited; moreover they seem to have difficulties in recognizing and describing their feelings identifying their anxiety-charged thoughts, connecting them to their environmental triggers, and mastering them.

There are different kinds of anxiety such as separation anxiety (fear of losing the attachment object), castration anxiety (fear of damage of the body, especially about sexual mutilation), moral anxiety (dread of violating one’s core values), and annihilation anxiety (as conceptualized by Kohut in 1977 describing the concept of disintegration anxiety) that is the terror of fragmentation with consequent loss of the sense of self or the terror of destruction based on prior traumatic events (see chapter on traumatogenic disorders).

The etiology of ASD may lie in affective dysregulation (Schore 2003a) and consequent failure to have developed coping strategies or defenses that mitigate normal developmental fears. These individuals usually are characterized having had experiences with a caregiver who, because of the caregiver’s own anxiety and attachment style, could not function as an affective regulator and covey a sense of support and as secure base to permit the developments of a sense of agency for the self.

In fMRI research little has been studied on ASD; however studies of generalized social anxiety disorder, a disorder thought to be associated with ASD, have identified decreased insula-dorsal anterior cingulate functional connectivity relative to healthy subjects during viewing of fearful faces (Klumpp et al. 2012). In another study based on a habituation task, it has been reported that the thalamus, parahippocampal gyrus, ventrolateral prefrontal cortex, and dorsal anterior cingulate in ASD patients were not activated as strongly as in the healthy subjects during viewing of repeated versus novel negative pictures. In addition, insula connectivity to extensive cortical regions, including the rostral anterior cingulate, the medial and dorsolateral prefrontal cortex , and the posterior cingulate, did not increase to the extent that it did in the healthy subjects. These results suggest that the failure of this connectivity to increase adequately may contribute to impaired behavioral habituation and consequent faulty emotion regulation in ASD patients as well in BPD (Koenigsberg et al. 2014).

5.2 Dependent Personality Disorder (DPD)

Definition

Dependent personality disorder is a pattern of submissive and clinging behavior related to an excessive need to be taken care of.

5.2.1 Psychodynamic Aspects

People with a dependent personality disorder are characterized by the total inability to live autonomously. They define themselves in relation to others, feeling secured and satisfied in interpersonal context, particularly with the primary attachment relationship. DPD individuals become dysregulated when expected to depend on their own resources and use defense mechanism as somatization and acting out to elicit the care in others.

An important variant of dependency is the passive-aggressive pattern, in which the dependent relationship is characterized by hostility and negative valence. In this variant individuals defined themselves in opposition to others; this makes difficult to pursue their goals and their directedness and in addition triggers aggression and mistreatment from the others.

Another variant is constituted by counterdependency (Bornstein 1993), which is characterized by individuals that may define themselves as the source of other’s dependency, keeping out of awareness their needs and vulnerability via denial and reaction formation defense mechanisms.

The etiology of DPD has been associated with failure in the child’s dependence on the nourishment received from the caregiver. The internalized message is that independence is a source of dangers and often is associated with hyper-involved and intrusive mothers. Usually parents refused children whenever there was an attempt toward separation-autonomy. There are similarities with the anaclitic aspects of borderline patients, but dependent subjects differ in the quality of relationships, characterized by submission and angry appetites, which are not manifested as in borderline patients but systematically denied defensively.

5.3 Obsessive-Compulsive Personality Disorder (OCPD)

Definition

Obsessive-compulsive personality disorder is a pattern of preoccupation with orderliness, perfectionism, and control.

5.3.1 Psychodynamic Aspects

The main difference between the obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD) is that the first is experienced as ego-dystonic , while the OCPD is experienced as ego-syntonic .

Perfectionism and inflexibility are the main features of people with OCPD. The core of this disorder is related with the great uncertainty that these people perceive about themselves and about their value; indeed there are common psychodynamic elements with narcissistic personality disorder and problems in self-regulation and maintenance of self-esteem.

Many aspects of the OCPD are probably due to the childish need to show perfectionism and deserving of love in front of their own parents who are perceived as both demanding and distant. The subject feels a desire of love and attachment but in parallel feels that his/her wishes are not destined to be satisfied; hence a deep and strong rage emerges from all past experiences with people which were felt as no more emotionally available.

Both the desire for dependency and anger are perceived to be wrong because they are destructive for the object, so that the subject tries to overcome them with defense mechanism such as isolation of affects, intellectualization, reaction formation, and retroactive cancelation. Unconsciously remains the anger, the unfulfilled need of affection and attention, and the feeling of being not loved and not appreciated that continue to threat the individual’s self.

Psychoanalytic scholars (Fisher and Greenberg 1985; Salzman 1980) suggest that the core affect of people with obsessive-compulsive personality is the fear of losing control. Most obsessive thoughts and compulsive actions involve efforts to undo or counteract impulses toward destructiveness, greed, and messiness.

The superego is severe and extremely demanding: these individuals are highly self-critical (as well critical toward others).

These subjects are trapped in an ambivalence that forces them to suffocate desires and emotions to adopt the values of others as true. Despite all the efforts of perfection, they rarely experience a sense of satisfaction.

Beneath an ordered and rigid external appearance, OCPD individuals are internally preoccupied with underlying issues of control and caught in an unconscious conflict between feeling that they must submit to others’ demands (which elicits rage and shame ) or rebel and defy them (which elicits anxiety and fear of retaliation).

Rigidity, order, and intellectualization defend against awareness of the underlying conflict and the emotions that accompany it.

To our knowledge there are no fMRI studies on the OCPD while there are several on obsessive-compulsive disorder (OCD) that have greatly increased our understanding of the neural mechanisms behind the OCD symptomatology. Although the replicability among these studies has been imperfect, they strongly link obsessive-compulsive symptoms with activation of the orbitofrontal cortex, with less consistent involvement of the anterior cingulate gyrus, the striatum, the thalamus, the lateral frontal and temporal cortices, the amygdala, and the insula (Saxena et al. 2001).

6 Toward a Neuropsychodynamic Understanding of Personality Disorders and Personality Organizations

6.1 A Psychodynamic View on Personality

Psychodynamically, the concept of personality refers to the dynamic and individual way concern to the organization of enduring patterns of behavior, cognitions, emotions, motivations, and way of relating to oneself and others.

The development of personality can be traced as a part of the experience of oneself in relation to the world, and it develops from the early relational experiences with the animate world (Trevarthen and Aitken 2001. Psychological and psychiatric problems are always intertwined with personality and need to be appreciated within the relational and cultural context of the individual.

Kernberg and Caligor (2005) defined personality as to refer to the dynamic integration of the totality of a person’s subjective experience and behavior patterns, including:

  1. (a)

    Conscious concrete and habitual behaviors, experiences of self and of the surrounding world, conscious, explicit psychic thinking, and habitual desires and fears

  2. (b)

    Unconscious behavior patterns, experiences and views, and intentional states

Personality derives from the human organism’s capacity to experience subjective states that reflect the internal condition of the body as well as of the perception of external environment. Thus, personality refers to the self and to the continuous exchange between internal and external stimuli and the way of processing and dealing with them.

It includes discrete psychic functions, such as affects, perception, cognition, and instrumental as declarative memory, and various levels of self-reflective functions, from relatively simple mirroring of perceived and intended motor movements and perceived sensory experiences to complex self-reflective evaluation of cognitive and affective states (Kernberg 2016).

6.1.1 Personality Organization: Integration Between Descriptive and Structural Understanding of PDs

First it needs to be noted that the term “borderline” when used by psychodynamic clinicians and researcher, as introduced by Kernberg (1967), denotes a level of personality organization and has a different meaning from the “borderline” term used to describe the personality disorder in DSMs, conceptualized as a list of traits to describe a categorical diagnosis, in which only one specific prototype of personality organization is labeled “borderline personality disorder.”

From a psychodynamic point of view, a description of personality pathology needs to include (1) the descriptive features of the disorder, (2) the structural organization underlying the descriptive features, and (3) a framework theory about the patient’s psychodynamics.

Descriptive features inform about maladaptive personality features and relationship with significant others and constitute a useful approach to formulate a descriptive diagnosis.

Complementarily, the structural assessment informs about the severity of the personality pathology through the assessment of the individual’s experiences of the relationship with the self and with others (identity), defense mechanisms, and reality testing.

Kernberg (1984) developed a theoretical classification of personality disorders that combines categorical (i.e., DSM oriented) and dimensional (i.e., relative degree of infusion of mental life with aggression, and introversion vs. extroversion) constructs for understanding PDs.

Personality can be expressed in several ways: at the behavioral level, personality pathology is characterized by the inhibition, the exaggeration of certain behaviors or contradictory behaviors together with symptomatic expressions. Behind this wall we can look at what is defined as the structural level of personality which can be organized by the sense of identity, intrinsically constituted by the sense of self and others (coherent and integrated in normal personality while incoherent, not integrated, or “diffuse” in borderline conditions).

The borderline personality organization (BPO) contains both specific personality disorders as described in DSM-5 Sect. 18.6 (American Psychiatric Association 2013) and other PDs not mentioned in the DSM (e.g., hypomanic, sadomasochistic, hypochondriasis, malignant narcissism ) (Kernberg and Caligor 2005).

Focusing on the “neurotic level of personality organization ,” it is possible to explain maladaptive personality features within the context of (1) a normal identity, (2) the predominance of higher-level, repression-based defense mechanism, and (3) intact reality testing.

Considering the “borderline level of personality organizations ,” the maladaptive personality rigidity is characterized by (1) identity diffusion, (2) lower-level, splitting-based, defense mechanism, and (3) variable reality testing.

Finally the “psychotic level of personality organization ” is characterized by (1) identity diffusion, (2) lower-level, splitting-based, defense mechanism, and (3) lack of reality testing.

6.1.2 Intrapsychic and Neurobiological Organization of Personality

The psychodynamic approach in assessing the level of organization implies the basic assumption that the psychological structure is connected with the underlying neurobiological correlates in the development of self in relation with other. In more general terms, the intrapsychic structures represented by object relations theory reflect a second, intrapsychic level of organismic organization, based on a primary, neurobiological one (Kernberg 2015). It is proposed that primitive mental mechanism associated with splitting and their derivatives would be based on biological, subcortical limbic developments of separate positive and negative affective systems, and their potential integration would be based on a cortical level of processing of emotional experience originally sharply dissociated (Roth 2009; Kernberg 2015; Schore 2015, Schore 2003a). The intrapsychic structure, or personality organization, could reflect a second level of organization based upon a primary neurobiological one; however what remains unclear is how the development of the self and personality features influence the neuronal processing in different contexts.

The intertwining of scientific advances in various areas from neuroscience (e.g., Northoff et al. 2006; Northoff and Panksepp 2008; Panksepp and Biven 2012) to infant research studying the interactive regulatory processes between the caregiver and the baby (e.g., Schore 2000, 2001; Lyons-Ruth 2008; Beebe and Lachmann 2014) is facilitating the integration of various forms of knowledge about the complex construct of personality and self.

6.1.3 Self-Definition and Interpersonal Relatedness in Personality Disorders

Personality disorders (PDs) have always been a core object of interest in clinical psychology and psychiatry, and they are considered as associated with fundamental disturbances of self and interpersonal relations, problems that extend in severity within and across disorders.

In diagnosing PDs we should take in account that there is an evidence that the person’s psychology causes significant distress to self or others, is of long duration, and is so much a part of the person’s experience that he or she cannot remember, or easily imagine, being different (PDM-2, Lingiardi and McWilliams 2017).

Personality can be considered as a dimension or a continuum from healthy features (coherent sense of self and personal identity, engagements in satisfying relationships, relatively flexible functioning when stressed by external events or internal conflict, expression of impulses in a manner appropriate to the situation, internalized moral values in accordance with behavior) to maladaptive-disturbed features (identity diffusion and incoherent sense of self in time, problems in self-other differentiation and relatedness, lack or transient loss in reality testing, problems in affect regulation, attention and learning, inflexibility and rigidity in several domains).

Historically only in 1938, Stern proposed the borderline concept to describe a group of patients who were apparently “unanalyzable” and did not reach the criteria to be placed either in neurotic or in psychotic diagnosis.

Several authors tried to classify and give a name to this group of patients (e.g., Knight 1953 “Borderline States of the Ego”), but only in the 1960s, as previously specified, Kernberg (1967) proposed a broader concept of borderline personality organization, which included primarily the evaluation of the identity, and the evaluation of defense mechanisms and reality testing, as closely associated with the continuity and coherence of the sense of self.

Few years later Kohut (1971) postulated a failure of the development of a cohesive sense of self during its own development and in relation with the environment, leading to fragmentation of the body, mind, self, and self-object.

Lately Fonagy et al. (2007) proposed that the construction of the sense of a subjective self is a fundamental aspect of acquiring knowledge about the world through the caregiver’s pedagogical communicative displays which in this context focuses on the child’s thoughts and feelings. The parent-infant dyad can be considered as the first intersubjective encounter that predispose to the development of the self and its agency in healthy individuals, while it predisposes to the development of the alien self (Fonagy et al. 2010) in borderline conditions.

Hence it can be considered that the concept of self seems to constitute a predisposition for individual differences in behavior, affects, cognition, and sensorimotor expression, i.e., one’s personological profile.

6.1.4 The Alternative Model for Personality Disorder in DSM-5

In line with psychodynamic tradition and taking into account the increasing interest for the concept of self, the DSM-5 and the proposed ICD-11 are moving toward a self and other classification of personality, an empirically based dimensional model for maladaptive personality traits.

In the AMPD personality disorders are not following categorical criteria while they are characterized by impairments in personality functioning and pathological personality traits. First the clinician needs to evaluate the impairments in the personality functioning (concerning specifically the self and interpersonal impairments), and only if this criterion is considered clinically relevant it is possible to proceed with the trait-based diagnosis.

It proposes that different degrees of impairments in levels of self-definition and interpersonal functioning are central to defining personality disorders, which range from no impairment to extreme impairments as expressed in a profound inability to reflect on the self together with severe impairments in self-other boundaries (self-impairments) and in significant impairments in the awareness and understanding of the thoughts, feelings, and motivations of others (interpersonal impairments; Skodol 2012).

The notion that interpersonal relatedness and self-definition issues are central in personality disturbances has been strongly influenced by attachment theory (Fonagy and Luyten 2009; Fonagy et al. 2010; Levy 2005) and contemporary interpersonal formulations (Pincus 2005). Theory and research in this field have addressed the role of early caregiving relationships in the development of representations of self and others in both normal and disrupted developments (Blatt et al. 1997).

This conceptualization is very much coherent with several psychoanalytic formulations that point out how relatively satisfactory caring experiences are potentially facilitating the development of a differentiated and cohesive sense of self and a capacity for increasingly mature interpersonal relatedness and capacity for intimacy (Blatt and Blass 1990, 1992; Blass and Blatt 1996; Kernberg 1984; Kohut 1971).

This emphasis on the concept of self and its development through the relation with the environment and significant others also emphasize the relational quality of the self.

Indeed, several authors are emphasizing how the dual exchange between caregiver and the infant, continuously modulated, influences epigenetically the structure and the formation of the growing subject, organizing the mind-body-brain interceptive and exteroceptive connections in relation to the other (Mucci 2018; Schore 2012).

6.1.5 Neuroscientific Correlates of the Self

In particular authors as Northoff and Bermpohl (2004), Northoff et al. (2006), Damasio (2010, 2012), and Panksepp and Biven (2012) emphasized the existence of a complex, distributed, and functionally based system of the self.

The core self is described as a trans-species functional entity based in medial midbrain structures and extending to deep, subcortical forebrain regions. This system is implicated in an unconscious perceived of “felt” sense of an embodied self, arising from basic proprioceptive and sensorimotor processes.

Panksepp and Biven (2012) have also suggested that the core self as mediated by these subcortical midline structures allows the operation of core automatic “self-referential processing .” This allows the linking of external events to the motivational and emotional impulses of the organism. The core self functions have been conceptualized as the basis of an ultimate, more complex, reflective, idiographic self that permits awareness, as opposed to raw experiences, of phenomenal-affective contents. These two different aspects of the self are mutually regulating.

Northoff (2015) emphasized how the self has been operationalized in many experimental studies in term of self-relatedness (SR) and how SR influences behavioral performance. SR has been associated with functions as basic as perception (Sui et al. 2012, 2013), action (Frings and Wentura 2014), reward (de Greck et al. 2008), and emotions (Northoff et al. 2009; Phan et al. 2004). Interestingly the author (Northoff 2016a, b, c) also emphasized how the brain activity for SR is linked with the resting state suggesting how it is possible to conceptualize a rest-self overlap (Bai et al. 2016). Following his view it is possible to make the assumption that the self-reflecting basic aspect of the brain shows a certain functionality and connectivity related to the self when our brain is in a task-free state.

Indeed functional aspects of the self-system, involving self-processing, perception of the self, and perception of self in relation to others, are distributed through higher cortical midline structures (CMS), notably the medial prefrontal cortex, anterior cingulate gyrus, precuneus, and posterior cingulate cortex (for a review, see Qin and Northoff 2011). Interestingly these structures form a part of the default mode network (DMN) .

The DMN also comprises the posterior cingulate, anterior cingulate, and medial prefrontal cortices, the precuneus, and temporoparietal junctions (McKiernan et al. 2006). This network is activated when subjects are at “rest” and deactivated during performance of cognitively demanding tasks (Andrews-Hanna et al. 2010). Uddin et al. (2009) and Northoff et al. (2006) argue that the only kind of stimuli available to the brain during “rest” is internal and includes memory formation and retrieval, introspection, and ongoing monitoring of the self and its social relationships.

As such, this suggests that a disruption of resting-state activity might underlie the abnormal self-concept that appears to characterize PDs.

Further frontal neural systems involved in self-processes include a right (lateralized) frontoparietal network involved in self-recognition and self-awareness and social understanding. These include more lateral structures overlapping with the distribution of mirror neuron areas, which might also serve as a partial basis for recognition of intentional mental states in others and symbolic mental activity, as well as for bodily imitation (Panksepp and Biven 2012; Knox 2010; Schore 2012; Siegel 2015; Cozolino 2014; Iacoboni 2009; Rizzolatti and Sinigaglia 2008). Further, right hemispheric areas, notably the right orbitofrontal cortex, are implicated in aspects of the self, such as SR, awareness of the self in relation to others, subjective sense of continuity and coherence, and a sense of an embodied self. The early growth and maturation of these regions is experience dependent and requires nurturing self-other interactions. When an individual is denied these positive experiences, serious failures of development occur. As such, processes of the self can be adversely affected (Schore 2004; Mucci 2017).

It appears that much of the formation of the self occurs through the internalization of benign or adverse interpersonal and sociocultural experiences (Roth and David Sweatt 2011). This process of relational internalization is enabled by the human capacity for intersubjectivity, attunement, and empathy and the predisposition to joint meaning-making and companionship, which are present from birth (Trevarthen and Aitken 2001; Stern 2000; Tronick 2007; Lyons-Ruth 2008).

6.1.6 Self and Attachment: New Heading

Self-related processing or relational processing is closely linked to the primary sense of attachment, namely, the primary outward orientation to attach to objects (Brockman 2002). Similarly both attachment and self-related processing (Northoff 2011) enable the constitution and differentiation between self and others. Brockman (2002): “Attachment begins before any sense of self and before any sense of object to attach to” (p. 90).

Attachment plays a fundamental role in shaping personality, the self of individuals and the sense of relatedness; more specifically disorganized attachment stemming from parental traumatization and early relational trauma creates not only the vertical disconnection that is called dissociation in the mind-brain-body system but also the impulsivity and lack of effortful control that are characteristics of borderline pathologies or personality disorders in general (Mucci 2017). This is due to the fact that early traumatization does not allow the connection between limbic areas and amygdala (the limbic system, mostly connected with emotions, especially in the right hemisphere) and superior orbitofrontal areas, which are the areas of adult control and agency, and also of intentionality, decisionmaking, and so on. In few words all the “superior qualities” include imagination creativity and activation of planning. This creates the dysfunctions typical of borderline pathologies. They are pathologies created in long-term abuse and in dysfunctional families (Mucci 2013; Felitti et al. 1998).

A recent multimodal resting-state fMRI (rsfMRI), aversion task fMRI, glutamate magnetic resonance spectroscopy (MRS), and diffusion magnetic resonance imaging (dMRI) combined with the Childhood Trauma Questionnaire (CTQ) in healthy subjects aimed to examine the impact of negative childhood experiences on the brain (Duncan et al. 2015).

Interestingly and in line with our proposal, the research showed how increased measures of individual negative childhood experiences (NCEs) were related to lower levels of medial prefrontal cortex (mPFC) glutamate levels and how the degree of NCEs may impact resting-state activity properties in the mPFC —a key region within the default mode and affective processing networks (Daniels et al. 2011; Roy et al. 2012). Specifically increased instances of reported NCEs were related to increased entropy measures of mPFC.

The link between NCEs , glutamate, and entropy complements and extends previous studies showing an effect of early life stressors on EEG frequency bands which predict signal entropy (Bruce et al. 2009; McFarlane et al. 2005), and prior results demonstrating an effect of stress on mPFC resting-state activity CTQ scores and mPFC glutamate and entropy correlated with neural BOLD responses to the anticipation of aversive stimuli in regions throughout the aversion-related network, with strong correlations between all measures in the motor cortex and left insula.

Structural connectivity strength, measured using mean fractional anisotropy, between the mPFC and left insula correlated to aversion-related signal changes in the motor cortex. These findings highlight the impact of NCEs on multiple interrelated brain systems. In particular, they highlight the role of a prefrontal-insular-motor cortical network in the processing and responsivity to aversive stimuli and its potential adaptability by NCEs.

6.1.7 Neuropsychodynamic Model of Self and Personality Functioning

Although the neural mechanisms underpinning and determining normal and disordered mental function are clearly highly important, it is not possible to fully conceive of or describe a range of psychological phenomena, including some disturbed in BPD, such as subjective awareness and sense of coherence, identity, or more sophisticated executive functions, in these terms.

This leads us to hypothesize that self-specific information of individuals may be present in the resting state and that the study of neural architecture of the resting state may represent the predisposition of every individual to act in the world (Fig. 18.1).

Fig. 18.1
figure 1

Neuropsychodynamic model of self, personality, and brain: rest-self-containment and rest-stimulus interaction

Full size image

Moreover we may suggest how the study of the interaction between the ongoing activity of the brain and the role of individual personality differences in interaction with task-induced activity may be considered as a further investigation to better understand the human brain.

We are moving toward a new way in classifying and studying personality that can develop a bridge between neuroscience and clinical psychodynamic psychology: (1) self-based and (2) brain-based predisposition for individual differences, regarding the dimensional continuum from adaptive to maladaptive personality features, which characterize the individual differences to experience the relation between internal world and external reality given that our relational experiences with the world shape our self and in parallel our brain.

The study of personality has to take into account the so-called rest-stimulus interaction (Northoff et al. 2010) as a way to conceive, from a neuronal point of view, how the brain’s intrinsic activity with the own particular spatiotemporal schemata encodes self-specific information (rest-self overlap, e.g., Bai et al. 2016) of past and (possible) future input-output relationship (Northoff 2016a, b, c).

In this context we propose a novel conceptualization of the link between self-brain states and personality organization. In our view different and interconnected states of the self (i.e., self-relational alignment, self-constitution, self-manifestation, self-expansion) are embedded in the intrinsic activity of the brain which, as we already pointed out, predispose the expression of personality in the world:

First we propose that self-relational alignment is a prerequisite that gives the framework for the other states of the self. It is essentially linked with the relational continuity, which can also be conceptualized in a neuro-ecological continuum between brain and the external world. It is given by the first relational encounter with a caregiver and his/her capacity to attune with the mind-brain of the infant to give the possibility of a secure environment where the infant’s brain can start to exchange mutual informations with the world. The infant’s brain start to become part of the time and the space of the world by the relational alignment with the spatiotemporal structure of the animate and inanimate reality. This attunement capacity predisposes the constitution of the self.

Self-constitution represents the building blocks of the consciousness processing: it includes the perception of time and the perception of space. It is linked with the ownership of own body, location of self in space, authorship and control of own actions, and difference between fantasy and reality. It is linked with the capacity to distinguish self from nonself and internal from the external. Thus it’s strongly connected with reality testing and it is the self-state that distinguish psychotic organization of personality from the others. In the case of psychotic individuals, at the neuronal level the relationship from cortical midline structure (CMS) and somatosensory network is altered, resulting in lack of differentiation in processing intrinsic and extrinsic stimuli.

Self-manifestation represents actual consciousness in the present moment: it includes the experience of time and space with the perception of environment and identification with social reality; the cognitive functions as thinking, imaging, metalizing; and the affective and motivational system. It is particularly linked with the degree integration of self and significant others and, in parallel, with the quality of defense mechanism (higher order, lower order). In several personality disturbances, there is an altered relationship between the subcortical-cortical limbic circuits with orbitofrontal regions that are deputed to regulate emotions and mentalize affects.

Self-expansion is linked with stable and integrated aspects of the self in time and space: (a) autobiographical self, (b) social self, (c) linguistic self, and (d) mental self. There is the capacity to inhibit behaviors and to tolerate the ambivalence of the affects considering past, present, and future. The self and the consciousness can be expanded in time and space without losing the capacity to differentiate internal from external stimuli. Higher is the capacity to self-expand, higher will be the integrations of various aspects of self and others and more mature the quality of defense mechanism. In normal expansion there is an increased connectivity between DMN and other networks in learning from new experiences with the world, while in some neurotic disturbances, the coherence between certain networks can be lost according to the impossibility to elaborate the experience given the repression-based psychological defense mechanism.

How these different states of the self are linked to the intrapsychic structure of individuals?

When we consider the personality organization or intrapsychic structure (characterized by identity integration, defense mechanism, and reality testing) considered as a second level of organization, we may take into account a primary neurobiological one which, in our hypothesis, may be characterized by the brain’s intrinsic activity in term of form or structure characterized by space and time and hence spatiotemporal structure (Northoff 2016a, b).

Since the brain’s intrinsic activity can be characterized by particular and merely individualized spatiotemporal structure, we suppose that any contents (whether affective, cognitive, social or sensorimotor) and their underlying extrinsic activity must first and foremost be integrated within the brain’s intrinsic (internal) activity and in its spatiotemporal structure. The degree and the way the contents and their extrinsic activity are integrated into the brain’s intrinsic activity determine how we perceive them into consciousness and hence how we make experience of them, i.e., our subjective or personal approach to the external reality.

In this view our personality can be directly related to our subjective experience of temporal flow, which is related to our temporal structure of the brain’s intrinsic activity, thus the temporal balance between infraslow/slow and fast oscillations (Northoff 2017).

In psychotic personality organization , on a psychological level it is possible to find diffusion of identity (not integrated and fragmented), primitive defense mechanism, and loss of reality testing; on a neurobiological level we find disturbance at a level of self-constitution, a disruption in the global organization of the brain’s intrinsic activity: whole topography over all networks and frequency range are disrupted, and, for instance, the usual negative correlations between the default mode network (DMN) and the control executive network (CEN) that are usually characterized by an anticorrelation are in psychosis transformed into a positive correlation which in turn may lead to the breakdown of the rest-self overlap where there is a self-assignment to either internal or external stimuli (Carhart-Harris 2013; Carhart-Harris et al. 2014). In this case we may hypothesize that there is no possibility to differentiate the internal world from the external reality; there is a fragmentation of the perception of time and space, which results in the identity diffusion or fragmentation of self-constitution. We may hypothesize that this psychotic organization shows severe impairments at a pre-phenomenal level of experience on the spatiotemporal structure of brain’s intrinsic activity.

In borderline personality organization , characterized by intact reality testing, primitive defense mechanism based on splitting and projective identification, and identity diffusion, at a neurobiological level, we can see how the whole brain topography and organization between networks are preserved, but the balance between them can show abnormalities, as in the case of bipolar disorder (Magioncalda et al. 2015; Martino et al. 2016), and can be hypothesized how the relation with the external stimuli can be impaired. We may find abnormalities in the rest-task interaction (e.g., on narcissistic personality features, Scalabrini et al., in press) and lack of integration in brain’s networks; for example, in borderline personality disorders, we can observe alterations in orbitofrontal cortex and connected subcortical regions (amygdala and hippocampus) (Koenigsberg et al. 2009a, b; Minzenberg et al. 2007; Enzi et al. 2013). Moreover other studies have revealed the functional neuroanatomy of borderline disorders that are associated with the hypersensitivity, intolerance for aloneness, and attachment fears typical of patients in this broad diagnostic group (Buchheim et al. 2008; Fertuck et al. 2009; King-Casas et al. 2008).

We may hypothesize that individuals with borderline organization of personality show severe impairments at a pre-reflective level of experience, at a self-manifestation state, where it is possible to have information about implicit experience of self, body, others, time, and space as related to the spatiotemporal structure of brain’s intrinsic activity and consciousness.

Regarding the neurotic personality organization , characterized by intact reality testing, mature defense mechanism based on repression, and integrated sense of self and identity, we may find some compromission at the self-expansion state where at a neurobiological level the whole brain’s topography, organization between networks, and balance between them are preserved, but their coherence is not given, so we may expect that in neurotic organization we may find a decreased coherence between networks and decreased cross-frequency coupling while the spatiotemporal structure by itself is well integrated. Thus these individual have difficulty to expand themselves in time and to finalize their motives because of the internal conflict which are shaping their personality. We may hypothesize that the neurotic organization doesn’t show impairments at pre-phenomenal and at a pre-reflective level of experience, but it’s possible that some contents at the reflective level of the experience (explicit experience of cognitive, affective, social, sensorimotor functions) are not accessible to the consciousness so that they are repressed and they will manifest themselves in some incoherence in brain’s functioning to process either internal and external stimuli.

In sum we propose that different states of self intrinsically connected to the spontaneous brain spatiotemporal organization represent a primary neurobiological organization that is connected with different impairments in the second level of organization represented by the intrapsychic structure or personality organization of individuals.

The advance in fMRI studies that comprise the study of the intrinsic brain activity (during resting state), the task-evoked brain’s activity, and the interaction of the two conditions may shed a novel light in the understanding of personality pathology.

6.2 Clinical Case Example: The Case of F

F. was a patient of 24 years old who asked for clinical help because of her self-defeating and self-destructive behaviors such as cutting her wrist (not too severely), alcohol abuse, and incapacity to pursue her goals in study and work and with severe difficulty in maintaining a relationship.

F. was very smart, with an IQ approximately >120, but she never succeeded in school after she was 16 years old, and she decided to quit college after first 2 years because she was not constant in studying and she was convinced that the study of languages was not in line with her artistic talent. Moreover she wanted to work to save some money and travel in South America to learn Argentinean tango and to find the love of her life.

At the time of the first consultation she didn’t have any job, she was fired because of her irresponsibility and her “temper” in treating with clients. She was not economically autonomous, and she was receiving money from her parents.

About relationship and sexuality, F. described her relational life as confused and quiet messy. Her contact with men was always connected to alcohol abuse and promiscuous situations: “I’ve been drinking too much so I don’t really remember where I spent last night and with who… when I woke up I found some bites on my body and I was frightened…so I called my friend who told me what happened last night.”

She never had a relationship longer than few months saying that at the beginning she is always very passionate, but after a while she get bored of people who are not good anymore for her. At the same time if she felt of being abandoned, she would act desperately to get attention.

Her self-esteem was very low at that time of the first consultation, and she presented herself as a shy person and ashamed of her problems; however internally she had grandiose features such as: “I am different from anybody and I don’t want to reach any compromise…it is better to be the last of a mass of people then to be in the middle.”

She was impulsive in the area of alcohol and drugs, in spending money without thinking at any consequences. Moreover she had outburst of anger with parents, and she would easily get angry for nothing throwing things: “I’m always fighting with my roommate and last time I threw away a mug.”

She also reported that she couldn’t think about herself because she is nothing and feels empty all the time. When she felt to be under stress, she reported to cut her wrist and her arms: “I feel the pain and in these moments…it is strange but I feel kind of being alive.”

F. resulted to have problems mainly in the area of the self-manifestation, since she cannot experience a sense of self-continuity. What she experiences is continuously distorted or acted impulsively, resulting in a lack of effective expansion in time. Moreover it can be noticed how there is a disconnection between the affective experiences and the capacity to regulate her emotions, wishes, and self-defeating drives. It can be hypothesized that there is a disconnection between the orbitofrontal regions and cortico-limbic circuits suggesting the difficulty in integrating various aspects of self and others in a whole and multifaceted sense of self.

F. reached the extremes to be diagnosed with a borderline personality disorder at a categorical level (unstable or diffuse sense of self/identity, a pattern of unstable interpersonal relationship, frantic efforts to avoid abandonment, impulsivity in spending, sex and substance abuse, self-mutilating behaviors, difficulty controlling anger, chronic feeling of emptiness, and dissociative attitude); in addition she presents narcissistic features (sense of entitlement, believe of being special—in a covert manner, often preoccupied with fantasies of ideal love).

6.2.1 Familiar History of F

F. is the second child, and she has a brother 6 years older than her. Parents immigrated from the south of Italy to Germany when the brother was born, and then they came back when the mother was pregnant with F. The pregnant mother was depressed (Green 1993), and she had a history of abuse; in addition she was mistreated repetitively from the family of the husband when they come back to Italy. In detail the mother would lose weight instead of gaining it when was pregnant with F. From F. narrative the mother was severely depressed and under medication during her childhood, so the main caregiver was the father. He was a simple hardworking man who was taking care of her child. F. used to sleep between their parents until she was 15 years old. She was very close to her father until she became adolescent, and he started to develop a sexual interest for the daughter.

The father can be defined as incestual (Racamier 2010): he was obsessed with her body and used to spy on her in the restroom, to open her bedroom unexpectedly without knocking, and to gaze on her sexual parts inappropriately. She started to become angrier and angrier with him, while she did not find any support from the mother. Once she finally disclosed the sexual attention of the father to the mother, she reacted denying and telling her she was crazy. Subsequently they kicked her off the house when she was 23 years old (1 year before she asked for psychological and psychiatric help)

It can be hypothesized that the incapacity of the mother, because of her mental illness and her history of abuse, to take care of the child as an infant and as a young girl has resulted in a disorganized attachment (Liotti 2004; Fonagy et al. 2010; Schore 2003a, b) characterized by affective dysregulation, uncoherent sense of self and others and incapacity to tolerate and manage impulsivity, and lack in mentalization. In terms of object relation theory , the internalized good object is not consistent and thus is not felt as soothing and capable of mood and affective regulation. Moreover the atmosphere at home can be considered traumatic in the sense of a continual distortion of what happens at home and a negation of the truth of incestual attention from the third part (Van Der Kolk 1987, 1988). The attachment disorganized patterns together with the traumatic experiences explained the development of a dissociative attitude of F. especially connected with drinking. Through the act of drinking, she could disconnect from her reality, and she could depersonalize and forget what happens as a way to detach from herself and from reality. The proneness to disconnect from herself and from reality is closely related to dissociation phenomena which resulted from traumatic experiences. This brings us back to the self-relational alignment that we consider as a framework where the subject can start to exchange mutual informations with the world. Given the familiar and attachment history of F., here we can see how the traumatic events impaired her ability to attune and align with her own sense of self and with the environment. From a neuropsychodynamic point of view, it can be hypothesized a higher degree of entropy in the regions connected with self-referential activity and attachment, the anterior cingulate cortex (ACC) and the ventromedial prefrontal cortex (VmPFC) .

Together with descriptive features mentioned before, F. is framed in the low-level borderline personality organization as characterized by identity (unintegrated and discontinued sense of self and of significant others) and sexual diffusion (sexual promiscuity and object inconsistency); use of massive primitive defenses as splitting, projective identification, dissociation; and maintenance of reality testing but with severe cognitive distortions (a certain proneness to dissociation).

She was referred to a psychodynamic psychotherapist for twice a week treatment tailored for borderline personality disorder.