Reality Testing and Cognitive Functioning

Psychosis, Personality Disorders and Neuroses

By: Henry Kellerman and Anthony Burry

When the ego boundary is violated, the reality testing does not remain viable. In addition, the cognitive integration of perception, thinking, and feeling does not remain fully integrated. Thus, any disturbance in the ego boundary or ego integrity raises the issue of impairment of the primary or secondary autonomous ego functions.

So far, how such boundary violations appear with respect to the primary and secondary ego functions, and the effects of such impairment in terms of diagnosis, mostly concerning psychosis, Psychosis, Personality Disorders and Neuroses.

The nature of reality testing and ego functioning was considered in connection with Hartmann’s concepts regarding cognitive organization. A hierarchical arrangement of five ego functions forms the basis for evaluating the patient’s cognitive efficiency and for considering diagnostic implications in broad terms.

The most basic cognitive function is the primary autonomous function of the ego, which governs essential reality contact and alignment of perception, thinking, and feeling. If this function is impaired, a frank psychotic process is definitely present and perception, thinking, and feeling are fragmented. Only highly distorted, disintegrated ego functioning is possible in either a mood or thought disorder where florid psychotic material is evident.

The secondary autonomous ego function is the capacity for directed thought. When this function is impaired, directed thought can be discerned, but interference occurs from emerging primitive impulses. This signals the possible process of decompensation and is also a chief component in schizophrenia in its ambulatory or incipient forms, as well as in severe borderline states.

At the level of the integrative function of the ego, there is intactness and adequate reality contact.

Regulation of energy, feelings, and anxiety, and the capacity to focus on the external demands of reality, are central questions. When this function is impaired, interference with constructive interpersonal relating and inefficiency and inhibitions in goal direction are consequences even though external goals and satisfying relationships are viewed as being important. Among patients with personality disorders and neurotic pathology, inner conflicts deflect energy from external ambitions to personal preoccupations, leading to underachievement in these diagnostic contexts.

In the synthetic function of the ego, reality contact also is unquestionably intact. When this function is impaired, however, the energy that can be used to deal with ambiguities, uncertainties, and inconsistencies in reality conditions is channeled into passive, compensatory fantasy rather than into active, assertive striving. In addition, activity that is instrumental toward goal achievement is significantly compromised when this function of the ego is impaired. Paralysis, dependency, rumination, passivity, irritability, and aggressive outbursts derive from impairment of this cognitive function with detrimental consequences on planning, judgment, and commitment.

The final and most sophisticated cognitive function is the adaptive function of the ego, which achieves prominence when all other functions are operating with relative intactness. This ego function governs the capacity for flexible problem solving, creative and inventive resources, originality, stability, and adaptive assimilation of unconscious fantasies enabling full realization of external goals and gratifying relationships.

In communicating the findings relevant to these cognitive functions, emphasis was placed on describing the test subject in specific, nontechnical terms of intactness or impairment of reality contact, regulation of anxiety and impulses, assimilation of fantasy, and assertive goal direction.

Primary and secondary autonomous ego functions that relate to cognitive organization and reality testing.

Primary Autonomous Ego Function. Impairment in this function is marked by:

• Gross perceptual distortions.
• Fragmentation among perception, thinking, and feeling, reflecting a diagnosis of psychosis.
• A breakthrough of primary process material.
• An impulse-dominated record along with compensatory ideational material.
• The presence of hallucinations and delusional material.
• Illogical thinking.
• Judgmental lapses, perceptual distortions, and highly idiosyncratic responses.
• Impaired intellectual functioning.

Diagnostic possibilities include overt psychosis such as depressive disorders or bipolar disorders with psychotic features or schizophrenia.

Secondary Autonomous Ego Function. Impairment in this function is marked by:

• Disturbances in directed thought; a constant threat of impulse breakthrough is present although reality testing may be strained and impaired but not deteriorated.
• The processes of decompensation and depersonalization experiences are apparent.
• The presence of primary process colors cognitive processes, including loss of control of direction of thought and a propensity for acting-out.
• The experience of anxiety may be reduced because of acting-out and/or an over-ideational style, apparent as a compensatory device to manage excessive impulses.
• In those persons with decompensation process, turmoil, disorganization, and anxiety may be seen.

Diagnostic possibilities include schizophrenia that is ambulatory, incipient psychosis, and borderline personality organization.

Reality testing and cognitive functioning: Personality disorders and neuroses.

Integrative Ego Function. Impairment in this function indicates the following:
• Reality contact is not in question.
• Pathological focus is on regulation of impulses and management of anxiety.
• Lability and acting-out are still possible; therefore, the psychologist needs to assess defensive controls over impulses.
• Goal directedness and interpersonal relating may be impaired because of energy deflected in service of regulating impulses and anxiety. Such impulses and inner concerns can be expressed through sexual preoccupations, compulsions, dependency needs, and fantasies.
• Underachievement can be seen. Fantasies are characterized by grandiosity and are compensatory. An intuitive approach rather than the ability to accumulate information can be observed.
• A magical approach to problem solving is used, and reduced instrumental activity is seen. Thus, there is a significant distinction between aspiration and achievement.
• An action-orientation or a passive approach may be utilized.
Diagnostic possibilities include hysteric, phobic, obsessional, and narcissistic dispositions.

• Non-psychosis has been established.

Synthetic Ego Function. Impairment in this function indicates the following:

• Ambiguity, passivity, and fantasy interfere with goal achievement.
• Frustration and aggressive functioning, along with increasing discrepancy between aspiration and achievement, are seen.
• Activity toward goals reflects interference.
• The capacity to deal with ambiguity and to utilize effort and energy in life is compromised.

Diagnostic possibilities include passive-aggressive and obsessional patterns.

Adaptive Ego Function. Achievement of this function indicates the following:

• Effective coping ability reflects adaptive behavior in school, at work, and in relationships.
• There is flexibility in problem solving, access to inner resources, and evenness in functioning.
• Sustained mastery can be seen.
• Anxiety is not translated into symptoms.

Basic Themes.

The ego function system is organized with respect to:
• Diagnosis: psychoses and non-psychoses.
• Intrapsychic Phenomena: regulation of impulses and management of anxiety.
• Interpersonal Activity: achievement of goals and management of relationships.

References

Henry Kellerman and Anthony Burry, Handbook of Psychodiagnostic Testing, Fourth Edition, 2007, Springer ScienceBusiness Media, LLC.

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Diagnostic Principles