Perversion: Pedro PrezAffect Garcaand et al.

Thought

Perversion: Affect and Thought

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Pedro Prez Garca

Foundation Jimnez Diaz

A. Tomayo Lacalle, M. L. Plumed Martin, and N. Briones del Dedo

Sociedad Espaola de Rorschach, Madrid, Spain

The word perversion traditionally was used as a qualifying adjective (perverse or pervert) to designate degenerate moral conduct, with reference mainly though not exclusively to sexuality. Etymologically, per-vertere indicates the action of changing qualitatively the state or order of things, disturbing or reversing them (Real Acadaemia Espaola, 1992). It always appears in association with offense, damage, deceit, malice, and the like (Casares, 1994). To avoid such judgmental connotations when referring to sexual perversions, the term deviation was introduced. However, the clinical concept of perversion includes more than merely a simple deviation or selection of a different route for arriving at the pleasure of normal sexuality. The CIE 10 uses instead of the word perversion the phrase disorders of sexual inclination. The DSM-IV, just as the DSM-III-R, classifies this type of conduct as paraphilias, which means literally diverted attraction (philia for attraction; para for diverted), and locates it in a chapter on Sexual and Gender Identity Disorders. Both diagnostic manuals include the customarily recognized forms of perversion, such as fetishism, masochism, and sadism. Sexual orientation, whether heterosexual or homosexual, is not considered a disorder but an associated circumstance. The use of the term paraphilia has two advantages. It underscores the importance in perversion of the desires for attraction and rejection, and it avoids much of the cultural stigma, although several
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of the descriptions still contain such adjectives as antisocial, immoral, excessive, and unnatural. More than two decades ago, Laplanche and Pontalis (1971, p. 285), in their Dictionary of Psychoanalysis, included homosexuality in a list of perversions and offered a psychoanalytic definition that closely resembles the DSM-IV description: deviation with respect to the normal sexual act. For many psychoanalysts the concept of perversion has continued to be regarded as equivalent to that of deviation from the sexual norm (e. g., Valls, 1995). However, the problem remains of not being able in many cases to establish a clear boundary between normal and pathological sexuality. For many others, with whom we are in agreement, the concept of perversion in its clinical psychoanalytic sense seems quite different from the earlier propositions, and what is required is less emphasis on diverted sexual conduct and more on the latent pathological meaning of such deviations. In large part, the current clinical meaning of the perversion concept has two aspects: (a) use as an adjective to characterize a symptoms of diverted sexuality, and (b) use as a noun to represent a mental organization involving severe latent disorders and underlying diverted sexual conduct. A clinical case can be studied and defined from different perspectives, such as description of the symptoms, delineation of the underlying structure, deviations from normative expectations, etiology, and the like. The DSM-IV and CIE 10 classify and describe deviant behavioral symptoms, but they do not address issues of etiology with respect either to inherent structural differences or deviations from normal. Many of the behaviors listed in describing perversions can also appear in neurotic individuals, in those with borderline organization, and in psychotic persons. For the most part they do not define with clarity the boundaries between various conditions within a structural diagnosis. Our interest is in describing an integrated diagnostic system in which descriptions of behavior are related to the psychic structure of the individual and his or her psychodynamic motivations. For this reason, and despite its negative cultural connotations, we prefer to use in this presentation the psychoanalytic term perversion in its contemporary clinical sense, in which emphasis is placed not so much on external symptoms, but rather on underlying structural and dynamic components relating to narcissism, splitting, and aggression as the fundamental etiological basis of the manifest symptoms in the behavior. Thus, as stated by McDougall (1987),
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Pedro Prez Garca et al. Perverse sexuality is no more than one of the manifestations of a complex state . . . It is not a simple deviation in the path toward sexual satisfaction, but rather a complex organization that must satisfy multiple needs, thus giving this neosexuality a particularly compulsive characterological dimension. . . What is the significance of sexual acts in which anxiety and suffering are rarely absent? (p. 237).

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Freud (1905) himself employed perversions initially as an adjectives, referring to them as normal and universal aspects of infantile sexuality. He nevertheless indicated the following in his analysis of the Dora case (Freud, 1905):
Perversions are not degeneracies in the pathetic sense of the word. They are contained within the indifferent sexual disposition of the child, the direction of which toward higher goals is destined to provide the motivating force behind a good number of our cultural achievements. Accordingly, whenever someone is called perverse, it can be said that this exemplifies a situation of developmental inhibition. The psychoneuroses are thus the negative of the perversions (Fragment of an analysis of a case of hysteria (p. 45).

Freud subsequently discovered and described serious contradictions in using this term and latent disorders associated with the conversion of perversion into a sever clinical problem. This resulted in progressively restricting the clinical use of the term, and it was not until much later that he finally used it in a substantive sense. By asserting that Perversion clearly approximates psychosis, he put in perspective the importance of narcissism, defects in the superego and the identificatory process, the relational disorders, and the paradoxical splitting of the ego (Freud, 1905, 1910, 1914, 1924, 1927, 1940). Contributions provided by different psychoanalytic schools have made it possible to demarcate with greater precision the differential diagnosis between normality and pathology with respect to the perversions and the psychodynamic processes the involve. In descriptive terms, sexual perversions are characterized by compulsive behaviors that are fixed, repetitious, and obligatory and by rituals that are repeated over and over as necessary means of obtaining sexual gratification. However, in clinical practice it is easy to observe how, behind this obligatory ritualization, patients do not all present the same underlying dynamics or the same structure of defense mechanisms. In some, primitive systems of defense predominate that are similar to the limited organization of borderline or psychotic persons. In others, the perverse symptoms coexist with neurotic structures and defenses involving pathology that is less serious and more amenable to psychoanalytic treatment. This can be said equally well for masculine and for feminine homosexuality. Currently, agree165

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ment appears to have been reached that homosexuality and heterosexuality do not exist entirely distinct from each other; instead there is a broad spectrum of possibilities cutting across these sexual options. The essential ingredient of perversions is not the nature of the rituals or the eccentric or atypical actions, but the degree of pathology that lies under the mask of these behaviors ink the organization of the ego, in the developmental level of object relationships, in the formation of the superego, in the narcissistic disturbances, and in the predominance of aggression over adaptive affective connections. Without doubt, the origin of perversions has in the end to be sought, as Freud indicates, in the core of normal infantile sexuality, but it is equally certain that many environmental factors also shape the organization and affective development of each individual person. The affects constitute the motivational energy of behavior (Piaget, 1978, p. 156). They are, therefore, complex intrapsychic structures, not simple systems of discharge, that include cognitive aspects (good-bad; pleasure-pain) and modalities of relationships between people and their object representations. They are conditioned by early relationships and they in turn condition cognitive systems and interpersonal relationships; they are inseparable from cognitive-perceptual systems, but they can operate in dissociation and in parallel to them. This observation of Piaget coincides fully with a clinical fact observed in perversion, namely the coexistence of two parallel and split systems in ego functioning, one sufficiently adaptive and the other seriously disordered to the point of psychosis, as is verified in the results of the sample studied here. A half century ago, Klein (1946) and Winnicot (1953) indicated that perversion in adults constitutes a defense against paranoid and depressive anxiety of psychotic proportion, derived from early relationship and the mother-father-child interaction. Chaseguet-Smirgel (1979, 1985) and McDougall (1987) stress regression to anal fixations in perversion; subjects use these defenses for simultaneous denial and recognition (simultaneous due to ego splitting) of sexual differences. Perversion, says Kaplan (1994, pp. 2022), is an unconscious psychological strategy intended to gain mastery over excessively stimulating or humiliating childhood events that the subject now cannot or does not want to remember. These are masked by the rituals of crazy sex and a challenge to moral codes, and the subject exerts considerable control over these devastating emotional states by a felling of having triumphed over them. In our clinical experience we have observed that in Rorschach protocols there is an elevated frequency of white space answers (S) in chronic
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Pedro Prez Garca et al.

patients with depressive narcissistic symptoms. We believe that these problems with narcissism that are neither elaborated nor denied have originated in serious defects in the excitation barrier and in self-esteem; they serve as the dynamic base for most sado-masochistic relationships and defensive hostile attitudes (oppositionalism, negativism, arbitrary anger, and the like) usually associated with these answers. In the Rorschach there are two types of clearly differentiated S answers. One type of S responses appear occasionally and are well articulated and formally integrated (DQ+; FQ+/o); these are answers in which the subjects elaborations and mental process identify neurotic levels of adaptation and involve symbolic content. The other type of S responses are maladaptive, dissociated, and arbitrary (DQv, v/+; FQ; high S%), involve aggressive, violent, and destructive contents and are distributed throughout the protocol; these responses ref lect more severe psychopathology and primitive manic defenses, such as are seen in narcissistic, borderline, and psychotic character disorder. Our dynamic hypothesis is that, in cases of more serious psychopathology, white space in the absence of an object identifies intense excitement and anxiety related to a sense of dissolution and loss of being. Lacking resources to elaborate the white space in a symbolic manner, the subject finds it necessary to give direct and arbitrary expression to hostility and aggression. Distorted perceptions (FQ) and maniacal management of violence would serve as defenses against sorrow, as an excitation covering the distress, and as a narcissistic self-affirmation through the feeling of victory and control over the absent or bad object. In some of these answers, it can be clearly appreciated how reversal of the figure-ground perspective allows the subject to reverse the sense of the object relations situation. By aggression and depreciation of the object, the subject recreates reality, transforming it in maniacal form to fit the measure of his or her own desires. The sample studied in this work gave numerous S responses involving arbitrary and highly destructive contents. From the perspective of early relationships, Kernberg (1994, p. 42) indicates that when the affective experiences of the early years are negative, hatred gives birth to subsequent psychopathological conditions and sever personality disorders such as perversions and functional psychoses. The hatred can be justified and not pathological when it concerns the elimination of a real and objective danger. However, it can be constituted as a chronic characterological predisposition that is always found at the core of what Kernberg (1994) calls malicious narcissism and other authors call perverse transference (Meltzer, 1977). Intoler167

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Perversion: Affect and Thought

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ance for communication with the object, arrogance, reversal of perspective in comprehending meanings, predominance of sadism that can lead to dangerous aggressive conduct, self-glorification, and serious pathology of the superego tend to be their characteristics. Only the most serious cases of perversion appear in this type of patient with malicious narcissism. It can be associated just as much with heterosexuality as with homosexuality or promiscuity. To summarize, the term perversion can in a broad sense be associated with deviations from normative sexual conduct. Strictly speaking, however, the clinical term perversion should be applied only to those cases in which (a) deviations of sexual conduct are associated with severe and stable psychopathology involving borderline or psychotic structures, and (b) there is a specific modality of splitting of the ego and of object relationships. This splitting permits the coexistence of two nonhomogeneous ways of thinking: with respect to neurotic features, repression makes possible adequate contact with reality, symbolic creativity, adaptation, and efficiency; by contrast, denial of reality results in structural defects of the ego and superego becoming evident (confusion between good and bad, self and object, male and female, being and not being, etc.) And presenting as serious disorders of thinking and anxiety that approximate psychoses. In this near psychotic state, thoughts and feelings cannot be processes symbolically but instead are recurrently represented by perverse behavior.

Sample and Method

The sample used in this study comprised 18 male and 7 female subjects with a mean age of 29.7 (SD = 8.0). Of these, 15 were or had been married. All of them came for an evaluation to the General Hospital of Madrid with symptoms of anxiety and depression. Criteria for inclusion were (a) age 20- to 50-years-old, (b) no income or medications being received for psychiatric reasons, (c) no manifest psychosis prior to the evaluation, (d) symptoms having evolved for over a 1-year period, and (e) DSM-IV diagnosis of Sexual and Gender Identity Disorders. These disorders appeared in their biographical data in a manner that was overt and recognized by them.
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All subjects were given the Rorschach test according to the procedures of Exners Comprehensive System. Appropriate calculations were made for the summary scores, relationships, and indices in this system.

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Results
Affect These are subjects who have recourse to motives of depression and anxiety, but they do not recognize connections between these affects and variations in their behavior. Nevertheless, analysis of the Depression Index (DEPI) indicated surprisingly that neither DEPI nor customary markers of anxiety were significantly present in this sample. The right side of the eb (Sum Shading) was the same as is found in non-patients, but texture answers were notably infrequent. The left side of the eb (Fm + m) was low, although m was a little elevated, but not at a clinically significant level. These results identify a striking contrast between the conduct of these subjects and this measure of their emotional states. They have little awareness of need states and process their emotional problems by a different route from mentalization, giving very low values of EA and M. The prevalent EB style in these patients was ambient, which at 52% of the sample is markedly higher than the 20% of ambitents found by Exner in his normative population of non-patients. The inconsistency of these subjects and their ambiguity in identity formation correlates directly with the results for the CDI index, which was significantly high, and with an elevated risk of suicidal conduct shown by the S-CON. This was associated as well with structural indicators of immaturity, including a very low EA, es > EA, and a minus AdjD score. Taken together, these data identify subjects who have not achieved an adequate level of maturity and find themselves with few organized resources for confronting and resolving adverse and frustrating events in everyday life, or for maintaining stable interpersonal relationships. In this regard, their Affective Ratio was very low, and they showed little reactivity to the affective demands of others. On the other hand in the affective sphere, the number of S answers was strikingly high and included a significant S-%. On comparing AG and S, we observed that the number of AG responses did not differ from nor169

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mative expectations, despite the very high frequency of S. Hence, it appears that anger and hostility are expressed in an arbitrary manner, not as a reaction to a threatening real object (AG) but as a result of projection onto external objects of what was experienced at another time (i. e., internal objects) as frustrating and threatening (the frequent S). Responses of this type are equivalent to the hypomanic defense of transformation of reality. By inverting the figure-ground perspective, away from aggression and from the threatening internal object, reality is re-created according to the persons desires in relationship to the object. Others are treated as the persons themselves were treated. Traumatic experience from a previous stage is projected into a current aggressive linkage. The hostility is utilized as a system of arousal and narcissistic self-affirmation. The use of color was very unusual and poorly modulated. These subjects gave few chromatic color answers, and those that appeared gave scant consideration to form and included a high frequency of Pure C responses. Hardly any emotionally complex or blended responses were given by these subjects. Among other striking results, the Egocentricity Index was interesting to examine. In general, the Egocentricity Index was low in these records. However, this was due to the number of pair answers (2) being very low, whereas ref lection answers (Fr + rF) were significantly frequent. The desire of these subjects to be unique was shown in their giving very few Popular answers, which would interfere with their adaptability to what is conventional and prevented them from displaying much of their own needs states, as indicated by low FM and T scores. The excessive self-centeredness of these subjects, the overestimation of their personal value, and the priority they give to their own points of view leads them to pay little attention to other people and the external world. Instead, by self-glorification and by imposing their needs on others, they seek to defend themselves against their ego weakness and states of defenselessness (as shown in their elevated CDI). Their inf lated selfimage correlates with the poor quality of their interpersonal relatedness and affective responsiveness, and there was also in their responses a low frequency of human contents with apparent displacement to (A), An, Bl, Sx, and Xy contents. This last finding suggests to us an increase of narcissistic libido at the expense of object libido. The depressive features to which they have recourse therefore have a narcissistic component that can lead to psychosomatic symptoms or acting out behavior, including suicide.
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Despite these indications of distortion in their modes of contact at a deeper level, their Rorschachs did not show an elevated Isolation Index, which again calls our attention to the contradictions between their precarious underlying narcissistic structure and their acceptable level of manifest social activity.
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Thought The ambiequal coping style of these subjects contributes to diffuse thinking and a lack of formal limits (elevated DQv, frequent idiographic content). Also of note, were low values of Zf, indicating difficulties in integration. We were struck further by a high frequency of Special Scores that paralleled the severe form quality distortions of these subjects. The number of good Form Quality responses (FQ +, FQo) was low, and the number of minus Form Quality responses (FQ) was very high and always associated with emotional interferences that made these subjects very vulnerable. These data are shown in Table 1, which indicates in addition that 76% of the sample showed a predominance of unusual or inaccurate form perception. Therefore, the correct meaning and function of objects are distorted and disorganized by massive projection.
Table 1. Frequency of schizophrenia index variables in 25 subjects with sexual and gender identity disorders. Variable X+% < 0.61 and S% < 0.41 or X+% < 0.50 X% > 0.29 FQ > FQu or FQ > (FQo + FQ+) Lv 2 Special Sc > 1 and FABCOM2 > 0 Sum6 Special Sc > 6 or WSUM6 > 17 M > 1 or X% > 0.40 Frequency 56% 56% 76% 20% 36% 44%

Nevertheless, we did not find unusual values in the a:p, Ma:Mp, and 2AB + Art + Ay indices as might appear in borderline patients. Nor did these subjects give frequent CONFAB answers, which according to the criteria proposed by Blatt and Auerbach (1987) differentiates them from anaclitic borderline patients.
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On the other hand, the subjects in this study showed frequent recourse to arbitrary and over-ideational thinking, with high values for FABCOM and INCOM. They do not recognize the defects in their causal thinking, and they tend to create imaginary relationships between objects according to their needs for wish-fulfillment. Also, in the sample a high frequency of FABCOM2 and INCOM2 responses corroborated serious thinking disorder that was a consequence and not a cause of these subjects distorted objection relationships. Their difficulty in differentiating internal-external boundaries causes them to confuse realistic perceptions with their fantasies. This frequent arbitrariness in their ways of thinking, which closely approximates frank psychosis, led us to examine each case, analyzing other diagnostic elements, such as their history and other test findings, to verify that they had been able to maintain adequate contact with reality without ever decompensating. We found that these subjects were able to maintain critical awareness of their inappropriate responses and peculiar associations in their Rorschach responses. Thus a part of their ego retains a stable capacity for critical judgment of reality, while another part seems submerged in a psychotic fashion. Thus these subjects manifest the peculiar splitting of the ego identified by Freud in this type of patient. The results obtained from the sample in this study coincide with those obtained by Blatt and Auerbach (1987) from borderline schizophrenics, whom they describe as maintaining a precarious balance in which they closely approach but never reach a state of decompensation.

Conclusions
Individually, each of the subjects in our sample maintained adequate social adaptability and adjustment to reality. As a group, however, they evidenced severe disorders that place them close to the usual criteria for borderline (Kernberg, 1979, 1991, 1994; Lerner, 1984; Exner, 1986). They diverge from the criteria proposed by Blatt and Auerbach (1987) for anaclitic borderlines, and they appear more like the introjective borderlines, with severe ideational distortions, especially because of their frequent FABCOM and INCOM (both Level 1 and Level 2) responses. We believe that, as a group, they closely approximate a picture of psychotic distortion in the structure of their thought. However, their para172

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doxical ability to maintain a precarious but adequate adaptation to external reality may be their specific characteristic. These subjects preserve the appearance of neurotics, such as outwardly well adapted personality and achievements and successes in their social and occupational life. Nevertheless, the specific nature of their ego split and their object relationships frequently leads to massive projection as a defense against anxiety that in turn causes prevailing depressive-narcissistic features and archaic psychotic defenses against their distress. The aspects of these subjects relationships that qualify as deviant or peculiar sexual behavior are important manifestations of their pathology (Merceron, Hussain, & Rossel, 1984). However, we think that the are neither fundamental nor a basic and essential nucleus of perversion, but rather that they result from a structural defect of the ego, involving serious disorders in thinking, that closely approximates psychosis. This specific structural modality can contribute to misleading diagnoses and lead to notable therapeutic difficulties if analysis of their affective relationships is not accompanied by attention to repairing their defective mental apparatus.

References
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association. Baranger, W., Goldstein, N., et al. (1980). About the perverse structure. Revista de Psiconlisis, 37, 653670. Blatt, S. J., & Auerbach, J. S. (1987). Tres tipos de pacientes borderline y sus respuestas diferenciales a test psicolgicos. Rev de la Sociedad Espaola de Rorschach y Mtodos Proyectivos, 1, 2738. Casares, J. (1994). Diccionario ideolgico de la lengua Espaola (2nd ed.). Barcelona: Gustavo Gili. Chaseguet-Smirgel (1979). Los caminos del anti-Edipo. Buenos Aires: Paidos. Chaseguet-Smirgel (1986). Sexuality and mind: The role of the father and the mother in the psyche. New York: New York University Press. Exner, J. (1986). Algunos datos del Rorschach comparando esquizofrnicos con trastornos borderline y esqquizotpicos de la personalidad. Revista de la Soc. Espaola de Rorschach y Mtodos Proyectivos, 1, 926. Exner, J. (1994). El Rorschach: Un sistema comprehensivo, Vol. 1 (3rd ed.). Madrid: Psimtica.

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Perversion: Affect and Thought Exner, J., & Sendin, C. (1995). Manual de interpretacin del Rorschach. Para es Sistema Comphrensivo. Madrid: Psimtico. Freud, S. (1905). Tres ensayos sobre una teoria sexual. Obras Completas. Buenos Aires: Amorrotu. Freud, S. (1910). Un recuerdo infantil de Leonardo da Vinci. Obras Completas. Buenos Aires: Amorrotu. Freud, S. (1914). Introduccin al narcisismo. Obras Completas. Buenos Aires: Amorrotu. Freud, S. (1921). Psicologa de las masas y anlisis del yo. Obras Completas. Buenos Aires: Amorrotu. Freud, S. (1924). El problema econmico del masoquismo. Obras Completas. Buenos Aires: Amorrotu. Freud, S. (1927). Fetichismo. Obras Completas. Buenos Aires: Amorrotu. Freud, S. (1940). La escisin del yo en al proceso defensivo. Obras Completas. Buenos Aires: Amorrotu. Kaplan, L. J. (1994). Perversiones femeninas. Buenos Aires: Paidos. Kernberg O. F. (1979). Desrdenes fronterizos y narcisismo patolgico. Buenes Aires: Paidos. Kernberg, O. F. (1991). Sadomasochism, sexual excitement, and perversion. Journal of the American Psychoanalytic Association, 39, 333362. Kernberg, O. F. (1994). La agresin y las perversiones en los desrdenes de la personalidad. Buenos Aires: Paidos. Klein, M. (1946). Notas sobre algunos mecanismos esquizoides. Desarrollos del psicoanlisis (3rd ed., pp. 252277). Buenos Aires: Horm. Kwawer, J. S. (1980). Primitive interpersonal modes, borderline phenomena, and Rorschach content. In J. S. Kwawer, H. D. Lerner, P. M. Lerner, & A. Sugarman (Eds.), Borderline phenomena and the Rorschach test (pp. 89106). New York: International Universities Press. Laplanche, J., & Pontalis, J. B. (1971). Diccionario de psicoanlisis. Barcelona: Labor. Lerner, P., & Lerner H. (1980). Rorschach assessment of primitive defenses in borderline personality structure. In J. S. Kwawer, H. D. Lerner, P. M. Lerner, & A. Sugarman (Eds.), Borderline phenomena and the Rorschach test (pp. 257274). New York: International Universities Press. McDougall, J. (1987). Treatos de la mente. Madrid: Tecnipublicaciones. Meltzer, D. (1977). Los estados sexuales de la mente. Buenos Aires: Kargieman. Merceron, C., Husain, O., & Rossel, F. (1988). A specific category of borderline conditions: Perverse personality organizations and the Rorschach. In H. Lerner & P. Lerner (Eds.), Primitive mental states and the Rorschach (pp. 377402). New York: International Universities Press. Piaget, J. (1978). Psicologa del nio. Madrid: Morata. Real Academia Espaola (1992). Diccionario de la lengua Espaola (XXI ed.). Madrid: Ed Espasa Calpe. Valls, J. L. (1995). Diccionario Freudiano. Madrid: Julian Ybenes.

This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

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Pedro Prez Garca et al. Winnicott, D. W. (1958). Transitional objects and transitional phenomena. In Collected papers (pp. 229242). New York: Basic Books. Winnicott, D. W. (1993). Los procesos de maduracin y el ambiente facilitador. Buenos Aires: Paidos.

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Resumen
El concepto de perversin, tal y como es usado corrientemente en la clnica, parece tener dos significados. Uno de ellos involucra su uso como adjetivo para indicar un sntoma de sexualidad desviada. El otro uso designa con un substantivo una organizacin mental severamente perturbada la cual se oculta o permanece latente bajo la conducta sexual desviada. El CIE-10 utiliza en lugar de la palabra perversin la frase trastornos de la inclinacin sexual. El DSM-IV clasifica este tipo de conducta como parafilias, y lo ubica entre los trastornos sexuales y de la identidad del gnero. Ambos manuales de diagnstico incluyen las formas habitualmente reconocidas de perversin, tales como el fetichismo, el masoquismo y el sadismo. La orientacin sexual, ya sea heterosexual u homosexual, no es considerada un trastorno sino una circunstancia asociada. Para muchos psicoanalistas el concepto de perversin ha continuado siendo considerado como equivalente al de desviacin de la norma sexual. Permanece, sin embargo, el problema de la imposibilidad de establecer en muchos casos una delimitacin clara entre sexualidad normal y patolgica. Un caso clnico puede ser estudiado y definido desde diferentes perspectivas, tales como la descripcin de los sntomas, el delineamiento de desviaciones estructurales subyacentes respecto a las expectativas normativas, la etiologa, y as sucesivamente. El CIE-10 y el DSM-IV clasifican y describen sntomas conductuales desviantes, pero no aclaran cuestiones de etiologa con respecto a diferencias estructurales inherentes o desviaciones de la normalidad. Muchas de las conductas enumeradas al describir perversiones pueden presentarse en individuos neurticos, sujetos con una organizacin borderline de la personalidad, o personas psicticas. Nuestro inters consiste en disear un sistema diagnstico integrado en el cual las descripciones de conducta se relacionen con la estructura psquica del individuo y sus motivaciones psicodinmicas. En trminos descriptivos, las perversiones sexuales se caracterizan por comportamientos compulsivos que son fijos, repetitivos y obligatorios, y por
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rituales que son repetidos una y otra vez como el medio necesario para obtener la gratificacin sexual. En la prctica clnica es sin embargo fcil observar cmo, trs la ritualizacin obligada, los pacientes no presentan la misma dinmica subyacente ni la misma estructura en sus mecanismos de defensa. En algunas instancias los sntomas parecen coexistir con defensas neurticas que constituyen psicopatologa relativamente leve y las personas son muy receptivas a la terapia. En otros casos, incluyendo la mayora de los pacientes que presentan este tipo de comportamiento sexual desviante, predominan los sistemas primitivos de defensa que son similares a la organizacin psictica o borderline. En resumen, el trmino perversin puede ser asociado, en sentido amplio, con las desviaciones del comportamiento sexual normativo. Estas pueden coexistir con condiciones que van desde variacin normal o neurosis hasta psicopatologa severa y estable. Sin embargo, hablando estrictamente, el trmino clnico perversin debera aplicarse solamente a aquellos casos en los cuales: (a) las desviaciones en la conducta sexual estn asociadas con psicopatologa severa y estable que involucra estructuras borderline o psicticas, y (b) en las cuales hay una disociacin especfica del yo y de las relaciones objetales. Tal es el caso con los resultados obtenidos en la muestra de sujetos estudiada en nuestra investigacin. Se utiliz el mtodo Rorschach siguiendo el Sistema Comprehensivo de Exner con 25 sujetos (18 hombres y 7 mujeres) con una edad promedio de 29.7 l, los cuales asistieron a la clnica ambulatoria de un hospital general en Madrid con quejas de ansiedad y depresin. Los criterios de seleccin para la inclusin en el estudio fueron: (a) duracin de los sntomas por ms de un ao, (b) diagnstico clnico de Trastorno Sexual y de la Identidad de Gnero, (c) ausencia de psicosis manifiesta, de tratamiento con medicacin psicotrpica, o de ingresos econmicos recibidos por motivos psiquitricos antes de la evaluacin. Los resultados obtenidos condujeron a concluir que lo ms importante en la conducta sexual perversa o los trastornos de la identidad sexual no es la fachada que presenta sntomas de desviacin sexual, sino, en su lugar, la presencia de deficiencias severas subyacentes en la estructura de personalidad bsica, especialmente en la organizacin del pensamiento y en las relaciones objetales. Esta organizacin mental hace posible la coexistencia de elementos neurticos, borderline y psicticos. Sin embargo, como grupo, parecen ms personas psicticas que de los otros tipos, y son distinguibles de los psicticos en que preservan, por medio de una disociacin del yo, un sistema precario pero adecuado de adaptacin a la realidad externa.
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Pedro Prez Garca et al.

Rsum
Le terme de perversion semble aujourdhui tre employ en clinique dans deux sens diffrents: dune part comme un adjectif qualifiant une dviation sexuelle, dautre part comme un substantif renvoyant une organisation mentale gravement perturbe, latente ou masque derrire une conduite sexuelle dviante. La CIM 10 utilise, pour dsigner la perversion, une priphrase: troubles de linclination sexuelle. Le DSM-IV classe ce type de conduite comme paraphilie dans la rubrique des troubles didentit sexuelle et de genre. Les deux manuels diagnostiques incluent les formes de perversion habituellement reconnues, telles que le ftichisme, le masochisme et le sadisme. Lorientation sexuelle, quelle soit htrosexuelle ou homosexuelle, est considre non pas comme un trouble mais comme une circonstance associe. Pour beaucoup de psychanalystes, le concept de perversion continue tre considr comme un quivalent de dviation par rapport une norme sexuelle. Toutefois, il arrive souvent quon ne puisse tablir la frontire entre une sexualit normale et pathologique. On peut tudier un cas clinique et le dfinir selon diffrents points de vue, tels que description des symptmes, mise en vidence des dviations structurales sous-jacentes par rapport aux attentes normatives, tiologie etc. La CIM 10 et le DSM-IV classent et dcrivent les symptmes du comportement dviant mais ils ne touchent pas la question de ltiologie en rfrence aux diffrences structurales inhrentes ou aux dviations par rapport au normal. Plusieurs des comportements incluent dans la liste peuvent aussi apparatre chez des individus nvrotiques, ceux lorganisation limite de la personnalit, et chez des psychotiques. Notre propos est dlaborer un systme diagnostic intgr dans lequel les descriptions de comportement seraient lis la structure psychique de lindividu et ses motivations psychodynamiques. En termes descriptifs, les perversions sexuelles sont caractrises par des comportements compulsifs qui sont fixs, rptitifs, et contraignants ainsi que par des rituels qui sont inlassablement rpts comme des moyens ncessaires lobtention de la gratification sexuelle. Toutefois, dans la pratique clinique, on observe aisment que, au-del de la ritualisation contraignante, les patients ne prsentent pas tous la mme dynamique sousjacente ou la mme structure dans les mcanismes de dfense. Parfois, les symptmes semblent coexister avec des dfenses nvrotiques de porte psychopathologique relativement faible, et tout fait accessibles
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Perversion: Affect and Thought

This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

la thrapie. Dautres fois, et chez la majorit des patients qui prsentent ce type de conduite sexuelle dviante, les systmes de dfense primitifs sont prdominants, similaires ceux quon trouve dans les organisations limites ou psychotiques. Pour rsumer, le terme perversion peut,au sens large, dsigner des dviations par rapport aux conduites sexuelles normatives. Ces dviations coexistent avec des tats qui vont des variations de la normale la nvrose, la psychopathologie grave et chronique. Au sens strict, toutefois, le terme perversion ne devrait sappliquer qu ces cas o (a) les dviations sexuelles sont associes une psychopathologie grave et installe des structures limite ou psychotique et (b) o existe un clivage du moi et des relations dobjet spcifique. Cest le cas des sujets de notre tude. La mthode du Rorschach en Systme Intgr (Exner) fut applique 25 sujets (18 hommes et 7 femmes) avec une moyenne dge de 29,7 ans, qui avaient consult dans un hpital gnral de Madrid pour symptmes anxieux et dpressifs. Les critres dinclusion ont t (a) dure des symptmes suprieure un an, (b) diagnostic clinique de Trouble de lIdentit Sexuelle et de Genre, et (c) absence de signes manifestes de psychose, de traitement psychotrope, ou de pension dinvalidit pour raisons psychiatriques au moment de la consultation. Les rsultats nous ont conduit conclure que llment le plus important dans les conduites sexuelles perverses ou les troubles de lidentit sexuelle nest pas la faade qui prsente les symptmes de dviation sexuelle, mais bien des dfauts graves dans la structure de la personnalit, en particulier dans lorganisation de la pense et des relations dobjet. Ce type dorganisation mentale rend possible la coexistence ventuelle dlments nvrotiques, limites et psychotiques. Toutefois, dans son ensemble, ce groupe ressemble plus des psychotiques que dans les autres types de perversion, mais ils sen distinguent nanmoins par le maintien, grce au clivage du moi, dun systme adquat, quoique prcaire, dadaptation la ralit extrieure.

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