Better Diagnoses and Case Formulations with the Psychodynamic Diagnostic Manual 3 hour C.E. Course F

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Better Diagnoses and Case Formulations with the
Psychodynamic Diagnostic Manual3 hour C.E.
Course Focusing on the Adult P Axis of the
PDMPresented by Robert M. Gordon, Ph.D. ABPP in
Clinical Psychology and Psychoanalysis in
Psychology

• Understand the psychodynamic assumptions of
  personality.
  
• Learn about the first complete psychological
  nosology that goes deeper than just symptoms, and
  includes levels of personality organization,
  personality patterns, and mental functioning.
• Learn to better understand your patients
  personality for more effective psychological
  interventions.
  

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My Eclectic Background

• Undergrad focus on science and epistemology
• Temples psychology department heavily influenced
  by Wolpe and Lazarus. It was anti-psychoanalytic.
  
• I studied with Rosnow and Lana the artifacts and
  assumptions in research (applied epistemology).
  
• After my Ph.D., I studied with Albert Ellis
  (Rational Emotive Therapy), Salvador Manuchin,
  Jim Framo, and Peggy Papp (family therapy).
  
• For a while my primary identification was,
  family therapist. (AFTA, AAMFT Supervisor)
  
• Eventually, I became convinced that projections
  and transferences were the main issues in couples
  work and went on to study object relations.
  (Institute training and my psychoanalysis)

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A Quick Review of Psychodynamic

• The systematized study and theory of the
  psychological forces that underlie human
  behavior, emphasizing the interplay between
  unconscious and conscious motivation and the
  functional significance of emotion definition by
  WebMD
• The PDM uses the terms psychoanalytic and
  psychodynamic more or less interchangeably.

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Not historical, Not developmental, Learned

Historical , Structural, Gestalt, Developmental
Schools of psychology originated with
philosophical assumptions of the mind.
Psychoanalysis assumes the evolution of brain
structures that are often in conflict, and that
child rearing and temperament add to or mitigate
these conflicts. Behaviorism grew in opposition
to the idea of an unobservable mind (as a defense
against insight). Gordon, R.M.  (2008a) An Expert
Look at Love, Intimacy and Personal Growth.
Second edition. (Chapter 9 Integrating Theories)
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There is much current misunderstanding about
contemporary psychodynamic theory

• As a theory of the mind
• As a theory of psychopathology
• As a theory of social and group phenomena
• As the basis for psychotherapeutic treatments
• Adapted from the power point presentation
  Enduring Significance of Psychoanalytic Theory
  and Practice," a powerpoint presentation created
  by Greg Lowder, in collaboration with Nancy
  McWilliams, James Hansell, and the Board of
  Directors of Division 39.

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Psychodynamic View of Consciousness
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Unconscious motivation

• Consciousness is a recent development
  superimposed on an information processing system
  that worked well for millions of years
  
• Our ancestors successfully navigated complicated
  situations and relationships using resources and
  abilities other than individual consciousness
  
• Our culture highly values consciousness and free
  will and generally defends against acknowledging
  a dynamic unconscious

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Adams, Wright, Lohr (1996) Homophobic men
reported low levels of sexual arousal to
depictions of homosexual intercourse, but
physiological measures indicated higher degree of
arousal than non-homophobic men. Morokoff
(1985)Women highest on indexes of sex guilt
showed more physiological arousal to erotic
pictures, however, they denied being aroused.
Reaction Formation Research- Indications of
Unconscious Defenses
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Experimental Test of Unconscious
Transference

• Study subjects are subliminally shown aggressive
  (A) or positive (B) stimuli
  
• and then rate a neutral stimulus (C)
• Subjects shown panel A subsequently rated the boy
  in panel C more negatively (Eagle, 1959)
  

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Neuro-psychoanalysis

• A new discipline called neuro-psychoanalysis
  is completing Freud's project, made up of many of
  the world's most impressive neuroscientists, such
  as Nobel Prize-winner Eric Kandel, who stated,
  Much of what we do is unconscious. That is a
  revelation that largely comes from Freud.

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Eric Kandel

• My overriding concern is to bridge the gap
  between biology and psychoanalysis create what I
  call a new science of the mind, which would build
  on the insights of Freud
• His insights about instincts, about unconscious
  mental processes, were not only prescient, but
  also have held up very well that most mental
  life is unconscious is a profound idea that is
  obviously true.
• Rudnstsky, P.L. (2008) Nitty-Gritty Issues
  An Interview with Eric R. Kandel The American
  Psychoanalyst, 42,2, pp.6-7,15 and 16.

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Superego, Ego and Id as a First Step in
Understanding a Brain in Conflict

• The Amygdala (A) is an impulsive pleasure seeking
  structure.
  
• The Ventromedial prefrontal cortex (VMPC) also
  sends signals to the Striatum (S) with input from
  past experiences. If the associations are
  negative, the VMPC signals are inhibitory. The
  Striatum translates signals from the Amygdala and
  VMPC into body action.

S
VMPC A
Bechara, A., 2007. Decision-making, impulse
control and loss of willpower to resist drugs A
neurocognitive perspective. Nature Neuroscience
8(11)1458-1463.
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Emotions in mammals are all similar and evolved
for functional reasons. They may be affected by
thoughts, but they are not created by them.
Damasio, et al., 2002
Panksepp, J. (2003). Science, Oct 10th.
Herman Panksepp, 1979
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Bartels and Zeki used a fMRI to peer into the
brains of 17 people who had been madly in love
for an average of about two years. By comparing
the brains of these people as they looked at
loved ones and then as they looked at friends,
Bartels and Zeki produced what they believe are
the first pictures of the brain in love. Bartels
compared the brains of mothers looking at their
infants to those of lovers looking at their
significant others. Except for activity in the
hypothalamus--located at the base of the
brain--that seems to be linked to sexual arousal,
the intense devotion of a mother and a lover are
indistinguishable to an fMRI machine.
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Brain Injury Studies in Psychopathy

• A PET image of decrease in neural activity in
  the frontal area (upper part of the images) of
  the brain. This area of the brain is responsible
  for self-control, planning, judgment, and the
  balance of individual versus social needs.
  Patient (1A) sustained a closed head injury and
  developed a psychopathic personality. Figure 1B
  shows a normal brain in the same area.

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The influence of childhood experiences

• Psychoanalytic theory is a developmental model,
  which holds that the interaction of the childs
  innate temperament and relationship with
  parenting figures are significant in the
  formation of the adult character
• Especially in the last 30 years, research on
  attachment styles and early-life trauma have been
  looking at the influence of childhood experiences
  on later behavior and personality development

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Attachment Security in Infancy and Early
Adulthood A Twenty-Year Longitudinal
Study.Walters, E. Merrick., S. Treboux, D.
Crowell, J. and Albersheim, L. (2000), Child
Development.

• Researchers looked at relationship patterns in 50
  young adults who were studied 20 years earlier as
  infants.
  
• Overall, 72 of the adults received the same
  secure verses insecure attachment classification
  they had in infancy.
  

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Defensive Devaluation of Psychodynamic Theory

• The theory is intellectually challenging and
  complex compared to other psychological theories.
  
  
• The theory is emotionally challenging.
• It states that most of our personality is
  unconscious, and that the unconscious is
  irrational, peremptory and unbidden.
  
• (So lets deny that the messy unconscious
  exists!)
  

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"A Freudian slip is like saying one thing, but
meaning your mother.Examples of
Psychodynamically Motivated Slips

• The BL from Block? the unconscious fantasy
  
  
• http//www.metacafe.com/watch/1856/oops_a_slip/

Slips of the tongue. By Motley, Michael T. Scien
tific American. 1985 Sep Vol 253(3) 116-127
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Examples of Psychodynamically Motivated Slips

• The Co from Cop? the unconscious fantasy
• http//www.youtube.com/watch?voW0vhNRMFVQ

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Examples of Psychodynamically Motivated Slips

• The Tit from Title? the unconscious fantasy
  
  
• http//youtube.com/watch?v2VCWmHeTC_8featurerel
  ated
  

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Research Support

• Blatt, (2006), Norcross (2002), Wampold (2001)
  have concluded that the nature of the
  psychotherapeutic relationship, reflecting
  interconnected aspects of mind and brain
  operating together in an interpersonal context,
  predicts outcome more robustly than any specific
  treatment approach per se.
• Westen, Novotny, and Thompson-Brenner (2004) have
  presented evidence that treatments that focus on
  isolated symptoms or behaviors (rather than
  personality, emotional, and interpersonal
  patterns ) are not effective in sustaining even
  narrowly defined changes.
• A number of recent reviews (e.g., Fonagy's and
  Leichsenring 2006) demonstrate that in addition
  to alleviating symptoms, psychodynamically based
  therapeutic approaches improve overall emotional
  and social functioning.

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Empirical Support for Psychoanalytic Theory of
Conflict in the MMPI Hysteria Scale

• Dahlstrom, Welsh, and Dahlstrom (1972) stated
  that the items on the Hysteria scale seem
  mutually contradictory. They developed this scale
  on actual hysterics. It turns out to support
  Freuds theory of hysteria.
• The Hysteria scale has such seemingly unrelated
  issues such as
  
• somatic complaints,
• naiveté,
• denial of aggressive motives,
• unhappy home life
• and sexual conflicts.
• Scales derived from populations with functional
  psychopathology are likely to reflect the
  conflicts, symptoms and defenses within the
  scale. Therefore, these scales should not
  necessarily have high item consistency, but
  rather reflect the complex of dynamics typical of
  the psychopathology. (Gordon, R.M. (2006c) False
  Assumptions About Psychopathology, Hysteria and
  the MMPI-2 Restructured Clinical Scales.
  Psychological Reports, 98, 870-872.)

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Value of Insight

• 800 Psychologists ranked a list of 38 of the most
  beneficial things they got from their own
  psychotherapy. They listed first,
  Self-understanding.
• The results of the survey had symptom relief as
  halfway down the list of 38 benefits.
  
• Included in the survey were psychologists from
  all theoretical orientations (Behaviorists,
  Cognitive-Behaviorists, Psychoanalytic, etc.) .
  
• Pope, K. T., B.G. (1994). Therapists as patients
  A national survey of psychologists' experiences,
  problems, and beliefs. Professional Psychology
  Research Practice, 25(3), 247-258.
• Dattilio, F. M. (2003). To thine own self be
  true Comment. Behavior Therapist, 26(5),
  309-310. Dattillo felt that CBT therapists became
  desensitized to CBT so they went to psychodynamic
  therapists.

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Patients experiences of change in
cognitive-behavioral therapy and psychodynamic
therapy a qualitative comparative
study,Psychotherapy Research, 1-14 Nilsson,
T., Svensson, M., Sandell, R., Clinton, D.
(2007)

• Thirty-two patients who had terminated
  cognitive-behavioral therapy or psychodynamic
  therapy were interviewed about their experiences
  in psychotherapy.

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Patients Experiences of Change

• 
  Patients
  
• Patients Experiences of Change
• CBT
  Psychodynamic (PDT)
  
• Item
• Am able to cope with difficult situations 88 45
  
  
• Can set limits and boundaries
  25 82
  
• Can understand myself better 0 82
• Changed my way of relating to others 0 73

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PatientsWhat Aspects of Therapy Contributed to
Change?
________________
CBT
PDTItemEmotional support
38 73 Exposure to
frightening things 75
9 Finding connections and
patterns

0 55
Straightforward explanations

100
0 The therapists
professionalism

13 64 The
therapists sensitivity

25
55 Working through trauma


13 55
Patients What are Clients Theories Abou
t How Change Has Come About?
______________
CBT
PDT Item Facing fear/using exposure techniques
75 9 Getting to the root of t
hings 0 73
Taking time and having patience 13
55
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With Technical Integration We May Have Better
Results

• But
• theoretical integration is not possible since the
  assumptions are too different.
  
• However, ANY form of psychological intervention
  will be improved with a psychodynamic
  formulation.
  
• No theory is as helpful in understanding people.

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After Over 100 Years of Psychodynamic Formulation
and Research, comes the PDM

• The PDM is based on neuroscience, treatment
  outcome, personality, developmental and other
  empirical investigations.
  
• Research on brain development and the maturation
  of mental processes suggests that patterns of
  emotional, social, and behavioral functioning
  involve many areas working together rather than
  in isolation.

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Classification of Adult Mental Health Disorders

• Level of Personality Organization
• Personality Patterns and Disorders
• Profile of Mental Functioning
• Symptom Patterns Subjective Experience

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Classification of Child and Adolescent Mental
Health Disorders

• Mental Functioning - MCA Axis
• Emerging Personality Patterns - PCA
• Symptom Patterns Subjective Experience - SCA

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The Classification of Mental Health and
Developmental Disorders in Infancy and Early
Childhood

• Primary Diagnosis
• Interactive Disorders
• Regulatory-Sensory Processing Disorders (RSPD)
• Neurodevelopmental Disorders of Relating and
  Communicating
  

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The PDM Can Help You Better Understand People by
Considering Many Levels of Personality

• Over-all level of personality organization
• (Healthy, Neurotic or Borderline)
• Personality patterns and disorders
• (Temperament, conflicts, affects, cognitions
  and defensives)
  
• Specific capacities of mental functioning
• (learning, relationships, self regard,
  affective experience, internal representations,
  differentiation and integration, psychological
  mindedness, a sense of morality)
• The subjective experience of symptoms

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We Will Focus On The Adult Mental Health
Disorders- P Axis

• This dimension has been placed first in the
  Adult PDM system because of the accumulating
  evidence that symptoms or problems cannot be
  understood, assessed, or treated in the absence
  of an understanding of the personality and mental
  life of the person who has the symptoms.

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P Axis
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Dimension II Mental Functioning

• The second PDM dimension offers a description
  of the capacities that contribute to an
  individual's personality and overall level of
  psychological health or pathology such as

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Profile of Mental Functioning -  M Axis

• Capacity for Regulation, Attention, and
  Learning
  
• Capacity for Relationships (Including Depth,
  Range, and Consistency)
  
• Quality of Internal Experience (Level of
  Confidence and Self-Regard)
  
• Affective Experience, Expression, and
  Communication
  
• Defensive Patterns and Capacities
• Capacity to Form Internal Representations
• Capacity for Differentiation and Integration
• Self-Observing Capacities (Psychological-Mindednes
  s)
  
• Capacity for Internal Standards and Ideals A
  Sense of Morality

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Dimension III Manifest Symptoms and Concerns

• Dimension III begins with the DSM-IV-TR
  categories and goes on to describe the affective
  states, cognitive processes, somatic experiences,
  and relational patterns most often associated
  clinically with each one. These are the patient's
  personal experience of biopsychosocial symptom
  clusters.
• These are seen in the context of the person's
  personality and mental functioning. This multi
  dimensional approach provides a systematic way to
  describe patients that is faithful to their
  complexity and helpful in planning appropriate
  treatments.

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Kernbergs Differentiation of Personality
Organization That Preceded the PDM

• Neurotic Borderline
  Psychotic
  
• Identity integrated -
  diffused -
  
• Integration
• Defensive higher -
  primitive -
  
• Operations
• Reality
  -
  
• Testing

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Personality Patterns and Disorders P Axis
Level of Organization (Severity of Personality
Disorder)

• Healthy Personalities (Absence of Personality
  Disorder)
  
• Neurotic-Level Personality Disorders
• Borderline-Level Personality Disorders

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The Determination of Personality Organization or
Severity of Personality is Based on Seven
Capacities

• To view self and others in complex, stable, and
  accurate ways (identity)
  
• To maintain intimate, stable, and satisfying
  relationships (object relations)
  
• To experience in self and perceive in others the
  full range of age-expected affects (affect
  tolerance)
  
• To regulate impulses and affects in ways that
  foster adaptation and satisfaction, with
  flexibility in using defenses or coping
  strategies (affect regulation)
• To function according to a consistent and mature
  moral sensibility (super-ego integration, ideal
  self-concept, ego ideal)
  
• To appreciate, if not necessarily to conform to,
  conventional notions of what is realistic
  (reality testing)
  
• To respond to stress resourcefully and to recover
  from painful events without undue difficulty (ego
  strength and resilience).
  

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Personality Disorders P Axis

• Temperamental,
• Thematic,
• Affective,
• Cognitive, and
• Defense patterns

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P101. Schizoid Personality Disorders

• Contributing constitutional-maturational
  patterns Highly sensitive,shy, easily
  overstimulated
  
• Central tension/preoccupation Fear of
  closeness/longing for closeness
  
• Central affects General emotional pain when
  overstimulated, affects so powerful they feel
  they must suppress them
  
• Characteristic pathogenic belief about self
  Dependency and love are dangerous
  
• Characteristic pathogenic belief about others
  The social world is impinging, dangerously
  engulfing
  
• Central ways of defending Withdrawal, both
  physically and into fantasy and idiosyncratic
  preoccupations
  

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P102. Paranoid Personality Disorders

• Contributing constitutional-maturational
  patterns Possibly irritable/aggressive
  
• Central tension/preoccupation Attacking/being
  attacked by humiliating others
  
• Central affects Fear, rage, shame, contempt
• Characteristic pathogenic belief about self
  Hatred, aggression and dependency are dangerous
  
• Characteristic pathogenic belief about others
  The world is full of potential attackers and
  users
  
• Central ways of defending Projection, projective
  identification, denial, reaction formation
  

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P103. Psychopathic (Antisocial) Personality
Disorder P103.1  Passive/Parasitic
con artist P103.2  Aggressive
explosive, predatory, often violent

• Contributing constitutional-maturational
  patterns aggressiveness, high threshold for
  emotional stimulation
  
• Central tension/preoccupation Manipulating/being
  manipulated
  
• Central affects Rage, envy
• Characteristic pathogenic belief about self I
  can make anything happen
  
• Characteristic pathogenic belief about others
  Everyone is selfish, manipulative, dishonest
  
• Central ways of defending Reaching for
  omnipotent control
  

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P104. Narcissistic Personality Disorders  
P104.1  Arrogant/Entitled devalues, vain,
commanding   P104.2  Depressed/Depleted
idealizing, envious, easily hurt

• Contributing constitutional-maturational
  patterns No clear data
  
• Central tension/preoccupation Inflation/deflation
  of self-esteem
  
• Central affects Shame, contempt, envy
• Characteristic pathogenic belief about self I
  need to feel okay
  
• Characteristic pathogenic belief about others
  Others enjoy riches, beauty, power, and fame the
  more I have of those, the better I will feel
  
• Central ways of defending Idealization/devaluatio
  n
  

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Narcissistic PD Narcissistic Injury
The Doberman threw himself out the second-story
window after he realized the family had indeed
named him Binky.
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P105. Sadistic and Sadomasochistic Personality
Disorders P105.1  Intermediate
Manifestation Sadomasochistic
Personality Disorders alternate between
attacking and feeling insulted

• Contributing constitutional-maturational
  patterns Unknown
  
• Central tension/preoccupation Suffering
  indignity/inflicting such suffering
  
• Central affects Hatred, contempt, pleasure
  (sadistic glee)
  
• Characteristic pathogenic belief about self I am
  entitled to hurt and humiliate others
  
• Characteristic pathogenic belief about others
  Others exist as objects for my domination
  
• Central ways of defending Detachment, omnipotent
  control, reversal, enactment
  

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Sadistic PD I am entitled to hurt others
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P106. Masochistic (Self-Defeating) Personality
Disorders   P106.1  Moral Masochistic
self-esteem depends on suffering   P106.2 
Relational Masochistic suffer for sake of
relationship

• Contributing constitutional-maturational
  patterns None known
  
• Central tension/preoccupation Suffering/losing
  relationship or self-esteem
  
• Central affects Sadness, anger, guilt
• Characteristic pathogenic belief about self By
  manifestly suffering, I can demonstrate my moral
  superiority and/or maintain my attachments
  
• Characteristic pathogenic belief about others
  People pay attention only when one is in trouble
  
• Central ways of defending Introjection,
  introjective identification, turning against the
  self, moralizing
  

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Masochistic Personality Disorder
Penny for your thoughts, Arnold!
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P107. Depressive Personality Disorders 
 P107.1  Introjective self-critical,
self-worth   P107.2  Anaclitic concern with
attachment issues

• Contributing constitutional-maturational
  patterns Possible genetic predisposition
  
• Central tension/preoccupation Goodness/badness
  or aloneness/relatedness of self
  
• Central affects Sadness, guilt, shame
• Characteristic pathogenic belief about self
  There is something essentially bad or incomplete
  about me
  
• Characteristic pathogenic belief about others
  People who really get to know me will reject me
  
• Central ways of defending Introjection,
  reversal, idealization of others, devaluation of
  self
  

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Depressive Personality Disorder
Lodge owner Harold Shuffle saw only the negative
side of things.
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  P107.3  Converse Manifestation Hypomanic
Personality Disorder

• Contributing constitutional-maturational
  patterns Possibly high energy
  
• Central tension/preoccupation Overriding
  grief/succumbing to grief
  
• Central affects Elation, rage, unconscious
  sadness and grief
  
• Characteristic pathogenic belief about self If I
  stop running and get close to someone, Ill be
  traumatically abandoned, so Ill leave first
  
• Characteristic pathogenic belief about others
  Others can be charmed into not seeing the
  qualities that make people inevitably reject me
  
• Central ways of defending Denial, idealization
  of self, devaluation of others
  

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P108. Somatizing Personality Disorders

• Contributing constitutional-maturational
  patterns Possible physical fragility, early
  sickliness, early abuse
  
• Central tension/preoccupation Integrity/fragmenta
  tion of bodily self
  
• Central affects alexithymia, inferred rage,
  distress
  
• Characteristic pathogenic belief about self I am
  fragile, vulnerable, in danger of dying
  
• Characteristic pathogenic belief about others
  Others are powerful, healthy, and indifferent
  
• Central ways of defending Somatization,
  regression
  

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Somatizing Personality Disorder
My brother, Tilford, had trouble with
hemorrhoids and he never did anything like this!
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P109. Dependent Personality Disorders  

• Contributing constitutional-maturational
  patterns Possible
  
• placidity, sociophila
• Central tension/preoccupation Keeping/lossing
  relationships
  
• Central affects Pleasure when securely attached
  sadness and fear when alone
  
• Characteristic pathogenic belief about self I am
  inadequate, needy, impotent
  
• Characteristic pathogenic belief about others
  Others are powerful and I need their care
  
• Central ways of defending Regression, reversal,
  avoidance
  
• Subtypes  Passive-Aggressive,   Counterdependent
  
  

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Dependent PD Others are powerful and I need
their care
Youre gonna spoil that dog, Annie!
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P109. Dependent Personality Disorders P109.1 
Passive-Aggressive Versions of Dependent
Personality Disorders  

• Contributing constitutional-maturational
  patterns Possibly irritable, aggressive
  
• Central tension/preoccupation Tolerating
  mistreatment/getting revenge
  
• Central affects Anger, resentment, pleasure in
  hostile enactments
  
• Characteristic pathogenic belief about self I am
  inadequate, needy, impotent
  
• Characteristic pathogenic belief about others
  Others are powerful and I need their care
  
• Central ways of defending Regression, reversal,
  avoidance
  

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Passive-Aggressive Personality Disorder
Its almost like they do it on purpose, isnt
it, Fred?!
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P109. Dependent Personality DisordersP109.2 
Converse Manifestation Counterdependent
Personality Disorder

• Contributing constitutional-maturational
  patterns Possibly more aggressive than the
  overtly dependent type
  
• Central tension/preoccupation Demonstrating lack
  of or shameful dependence
  
• Central affects Contempt, denial of weaker
  emotions
  
• Characteristic pathogenic belief about self I
  dont need anyone
  
• Characteristic pathogenic belief about others
  Others depend on me and require me to be
  strong
  
• Central ways of defending Denial, reversal,
  enactment
  

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P110. Phobic (Avoidant) Personality Disorders

• Contributing constitutional-maturational
  patterns Possible anxious or timid disposition
  
• Central tension/preoccupation Safety/danger
  relative to specific objects
  
• Central affects Fear
• Characteristic pathogenic belief about self I am
  safe if I avoid certain specific dangers
  
• Characteristic pathogenic belief about others
  More powerful people can magically keep me safe
  
• Central ways of defending Symbolization,
  displacement, projection, rationalization,
  avoidance
  
• Subtypes Counterphobic

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  P110.1  Converse Manifestation of Phobic
Counterphobic Personality Disorders

• Contributing constitutional-maturational
  patterns Unknown
  
• Central tension/preoccupation Safety/danger
• Central affects Contempt, denial of fear
• Characteristic pathogenic belief about self I
  can face anything without fear
  
• Characteristic pathogenic belief about others
  Others frighten easily and admire my bravery
  
• Central ways of defending Denial, reaction
  formation, projection
  

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P111. Anxious Personality Disorders

• Contributing constitutional-maturational
  patterns Anxious or timid temperament
  
• Central tension/preoccupation Safety/danger
• Central affects Fear
• Characteristic pathogenic belief about self I am
  in constant danger from forces unknown
  
• Characteristic pathogenic belief about others
  Others are sources of either danger or
  protection
  
• Central ways of defending Failure of defenses
  against anxiety, surface anxiety may mask
  unconscious deeper anxiety
  

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• P112. Obsessive-Compulsive Personality
  Disorders  P112.1  Obsessive Self-esteem
  depends on thinking,ruminative  P112.2 
  Compulsive Self-esteem depends on doing,
  meticulous
• Contributing constitutional-maturational
  patterns Possible irritability, orderliness
  
• Central tension/preoccupation Submission
  to/rebellion against controlling authority
  
• Central affects Anger, guilt, shame, fear
• Characteristic pathogenic belief about self My
  aggression is dangerous and must be controlled
  
• Characteristic pathogenic belief about others
  Others try to exert control, which I must resist
  
• Central ways of defending Isolation of affect,
  reaction formation, intellectualization,
  moralizing, undoing
  

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Obsessive-Compulsive PD Compulsive type
Once again Elliot Zambinis tidiness ruins the
act.
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P113. Hysterical (Histrionic) Personality
Disorders   P113.1  Inhibited reserved,
naiveté, somatization   P113.2  Demonstrative
or Flamboyant seductive, dramatic

• Contributing constitutional-maturational
  patterns Possibly sensitivity, sociophila
  
• Central tension/preoccupation Power and
  sexuality/other gender
  
• Central affects Fear, shame, guilt (over
  competition)
  
• Characteristic pathogenic belief about self My
  gender makes me weak, castrated, vulnerable
  
• Characteristic pathogenic belief about others
  People of my own gender are of little value,
  people of the other gender are powerful,
  exciting, potentially exploitive and damaging
• Central ways of defending Repression,
  regression, conversion, sexualization, acting
  out
  

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P114.  Dissociative Personality Disorders
(Dissociative Identity Disorder/Multiple
Personality Disorder)

• Contributing constitutional-maturational
  patterns Constitutional capacity for
  self-hypnosis severe early and repeated physical
  and/or sexual trauma
• Central tension/preoccupation Acknowledging
  trauma/disavowing trauma
  
• Central affects Fear, rage
• Characteristic pathogenic belief about self I am
  small, weak, and vulnerable to recurring trauma
  
• Characteristic pathogenic belief about others
  Others are perpetrators, exploiters, or rescuers
  
• Central ways of defending Dissociation

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P115.  Mixed/Other

• For individuals with combinations of personality
  types or with particular patterns or themes

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Implications for treatment- Depressive
Personality Disorder(Most Common type in
Clinical Situations)P107.1  Introjective
self-critical, preoccupied with self-worth,
guilt   P107.2  Anaclitic concerned with
attachment issues, relatedness, trust, inadequacy
(May combine with dependent or narcissistic
personality disorder)
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Treatment for Depressive P.D.

• The Mood disorder responds to medication, but not
  the personality disorder, which requires
  long-term intensive treatment.
  
• The introjective type tends to respond better to
  interpretations and insight.
  
• The anaclitic type tends to respond better to
  the actual therapeutic relationship. May respond
  well to short term interventions.
  

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P107.3  Converse Manifestation Hypomanic
Personality Disorder

• Relatively stable state of inflated mood, high
  energy
  
• Little guilt
• Overly positive view of self
• Superficial relationships due to fear of being
  attached
  
• Highly resistant to therapy
• The mood disorder responds better to
  pharmacological interventions, but medication
  does not help the personality disorder.
  

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Treatment ImplicationsP107.3  Converse
Manifestation Hypomanic Personality Disorder

• The hypomanic type often flees from commitment
  and therefore does not stay long enough in
  treatment. The PDM suggests emphasizing that the
  commitment to the treatment is important to
  improvement.
• People with hypomanic personality disorders are
  most likely to be at the borderline level
  favoring defenses such as denial and the
  idealization of self and the devaluation others,
  as compared to those with depressive
  personalities who favor defensives such as
  repression, and the devaluation of self and the
  idealization of others.

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Take Home Message

• Be technically eclectic according to the needs of
  the patient.
  
• Use a psychodynamic formulation so you will know
  what interventions are likely be most effective,
  and to communicate that you understand your
  patient at all levels of existence (not just
  seeing symptoms).
• The PDM is the most non-doctrine, research based
  and concise source for learning about a
  psychodynamic formulation that is useful for all
  psychological interventions.

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Take Home MessageWhat to do next

• Consider the over-all level of personality
  organization
  
• Consider the personality patterns or disorders
• Consider the mental capacities
• Consider the subjective experience of the
  symptoms
  
• You will find that your greater empathy will be
  felt by your patient, and this can greatly
  improve any treatment.

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