Review of Affect Regulation Theory by Dan Hill: Dissociation and Narcissistic and Borderline Personality Disorders

Summary of Chapters 9 & 10 in Affect Regulation Theory by Daniel Hill

I thought some of my psychoanalytically trained colleagues might be interested in this short article I wrote after leading the discussion of chapters 9 and 10 from Daniel Hill’s book, for the Laufer Neuropsychoanalytic Study Group. I have reviewed these two chapters along with my own comments.

These two chapters have provided a way for me to understand my clinical work from a neurological perspective. Up until now I’ve experienced the clinical phenomena of dissociation and understood my work with borderline and narcissistic patients, mostly from psychoanalytic theoretical levels. More about this after my chapter summaries

Hill begins chapter 9 Chronic Dissociation, by reviewing his description of dissociated affect:

“Dissociated affect may be described as information about the state of the body that cannot be assessed and used for adaptive responses to one’s internal or external environments. Without this crucial information subjectivity and intersubjectivity break down. “As a result, affective information is not processed in the right hemisphere, does not receive primary implicit processing, and thus cannot be transferred to the left brain for secondary, conscious formulation and appraisal.” ?He further states that chronic dissociation is the key factor in developmental arrest and a primary obstacle to therapeutic process.

As a Freudian trained analyst, I see here parallels to what Freud described as an unanalyzable patient. Although Freud’s focus on this problem had more to do with what he felt to be an unanalyzable transference, where the patient was unable to have any capacity to reflect on the transference, understand context and eventually move on within the analytic process, both he and Hill agree on the lack of ability to mobilize analytic processing. For this patient, prediction error becomes a distorted reality based on a rigidly internalized early attachment schema, from which there was no escape.

I find that Pine’s concept about early deficits in affect regulation result in dysregulation and dissociation at low levels of stress or trauma, as a centrally important concept. These low levels, in others with healthier early affect regulation experiences, would not trigger dissociation. ?It’s been helpful for me in my practice, to point out to patients that their response to a current situation seems ‘out of sync’ with what most people might have to a similar situation. This type of ‘interpretation’ begins to awaken the observing ego to process the context of a situation using cognition, thus reducing the dissociation and enabling implicit functioning in the left hemisphere.

Another important idea that Hill clarifies is that while severe dissociation is seen as pathological, moderate dissociation is more prevalent and often overlooked. There is some modulation of the intensity of affect but not enough to stay regulated. One is hypoactivated but not completely immobilized, or hyperactivated but not completely out of control.

Hypoaroused dissociation is often described as a “feigned death”, adaptive in life threatening situations, but maladaptive when triggered by stress or trauma that would not necessitate such an intense reaction in one without a history of a dysregulated affect disorder. It is an immobilization without loss of consciousness,

Hyperaroused dissociation is adaptive to life-or-death situations where the shutting down of cognitive processes enables one to react quickly to the danger. But the closing off of ones’ cortical processes; verbal reflection and placement within the current context leaves one less able to properly assess the danger within less life-threatening situations. The example of PTSD demonstrates “the total immersion within context that would normally be quarantined, leaving ones’ behavior completely automated” (without conscious control).

Moderate hypo-aroused symptoms have similar origin but are less rigidly activated producing dissociated states that often remain in partial awareness but nonetheless are acted out, such as ?binge eating, and a general sense of emotional detachment. In hill’s words, “Agency is replaced by automaticity”. These patients often demonstrate withdrawal, lack of attention, absence of full engagement, distance from self and object and a sparse inner life along with sensory deprivation.

Moderate hyper-aroused symptoms leave patients unable to process thoughts and affects. They then experience feelings of being swept away or flooded; unable to digest somatic responses and experience appropriate context to current situations. Patients are unable to know what they are feeling and experience affect flooding, scrambled or fragmented thinking

Chapter 10: Personality Disorders: A sequela of Relational Trauma

I found this chapter particularly helpful in understanding the neurological ly based attachment issues we face in dealing with narcissistic and borderline personality disorder patients. Hill begins the chapter with a discussion of how early relational trauma leads to personality disorders. “Relational trauma give rise to character traits that serve to preempt and/or cope with expected misattunement, dysregulation and shame”. “The adult who struggles to maintain a positive sense of self is on guard against rejection and abandonment”. “Insecure attachment leads to personality disorders and a vulnerability to Axis 1 psychiatric disorders commonly comorbid with personality disorders” These are seen as developmental disorders with severe limitations of adaptive stress regulating functions. Hill believes that disordered regulation is at the core of all personality disorders with both hyper and hypo arousal playing parts in both borderline and narcissistic disorders, but with different surface manifestations and characteristics. He believes autonomic responses (unconscious mechanisms) are at the core of these working models.

Narcissistic Personality Disorders are seen as both extroverted and introverted, although the extroverted version is more commonly noticed because of its ‘larger than life’ presence. He describes the extroverted type as having a sympathetic bias (tendency towards primitive fear) stemming from an early preoccupied attachment pattern, and the Inhibited or introverted narcissistic type as having a parasympathetic bias (tendency towards deflated affect) stemming from an early avoidant attachment pattern.

The inhibited/introverted narcissist is seen as stemming from an early preoccupied attachment characterized by a deflated sense of self, avoidant attachment patterns and covert depression while the extroverted or hyper-aroused narcissist struggles with early dysregulated attachment manifesting in externalizing defenses (for example ‘externalization of blame’ seen often with borderline patients) and tending towards enmeshed object relationships. This is the ‘stereotype’ narcissist who draws attention to himself, fills the room with his large presence, is self-absorbed, arrogant, self-aggrandizing, attention seeking impervious to the hurt he instills upon others and is seemingly shameless. (I cannot continue without adding my own reaction to these characteristics as being the defining qualities of Donald Trump).

The continuous activation of the grandiose self defends against depression and they are quick to experience narcissistic rage in response to experiencing a narcissistic injury.This syndrome leaves them unable to moderate parasympathetic arousal (calming regulation) along with a poor capacity for autoregulation and a virulent fear of shame. According to Hill, dissociated shame, is at the core of the narcissist needing countermeasures in order to maintain emotional equilibrium.

The developmental origin is seen as the preoccupation of the care-givers dependence upon the infant for dyadic regulation, with the care-givers own shame and anger in response to perceived (emotional) abandonment by the infant as a narcissistic regulating object. Here he references Alice Millers book, The Prisoners of Childhood, which explores this dynamic in greater detail.

Hypo aroused narcissism manifests as a dearth of emotional connection and austere shaming stemming from avoidant relational trauma with parasympathetic dominance while hyper-aroused narcissism presents with sympathetic dominance.

In a sense, narcissistic disorders may then be seen as an imbalance of parasympathetic and sympathetic processing, or the inability to regulate your bodies stimulation by internal signals of heightened affect with its ability to self-regulate this affect.

Borderline personality disorders are seen as originating from both early disorganized attachment and preoccupied attachment. The severity of this early attachment disorder determines the association with borderline personality disorder. Cognitive symptoms include splitting, fluidity of self and object representations and deficient reflective functioning. Hill references Schore who also adds the instability of affect, intensity of dysregulation, vulnerability to severe depression and being prone to hypo-aroused dissociation. He also adds the extremely inefficient ability to regulate shame. Symptoms also include such maladaptive efforts at emotional regulation as suicidal and self-harm behaviors, substance abuse and bulemia. Intensely stressful and emotionally chaotic ambiance established by the caregiver leaves the infant catastrophically unable to self-regulate. When the caretaker dissociates, she ‘loses’ the baby, leaving the attachment figure a source of both danger and safety; a terror inducing attachment dilemma from which there is no escape.

As a practicing psychoanalyst for over 40 years, I’ve found Pines’ theories quite helpful to understand my work, often intuitive and guided by earlier theoreticians such as Masterson, Kohut, Winnicott, Mahler and Spitz. These clinicians hadn’t the scientific technology to understand the biology of what they were exploring, but nevertheless were able to provide working models that helped to offer treatment for patients who didn’t easily fit into classical analytic model. These patients presented unique challenges to clinicians, especially prior to modern psychiatric medications that were then unavailable.

Pines classification of narcissistic personality disorders is helpful from a neurological perspective but I am also reminded of Kohuts’ work with narcissistic disorders that I found essential to understanding that pathology and finding a way to work with narcissisticly injured patients through mirroring; seeing myself as a reparative self-object with whom my patient could repair and rebuild a new, less fragmented, healthier sense of self.

Winnicott’s work, especially his seminal essay on “Hate in the Countertransference” helped me to, in his words, ‘survive my destruction’ while working with borderline patients who needed to reach a point in treatment where they could safely externalize their rage within ‘holding environment’ that would hold and contain their rage without retaliation or abandonment as they had inevitably experience with many other earlier objects in their lives.

Masterson’s work on borderline patients with his theory of “Rewarding and Withdrawing Object Relation Units” was essential in my understanding borderline patient’s tendency to regress whenever they approached an autonomous experience or the perceived threat of abandonment.

Along with Bowlby and other attachment theorists, Spitz’ work focusing on the first year of life and Mahlers’ work on separation/individuation (the first 3 years of life) have been invaluable to me in forming my interventions and understanding my patients’ emotional processes from a developmental perspective.

Lastly, Art Robbins’ work on countertransference helped me to work with my own affect to meet with and follow my patients on an affective level.

I see Pine’s work on neurological processes as an important overlay to my earlier more classical training; one which offers a firmer understanding and a new language with which I can now put into words more clearly, that which I have done more intuitively for many years. It sharpens and affirms, giving a new enthusiasm and a new voice with which to continue to explore this ‘impossible profession’!

Professor Robert Irwin Wolf

Member of the Steering Committee of the

Laufer Neuropsychoanalytic Clinical Study Center at NPAP

Senior Member, NPAP