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Sense of reality, reality testing and reality processing in borderline patients.

Although borderline patients are suitable for it, they often undergo repeated testing of fantasies against objective reality without success. A reason for these partial failures is that subjects have not been able to build a solid sense of reality and have found many difficulties for processing reality demands and possibilities. The author puts forward some thoughts on this question, such as the importance of working through the depressive position and the Oedipus complex in the process of building up a solid sense of reality. A sense of reality also favours continuous reality processing. When reality processing becomes as continuous as life itself, the repetition of individual reality tests becomes less frequent and necessary, and more satisfying. The author also presents some recommendations for the psychoanalytic treatment of such patients, stressing the importance and the difficulties of the introduction of the borderline patient into the triangular situation because primitive defences--such as disavowal and denial--are mobilized.

Adult↗

Some observations on reality testing as a clinical concept.

This paper asserts that reality testing is a complex ego activity which cannot be characterized globally as either intact or defective. In normals, neurotics, and "borderlines" it is actually a highly variable function. Some problems of nomenclature are addressed. Among many analysts there is an implicit tendency to concretize the means by which reality testing is performed. This may lead to certain conceptual problems and clinical inaccuracies. The relationship of reality testing to unconscious conflicts from all phases of development is emphasized and illustrated. Issues in the technical handling in analysis of manifestations of disturbed reality testing are discussed.

Borderline Personality Disorder↗

Beyond posttraumatic stress disorder: object relations and reality testing disturbances in physically and sexually abused adolescents.

OBJECTIVE: To evaluate posttraumatic stress disorder (PTSD) symptom severity, object (interpersonal) relations disturbances, and reality testing disturbances in a sample of physically and sexually abused adolescents. METHOD: Subjects were 37 students, 16 boys and 21 girls, enrolled at a private, residential school for children with various conduct problems. Students completed several psychological tests, including the Child Post-Traumatic Stress Disorder Reaction Index (CPTSD-RI) and the Bell Object Relations and Reality Testing Inventory. RESULTS: Of the 37 students, 22 (59.5%) had CPTSD-RI scores in the severe and the very severe ranges. The most common object relations and reality testing disturbances were insecure attachment and uncertainty of perception, respectively. CPTSD-RI scores were positively correlated with two of the four object relations scores (insecure attachment and egocentricity) and with all three reality testing scores (reality distortion, uncertainty of perception, and hallucinations/delusions). Mean CPTSD-RI scores were higher for students whose abuse had involved sex (sexual and physical abuse, sexual abuse only) than they were for students whose abuse had been physical only. Alienation and social incompetence, the two object relations disturbances not correlated with PTSD symptom severity, were associated with having experienced abuse at an early age and having been abused by a parent or stepparent (versus a nonparent). CONCLUSION: To address more effectively the long-term difficulties associated with child maltreatment, clinicians and clinician-investigators ought to evaluate interpersonal and reality testing disturbances, as well as PTSD symptom severity.

Adolescent↗

Reality testing and self-reported AIDS self-care behavior.

This investigation examined the relationship between reality testing and AIDS self-care behavior for 509 urban college students. It was hypothesized that reality testing may become impaired in sexual interactions that carry the risk of HIV infection, leading to imperfect adoption of safer sex practices. Reality testing, measured by the Bell Object Relations and Reality Testing Inventory, was significantly related to AIDS knowledge as measured by the AIDS Prevention Survey of Thomas and not significantly related to self-reported safer sex behavior, measured by Bassman's HIV Infection Prevention Scale.

Acquired Immunodeficiency Syndrome↗

Assessment of object relations and reality testing in methadone patients.

OBJECTIVE: The authors studied methadone maintenance patients to determine the degree of their impairment in object relations and reality testing and the relationship of such impairment to comorbid axis I and axis II disorders. It was expected that deficits in object relations and, to a lesser degree, reality testing would be exhibited by the group as a whole and that they would be related to the presence of comorbid disorders. METHOD: The self-report Bell Object Relations Reality Testing Inventory was administered to 240 methadone maintenance patients. The subjects were first divided into groups on the basis of number of comorbid axis I disorders and then on the basis of number of comorbid axis II disorders. Finally, the subjects were placed into one of four groups on the basis of the combined presence or absence of axis I and axis II disorders. RESULTS: The methadone patients exhibited some specific impairments in object relations, but not in reality testing. Bell inventory scores did not significantly differ according to the number of comorbid axis I disorders, but they did significantly differ according to number of axis II disorders diagnosed. The scores were poorest for those with axis II disorders only, while subjects with only axis I disorders had scores similar to those with neither axis I nor II disorders. CONCLUSIONS: Comorbid axis II disorders, more than axis I disorders, may be associated with problems in object relations and reality testing in methadone patients.

Adult↗

The role of reality testing in psychoanalysis: followup of 22 cases.

As part of a prospective, longitudinal study of psychoanalytic outcome, 22 patients were evaluated for changes in their level of reality testing. These patients had been accepted for supervised psychoanalysis with candidates in training by senior analysts who had diagnosed them as neurotic. Psychological tests given prior to the beginning of analysis indicated, however, that more than one third of our sample demonstrated serious distortions in their perceptions of reality. When psychological tests administered one year after the completion of analysis were compared with these pretreatment tests, no significant improvement was found in the level of reality testing for the group as a whole. However, when excluding two patients who had suffered major traumas in the year following psychoanalysis, significant improvement in reality testing was found for the remaining 20 patients. Post-treatment interviews with the treating analysts revealed that in the course of analysis itself, approximately one third of these patients showed some disturbance in reality testing; only three of these patients showed significant improvement in the level of their reality testing during treatment. These findings suggest that while patients may not present clinically with evidence of impaired reality testing, such evidence may be available in psychological testing, and may become apparent in the course of the treatment.

Ego↗

Reality testing and judgment.

Both clinical and research efforts will be enhanced when professionals clearly understand the meaning of the terms reality testing and judgment. Until recently, clinicians and writers often failed to differentiate between them and also introduced other similar words and phrases that further diminished the specificity of the term reality testing. After reviewing some recent efforts to clarify the terminology, the author discusses the critical role of sensation as a precursor to perception and cognition, and the interaction of all three elements in the development of reality testing. He concludes with proposals to clarify the clinical applications of the terminology.

Ego↗

The relationship of object relations and reality testing deficits to outcome status of methadone maintenance patients.

Impairments in the ability to form and maintain meaningful interpersonal relationships and in the ability to distinguish between internal and external stimuli are related to an individual's psychological health. The Bell Object Relations and Reality Testing Inventory (BORRTI) scores of 146 methadone patients were used to evaluate whether transitory (TI) or chronic impairments (CIs) in object relations and reality testing were related to more severe drug use, family and social problems, psychological distress, as well as more time in treatment, seeking additional treatments, or taking psychiatric medication. The results showed no significant relationship between BORRTI scores and family or social problems, time in treatment, or the months of heroin use between follow-up evaluations. However, severity of drug use was related to an impairment in a specific dimension of object relations-egocentricity. There was a significant relationship between TIs and CIs in object relations and reality testing with levels of psychological distress and the likelihood of taking psychiatric medication.

Adult↗

Reality testing and auditory hallucinations: a signal detection analysis.

The hypothesis that hallucinators are deficient in the metacognitive skill of reality testing was tested using the methodology of signal detection theory. In Expt 1 undergraduate subjects scoring high or low on a scale measuring predisposition to hallucination were tested on an auditory signal detection task. High scorers on the scale were found to differ from low scorers on a measure of perceptual bias but not on a measure of sensitivity. In Expt 2 a similar methodology was used with hallucinating and non-hallucinating schizophrenic patients, with similar results. These results support the hypothesis that hallucinators or subjects highly disposed towards hallucination are deficient in reality testing and are therefore prone to identify imaginary events as real.

Adult↗

Object relations and reality testing in early- and late-onset schizophrenia.

One hundred fifty-seven U.S. military veterans with schizophrenia were divided into early-onset (i.e., onset at age 20 or before, n = 36) and late-onset (i.e., onset after age 30, n = 28) groups and completed the Bell Object Relations and Reality Testing Inventory (BORRTI), the Positive and Negative Syndrome Scale, and several representative neuropsychological instruments. Participants were compared on background characteristics and test measures. The early-onset group demonstrated significantly more object-relations and reality-testing deficits than the late-onset group. In contrast, no significant group differences were found on symptom or neuropsychological variables. An a posteriori three-group analysis that included the middle age of onset group (i.e., ages 21 to 30) found that the middle group had mean values that fell between early- and late-onset groups on most variables. No distinct patterns of BORRTI subscale scores distinguished the middle group. The finding that object-relations and reality-testing deficits are more pronounced in early-onset schizophrenia has implications for the treatment and rehabilitation of schizophrenia.

Adult↗

Are adult children of alcoholics unique? A study of object relations and reality testing.

This self-report questionnaire study revealed that adult children of alcoholics (ACAs, n = 49) were significantly different from adult children from normal families (ACNs, (n = 55) on five of nine Bell Object Relations Reality Testing Inventory (BORRTI; Bell, 1988) scales and from adult children from dysfunctional families (ACDs, n = 48) on the Reality Testing summary score. Both ACAs and ACDs were similar to each other and different from ACNs on Insecure Attachment and on two family background ratings- perceived quality of paternal and maternal caregiving. Discussion of these results plus separate exploratory regression analyses followed.

Adult↗

Patterns of object relations and reality testing deficits in schizophrenia: clusters and their symptom and personality correlates.

Bell Object Relations Reality Testing Inventory (BORRTI) profile scores were used to cluster 222 outpatients with schizophrenia or schizoaffective disorder. An eight-cluster solution was subjected to replication analysis, and six clusters were found valid and replicable. These clusters were sorted into three pairs that were interpreted as follows: Residually Impaired consisted of Sealed-Over Recovery and Integrated Recovery; Socially Withdrawn consisted of Socially Withdrawn and Socially Withdrawn-Autistic; and Psychotically Egocentric consisted of Psychotically Egocentric and Psychotically Egocentric-Severe. Clusters were compared on Positive and Negative Syndrome Scale ratings and on subscales from the Eysenck Personality Questionnaire. MANOVAs indicated significant differences among clusters. These differences provided further interpretations of cluster membership. Implications for the use of BORRTI profiles for treatment and rehabilitation planning are discussed.

Adult↗

A Rorschach form-color percentage and reality testing in adult patients and nonpatients.

This study sought to investigate the sensitivity of a Rorschach form-color percentage (FC+%) on affective dysfunction and reality testing via a decrease in form quality. The mean FC+%s of 46 psychiatric patients representing borderline, manic-depressive, schizo-affective, and schizophrenic groups were compared with those of 12 nonpatients. Data analysis revealed that the mean FC+%s of all the clinical groups were significantly lower than the mean FC+% of the nonpatient group. The results support the FC+% as an index of affective dysfunction and as a viable supplement to Exner's comprehensive Rorschach system.

Adult↗

Relation of surgery, tumor site, and age group to the loss of reality testing in Japanese patients with malignant tumors: a study of a hospital-based sample with a consultation-liaison service.

The relation between surgery and the loss of reality testing (LRT) in Japanese patients with malignant tumors were examined, taking into account the influence of the tumor sites and age groups. The patients were comprised of 277 men and 225 women with malignant tumors in Kyushu University Hospital, Fukuoka, Japan, who underwent a check-up at the Department of Neuropsychiatry for the first time using the consultation-liaison system. Those with known schizophrenia, dementia, mental retardation, and paranoid or schizoid (schizotypal) personality disorder were excluded. Surgery was statistically significantly associated with LRT in elderly men (> or =65 years of age), and in men with malignant tumors of the digestive organs (odds ratio [OR], 9.7; 95% confidence interval [95% CI], 3.2-29.3). Even after adjusting for tumor site and age, surgery was statistically significantly associated with LRT in men (OR, 2.6; 95% CI, 1.4-4.6) and nearly significantly associated in women (OR, 1.8; 95% CI, 0.9-3.6). There were no material associations between surgery and LRT in patients with malignant tumors of sex-specific organs or the head and neck area. The present study showed a positive relationship between surgery and LRT in Japanese men and women with malignant tumors. The association was stronger in elderly patients. As for tumor site, surgery was most strongly associated with an increased risk of LRT in patients with malignant tumors of the digestive organs.

Adult↗

Temporal levels and reality testing.

Psychoanalytic practice has tacitly assumed the existence of an absolute and objective temporal matrix in which physical, biological and psychological processes take place and to which the subjective time of the patient in therapy gets gradually attuned. But psychoanalytic thought does not demand an ontology of absolute frameworks independent of man but only an epistemology in which several visions of reality are traditional. This paper reformulates the concept of time so as to accommodate three demands which appear to be mutually exclusive. The new concept of time (1) eliminates the need for assuming that it is a feature of the world independent of man, (2) retains the advantages of the heuristic assumption that, to first approximation, there does exist an objective passage of time and (3) does not contradict the teachings of other sciences about time. Careful attention to the feeling of the uncanny as it relates to time, together with considerations of the development of the sense of time suggests that our conscious evaluation of noetic time is directed and weighted by unconscious, archaic modes of time perception. These phylogenetically old forms of the sense of reality determine the temporal character of the unconscious. The dynamics of psychic energy invested in the various levels of time seems to determine the rates at which time is experienced as passing. The feeling that time passes at right rate probably corresponds to such combination of perceived causations and temporalities which do not threaten the integrity of the ego. If, because of internal or external danger or physiological dysfunction that balance changes, so does the sense of reality and with it, the affective texture of experienced time. Judged from this perspective, the reliability of reality testing is a measure of the degree to which the patient is able to accommodate the archaic reality of primitive causations and temporalities, lodged in his fantasy, memory and dreams, and integrate them with the ambiguities of human freedom.

Dreams↗