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(BQ) Part 2 book “Psychodynamic psychiatry in clinical practice” has contents: Paraphilias and sexual dysfunctions, neurodevelopmental and neurocognitive disorders, hysterical and histrionic personality disorders, cluster a personality disorders - paranoid, schizoid, and schizotypal,… and other contents.
C H A P T E R 10 TRAUMA- AND STRESSORRELATED DISORDERS AND DISSOCIATIVE DISORDERS I n recent years, psychiatric interest in dissociation has grown in conjunction with the interest in posttraumatic stress disorder (PTSD) and responses to trauma in general Psychoanalytic thinking traditionally focused on unconscious needs, wishes, and drives in concert with the defenses against them Intrapsychic fantasy played a greater role than external trauma Dissociative disorders and PTSD have leveled the playing field so that contemporary psychodynamic clinicians now give equal weight to the pathogenetic influences of real events The growing body of research on reactions to trauma has led to new categorizations in the DSM-5 system (American Psychiatric Association 2013) Although PTSD was formerly included among the anxiety disorders, the revision in DSM-5 groups acute stress disorder, PTSD, adjustment disorder, and reactive attachment disorder into a new category designated as trauma- and stressor-related disorders A greater understanding of PTSD and acute stress disorder has broadened the array of responses to adverse events such that there is no longer a requirement that a subjective specific response to the adverse event must be one of fear or helplessness or horror Large numbers of people numb themselves during an adverse event that is experienced directly or indirectly and begin to have symptoms after a period of time PTSD now includes four distinct symptom clusters: reexperiencing, avoidance, persistent negative alterations in mood, and cognition and arousal Finally, the new dissociative subtype has been added to PTSD that 281 282 PSYCHODYNAMIC PSYCHIATRY IN CLINICAL PRACTICE requires all of the DSM-5 PTSD symptoms plus depersonalization and/or derealization Changes have also occurred in the conceptualization of the dissociative disorders in DSM-5 Dissociative fugue has been included as a specifier of dissociative amnesia, so it is no longer listed as a separate diagnosis The definition of dissociative identity disorder has been altered to emphasize the intrusive nature of the dissociative symptoms as disruptions in consciousness, including an experience of possession as an alteration of identity, and an awareness that amnesia for everyday events, not merely traumatic events, is typical Finally, derealization is no longer separate from depersonalization disorder In this chapter, I include both trauma- and stressor-related disorders and dissociative disorders because of their similar origins in traumatic experience Trauma- and Stressor-Related Disorders Research suggests that trauma is virtually a universal experience, with 89.6% of Americans having been exposed to a traumatic event in their lifetime (Breslau 2009) PTSD itself afflicts approximately 6.8% of Americans (Kessler et al 2005) Almost 40% of individuals who receive the diagnosis of PTSD continue to have significant symptoms a decade after onset (Kessler et al 1995), and many have significant work impairment (Davidson 2001) As noted in Chapter 1, there is some thought that genetic vulnerability interacts with adult traumatic events and childhood adversity to increase the risk of PTSD A study of acute and posttraumatic stress symptoms subsequent to a university campus shooting (Mercer et al 2012) suggested that the 5-HTTLPR multimarker genotype may serve as a useful predictor of risk for PTSD-related symptoms in the weeks and months following trauma It is also clear from numerous studies that child abuse itself provides significant risk liability for the development of adult PTSD Child abuse increases the vulnerability by altering the hypothalamic-pituitary-adrenal axis functioning and by altering the nature of the attachment profile of the young child In addition, child abuse appears to interact with genetic factors In a study involving highly traumatized inner city individuals (Binder et al 2008), four single nucleotide polymorphisms of the FKBP5 gene interacted with the severity of child abuse to predict adult PTSD symptoms The investigators could not find significant genetic interactions with trauma that did not involve child abuse as a predictor of adult PTSD symptoms One of the implications of the study is that specific variations in a stress-related gene can be influenced by trauma at a young age, specifically forms of childhood abuse Trauma- and Stressor-Related Disorders and Dissociative Disorders 283 Certain types of children seem to be more vulnerable to ultimately developing PTSD symptoms Prospective studies of children exposed to trauma show that traumatic events are fairly common and not often result in a full-blown picture of PTSD However, children who have preexisting anxiety and/or depression appear to be a greater risk for the development of PTSD following trauma exposure (Copeland et al 2007; Storr et al 2007) Whereas the severity of posttraumatic symptoms was once thought to be directly proportional to the severity of the stressor, empirical studies suggest otherwise The incidence of PTSD is actually rather low among people who are healthy before experiencing the trauma (Schnyder et al 2001) Events that seem to be relatively low in severity may trigger PTSD in certain individuals because of the subjective meaning assigned to the event Old traumas may be reawakened by present-day circumstances One investigation of 51 burn patients (Perry et al 1992) showed that PTSD was predicted by smaller burns, by less perceived emotional support, and by greater emotional distress More severe or extensive injury did not predict posttraumatic symptoms The findings of this study are in keeping with the growing consensus that PTSD is perhaps dependent more on subjective issues, such as individual meanings and the interaction of genetic and environmental factors in one’s history, than on the severity of the stressor Psychotherapy is generally the treatment of choice for PTSD, and a number of psychological treatments may be useful, including cognitive-behavioral, interpersonal, dynamic, and eclectic approaches (Youngner et al 2014) Reviews of the literature suggest that PTSD is most effectively treated with trauma-focused therapy, with meta-analyses demonstrating strong responses to cognitive-behavioral therapy (CBT; Bradley et al 2005) CBT techniques generally focus on having the patient confront rather than avoid his or her traumatic memories while also confronting distorted cognitions surrounding the trauma that allow PTSD symptoms to persist Psychodynamic therapy may be useful with some PTSD patients but lacks strong evidence from clinical trials (Forbes et al 2010) Psychodynamic approaches that emphasize the careful building of a therapeutic alliance may be useful in many cases As noted earlier, a dissociative subtype of PTSD has been added to DSM-5 Lanius et al (2010) identified neurobiological features of dissociative PTSD that differentiate it from the more traditional subtype involving hyperarousal symptoms The nondissociative subtype of PTSD, characterized by reexperiencing and hyperarousal, is regarded as a form of emotion dysregulation that involves emotional undermodulation This type is mediated by failure of the prefrontal inhibition of the limbic regions By contrast, the dissociative subtype of PTSD involves emotional overmodulation mediated by midline prefrontal inhibition of the same limbic regions Exposure treatments must be used with 284 PSYCHODYNAMIC PSYCHIATRY IN CLINICAL PRACTICE great caution in patients who have significant emotional overmodulation These symptoms may prevent emotional engagement with trauma-related information, thus reducing treatment effectiveness (Lanius et al 2010) In a study of borderline personality disorder (Kleindienst et al 2011), levels of dissociation served as an important negative predictor of response to behavioral and exposure treatments Hence, dissociative symptoms must be carefully assessed before proceeding to an exposure-based treatment for PTSD patients These patients require a phase-based intervention that includes identifying and modifying attachment schemas and developing mood regulation skills Brom et al (1989) compared patients receiving dynamic therapy, hypnotherapy, and systemic desensitization All three treatment groups with PTSD showed more improvement in symptoms than a control group Dynamic therapy achieved greater reduction in avoidant symptoms but had less impact on intrusive symptoms The desensitization and hypnotherapy group showed the reverse pattern Behavioral techniques have proven to be effective, but the relaxation necessary for behavioral modalities may be difficult for PTSD patients to achieve because of their impaired self-soothing abilities Lindy et al (1983) used a manualized brief dynamic therapy consisting of 6–12 sessions In a well-controlled study of this treatment with survivors of fires, these investigators demonstrated significant improvement in the 30 patients who participated, 19 of whom met DSM- (American Psychiatric Association 1980) criteria for PTSD alone or with comorbid depression Regardless of the type of treatment used, individual psychotherapy must be highly personalized for patients with PTSD Dropout rates as high as 50% and nonresponse are fairly common in the literature on PTSD treatment (Schottenbauer et al 2008) A significant subgroup of patients will be overwhelmed by the reconstruction of the trauma and will react with clinical deterioration The integration of split-off traumatic experiences must be titrated in keeping with the particular patient’s capacity for such integration The therapist must be willing to contain projected aspects of the traumatized self until the patient is able to reintegrate them Clinicians must be vigilant to the risk of suicide, especially with combat veterans Hendin and Haas (1991) found that combat-related guilt was the most significant predictor of the wish to kill oneself in veterans Many of these patients felt that they deserved to be punished because they had been transformed into murderers Because of these considerations, the dynamic psychotherapy of patients with PTSD must strike a balance between an observing, detached posture that allows the patient to withhold distressing information and a stance of gentle encouragement that helps the patient reconstruct a complete picture of the trauma Integrating the memory of the trauma with the patient’s continuous sense of self may be an unrealistic goal because the patient must not Trauma- and Stressor-Related Disorders and Dissociative Disorders 285 be forced to proceed at a pace that becomes overwhelming and disorganizing The building of a solid therapeutic alliance in which patients feel safe is critical for the therapy to succeed Education about common reactions to trauma may facilitate such an alliance An empathic validation of the patient’s right to feel the way that he or she does may also further the alliance Regardless of the type of therapy one is conducting, an emphasis on building and repairing the therapeutic alliance is essential in the treatment of PTSD Ruptures in the therapeutic alliance are common in prolonged exposure, and repair of those ruptures must be a high priority for the therapist In a study of 116 PTSD patients undergoing 10 weeks of prolonged exposure therapy (McLaughlin et al 2013), ruptures in the alliance occurred at a frequency of 46% Moreover, unrepaired ruptures predicted worse treatment outcome Lindy (1996) identified four kinds of transferences that are common with PTSD patients: 1) the transfer of figures involved in the traumatic event onto the therapist, 2) the transference of specific disavowed memories of the traumatic event onto the treatment situation, 3) the transfer onto the therapist of intrapsychic functions in the patient that had been distorted as a result of the trauma (with the hope that healthier function will be restored), and 4) the transfer onto the therapist of an omnipotent and wide role in which the therapist can help the patient sort out what happened and restore a sense of personal meaning All of these transferences, of course, evoke corresponding countertransference The therapist, intent on rescuing the patient from the horrible trauma he or she has experienced, may develop fantasies of omnipotence Alternatively, the therapist may feel overwhelmed, angry, and helpless in response to the patient’s seeming resistance to letting go of the trauma Therapists themselves may feel traumatized by simply listening to the horror that the patient experienced When the patient is particularly tenacious in holding on to memories of the trauma, the therapist may be filled with feelings of hopelessness and/or indifference Dissociative Disorders In essence, dissociation represents a failure to integrate aspects of perception, memory, identity, and consciousness Minor instances of dissociation, such as “highway hypnosis,” transient feelings of strangeness, or “spacing out,” are common phenomena in the general population Extensive empirical evidence suggests that dissociation occurs especially as a defense against trauma High frequencies of dissociative symptoms have been documented in the wake of firestorms (Koopman et al 1994), earthquakes (Cardeña and 286 PSYCHODYNAMIC PSYCHIATRY IN CLINICAL PRACTICE Spiegel 1993), war combat (Marmar et al 1994), torture (Van Ommeren et al 2001), and in those who have witnessed an execution (Freinkel et al 1994) Dissociation allows individuals to retain an illusion of psychological control when they experience a sense of helplessness and loss of control over their bodies Dissociative defenses serve the dual function of helping victims remove themselves from a traumatic event while it is occurring and delaying the necessary working through that places the event in perspective with the rest of their lives Trauma itself can be regarded as a sudden discontinuity in experience (Spiegel 1997) Dissociation during trauma leads to a discontinuous memory storage process as well Approximately 25%–50% of trauma victims experience some kind of detachment from the trauma, whereas others have partial to total amnesia for the event (Spiegel 1991) These mental mechanisms allow victims to compartmentalize the experience so that it is no longer accessible to consciousness—it is as though the trauma did not happen to them It is unclear why some people dissociate and others not An investigation of soldiers in survival training suggested that those who had reported threat to life in the past were more likely to dissociate under the stress of the training (Morgan et al 2001) Another study (Griffin et al 1997) suggested that physiological differences may have something to with the propensity to dissociate Magnetic resonance imaging (MRI) studies of Vietnam veterans have demonstrated reduced right hippocampal volume in those who have PTSD compared with those who not (Bremner et al 1995) Depressed women who have been subjected to severe and prolonged physical and/or sexual abuse in childhood also have smaller hippocampal volume than control subjects (Vythilingam et al 2002) The hippocampus is pivotal in the storage and retrieval of memory, leading some researchers to hypothesize that the memory difficulties associated with dissociation are linked to damage in that region (Spiegel 1997) Yehuda (1997) suggested that heightened responsiveness of the hypothalamic-pituitary-adrenal axis leads to an increase in the glucocorticoid receptor responsiveness that results in hippocampal atrophy If the high degrees of stress associated with a traumatic event effectively shut down the hippocampus, then autobiographical memory for that event will be compromised (Allen et al 1999) A common defensive response to trauma is dissociative detachment as a way of warding off intensive affects Allen et al (1999) pointed out that this detachment greatly narrows the individual’s field of awareness, so that decreased recognition of the context may interfere with the process of elaborative encoding of the memory Without the reflective thinking required for storage, the memory is not integrated into autobiographical narrative These authors also suggested that dissociative detachment may involve a problem with cortical disconnectivity (Krystal et al Trauma- and Stressor-Related Disorders and Dissociative Disorders 287 1995) that interferes with higher cognitive functions such as language production Rauch and Shin (1997) found that PTSD is associated with hypoactivity in Broca’s area on positron emission tomography (PET) scans The combination of hippocampal damage and hypoactivity in Broca’s area suggests an impaired ability to cope with memories in lexical terms Hence, dissociative phenomena may be helpful initially as a defense mechanism but may ultimately limit the brain’s ability to cope with traumatic memories (Spiegel 1997) Different patterns of neural activation appear to be related to different types of memory Several authors (Brewin 2001; Driessen et al 2004) have suggested a dual representation model of traumatic memories Memories that are verbally accessible tend to be more independent from cues and situations, whereas traumatic memories appear to be uncontrollable, unconscious, and cue dependent These latter memories, associated with the amygdala, the thalamus, and the primary sensory cortices, cannot easily be inhibited by the higher order brain areas, such as the cingulate, prefrontal, hippocampal, and language areas Genetic influences on vulnerability to dissociation are unclear In a study of 177 monozygotic and 152 dizygotic volunteer twin pairs from the general population (Jang et al 1998), subjects completed two measures of dissociative capacity taken from the Dissociative Experiences Scale (DES), a 28-item self-report questionnaire with established reliability and validity (Putnam 1991) The results showed that genetic influences accounted for 48% and 55% of the variance in scales measuring pathological and nonpathological dissociative experience, respectively On the other hand, a similar twin study (Waller and Ross 1997) found no evidence for heritability The link between dissociation and childhood trauma has been established in a number of studies In one investigation (Brodsky et al 1995), among the 50% of subjects who had DES scores indicating pathological levels of dissociation, 60% reported a history of childhood physical and/or sexual abuse In another study (Mulder et al 1998) of 1,028 randomly selected individuals, 6.3% were found to have three or more frequently occurring dissociative symptoms, and these individuals had a fivefold higher rate of childhood physical abuse and a twofold higher rate of childhood sexual abuse Psychodynamic Understanding Both repression and dissociation are defense mechanisms, and in both, the contents of the mind are banished from awareness They differ, however, in the way the dismissed mental contents are handled In the case of repression, a horizontal split is created by the repression barrier, and the material is 288 PSYCHODYNAMIC PSYCHIATRY IN CLINICAL PRACTICE transferred to the dynamic unconscious By contrast, a vertical split is created in dissociation so that mental contents exist in a series of parallel consciousnesses (Kluft 1991b) Moreover, the repression model has usually been invoked as a response to forbidden wishes, such as oedipal desires for a parent, rather than to external events Hence, dissociation may be mobilized by trauma, whereas repression is activated by highly conflictual wishes (Spiegel 1991) Once mobilized, however, dissociation can be reactivated by wishes and desires In most cases of dissociation, disparate self-schemas, or representations of the self, must be maintained in separate mental compartments because they are in conflict with one another (Horowitz 1986) Memories of the traumatized self must be dissociated because they are inconsistent with the everyday self that appears to be in full control One manager of a convenience store, for example, had dissociated a trauma involving anal rape during a holdup of the store because the image of himself as subjugated and humiliated in that situation was completely in conflict with his usual sense of himself as a manager who could “take charge” of all situations Dissociative amnesia and dissociative identity disorder have common psychodynamic underpinnings Dissociative amnesia involves an inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting Dissociative identity disorder (DID), formerly known as multiple personality disorder, involves the disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession This disruption in identity must involve marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning Individuals with DID also have recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting All of these disorders are frequently misdiagnosed In a typical case of DID, an average of years of treatment elapses before the DID diagnosis is established (Loewenstein and Ross 1992; Putnam et al 1986) Diagnosis of DID is particularly problematic because 80% of DID patients have only certain “windows of diagnosability” during which their condition is clearly discernible to clinicians (Kluft 1991b) Diagnostic rigor has been improved by the DES, which can be used effectively to identify high-risk patients However, a definitive diagnosis requires the use of a structured interview such as the Structured Clinical Interview for Dissociative Disorders (Steinberg et al 1991) Dissociative amnesia may be the most common of the dissociative disorders (Coons 1998), but the diagnosis is often complicated by the fact that Trauma- and Stressor-Related Disorders and Dissociative Disorders 289 almost all patients with this condition have additional psychiatric diagnoses Moreover, unless specifically asked, many patients not report periods of amnesia because of the very nature of amnestic episodes The patient may well feel that everyone experiences memory gaps and that therefore the lost time periods are not remarkable or worth reporting to the clinician Allen et al (1999) stressed the need to distinguish between the reversible memory failures associated with DID and dissociative amnesia and the irreversible memory discontinuities (during which autobiographical memories were not encoded and are therefore not retrievable) associated with dissociative detachment There is a risk of overdiagnosing DID if all memory gaps are assumed to be attributable to dissociative amnesia, which entails recoverable memories Sensationalized cases of DID in the media not reflect the fact that most patients with this disorder are highly secretive and prefer to conceal their symptoms The separate dissociated self states, or “alters,” are first deployed adaptively in an attempt on the part of the abused child to distance himself or herself from the traumatic experience The alters soon gain secondary forms of autonomy, and a patient may hold a quasi-delusional belief in their separateness The patient’s personality actually consists of the sum total of all the personalities, of course, and Putnam (1989) clarified that alters are highly discrete states of consciousness that are organized around a prevailing affect, a sense of self and body image, a limited repertoire of behaviors, and a set of state-dependent memories The old designation of multiple personality disorder was confusing, because the fundamental problem in the disorder is the state not of having more than one personality but of having less than one personality (Spiegel and Li 1997) Population studies in Europe and North America have found that DID is a relatively common psychiatric disorder that occurs in about 1%–3% of the general population and up to perhaps 20% of patients in outpatient and inpatient treatment programs (Spiegel et al 2011) Numerous studies using a variety of methodologies have documented a causal relationship between trauma and subsequent dissociation (Dalenberg et al 2012) Individuals with DID show the highest rates of early life trauma when compared with all other clinical groups Emotional, physical, and sexual abuse are common before the age of in persons with this disorder Although some people have questioned the prevalence of early sexual abuse, recent reports substantiate this alarmingly high rate The National Institute of Justice and the Department of Defense supported a survey in 2010 known as the National Intimate Partner and Sexual Violence Survey When the results were released, the study showed that in an international sample of 16,507 adults, one in five women reported being raped or being subjected to an attempted rape at some point in their lives One in four had been beaten by an intimate part- 290 PSYCHODYNAMIC PSYCHIATRY IN CLINICAL PRACTICE ner One in seven had experienced severe violence at the hands of their partner, according to the survey (Rabin 2011) It is also important to stress that DID individuals have had high rates of adult traumatization, including rape and intimate partner violation (Simeon and Lowenstein 2009) Most experts agree that trauma alone, however, is not sufficient to cause DID Kluft (1984) proposed a four-factor theory of etiology: 1) the capacity to dissociate defensively in the face of trauma must be present; 2) traumatically overwhelming life experiences, such as physical and sexual abuse, exceed the child’s adaptational capacities and usual defensive operations; 3) the precise forms taken by the dissociative defenses in the process of alter formation are determined by shaping influences and available substrates; and 4) soothing and restorative contact with caretakers or significant others is unavailable, so the child experiences a profound inadequacy of stimulus barriers One clear implication of the four-factor etiological model is that trauma is necessary but not sufficient to cause DID At the risk of stating the obvious, not everyone who is abused as a child develops DID Psychodynamic thinking has a significant contribution to make in furthering our understanding of the factors that lead to the full-blown syndrome The concepts of intrapsychic conflict and deficit are relevant in DID just as they are in other conditions (Marmer 1991) Traumatic experiences may be due to a variety of conflicts around such issues as guilt over collusion with abusers or guilt over sexual arousal with an incestuous object Moreover, dissociation can occur in the absence of trauma in individuals who are highly fantasy prone and suggestible (Brenneis 1996; Target 1998) Hence, the presence of dissociation does not, in and of itself, confirm a history of early childhood trauma Allen (2013) also notes that attachment research reveals intergenerational transmission of dissociative disturbances Infant disorganization measured at 12 months is linked to subsequent dissociative pathology at the age of 19 He stresses that when there is a chronic impairment in caregiver responsiveness, the mother or caregiver cannot serve as the haven of safety that the infant seeks in times of danger Hence, the infant may need to psychologically leave the situation by dissociating In this regard early dissociation can represent an adaptive response to inescapable threat and/or danger where flight or fight is impossible Moreover, early childhood dissociation can be considered a resiliency factor in DID in the sense that psychological sequestering of trauma memories appears to allow some aspects of normal development to occur (Brand et al 2009) Attachment theory has much to offer in furthering our understanding of the differential impact of childhood sexual abuse In a study of 92 adult female incest survivors (Alexander et al 1998), attachment style and abuse severity each appeared to make significant contributions to the prediction of post-trauma symptoms and distress as well as to the presence of personality 630 PSYCHODYNAMIC PSYCHIATRY IN CLINICAL PRACTICE Physical abuse (continued) depression and, 226 posttraumatic stress disorder and, 282 Placebo responses, and pharmacotherapy, 152, 156 Pluralism, theoretical in modern dynamic psychiatry, 66 Politics, and unconscious mental functioning, 11 Positive reinforcement, and treatment of anorexia nervosa, 363 Positive symptoms, of schizophrenia, 188, 189, 203 Posttraumatic stress disorder dissociative subtype of, 281–282 etiology of, 282–283 genetics and risk of, 18, 282 neurobiology of, 17, 287 substance-related disorders and, 353 treatment of, 283–285 Power See also Control anorexia nervosa and, 359 antisocial personality disorder and, 524 pedophilia and, 321 Practice Guideline for the Treatment of Patients with Borderline Personality Disorder (American Psychiatric Association 2001), 444 Practicing, as phase of development, 60 Praise, and expressive-supportive psychotherapy, 109–110 Preconscious, Premorbid phase, of schizophrenia, 189 Preoccupied individuals, and attachment patterns, 64, 92 Prevention See also Relapse of antisocial personality disorder, 537–538 of violence in paranoid patients, 409–411 Primary care therapists, and substance abuse, 356 Primary femininity, 58 Primary maturational failure, 417 Primate research, and environmental versus genetic influences on development, 16–17, 18, 441 Primitive defenses, 36, 37–38 Prisons prevalence of psychopathy in, 516 treatment of antisocial personality disorder in, 529, 531 Procedural memory, 10 Prodomal phase, of schizophrenia, 189 Projection definition of, 37 dementia and, 389 object relations theory and, 42 paranoid personality disorder and, 402 Projective identification anorexia nervosa and, 364 borderline personality disorder and, 431, 437, 460, 467–468, 469 definition of, 37 family/marital therapy and, 146 hospital settings and, 166–167, 168, 172, 173, 174 object relations theory and, 46–49 paranoid personality disorder and, 402, 404, 411 Projective psychological tests, 87–88 Psychic determinism, and basic principles of psychodynamic psychiatry, 12–14 Psychodynamic formulation, 93–94 Psychodynamic psychiatry See also Assessment; Psychodynamic psychotherapy; Theoretical framework; Treatment anorexia nervosa and, 358–361 antisocial personality disorder and, 519–527 avoidant personality disorder and, 593–594 definition of, 3–5 dependent personality disorder and, 598–601 depression and, 223–228 Index dissociative disorders and, 287–294 distinction between concepts of person and self in, 6–7 dynamic psychotherapy and, histrionic and hysterical personality disorders and, 554–558 narcissistic personality disorder and, 488–495 obsessive-compulsive personality disorder and, 579–584 paraphilias and, 313–323 past as prologue in, 14–23 psychic determinism and, 12–14 schizoid and schizotypal personality disorders and, 412–416 schizophrenia and, 189–193 sexual dysfunctions and, 333–336 suicide and, 228–231 unconscious and, 9–12 value of subjective experience in, 8–9 Psychodynamic psychotherapy See also Combined treatment; ExpressiveSupportive psychotherapy; Family and marital therapy; Group therapy; Individual psychotherapy; Psychotherapy compliance with pharmacotherapy and, 156–157 dementia patients and, 389 generalized anxiety disorder and, 273, 275, 276 neurobiology and, 23–25 panic disorder and, 265–266 sexual dysfunctions and, 336 social anxiety disorder and, 272 Psychoeducation See also Education borderline personality disorder and, 449, 467 families of schizophrenic patients and, 204 interventions in expressive-supportive psychotherapy and, 109 pharmacotherapy for bipolar disorder and, 236 631 schizophrenia in hospital setting and, 206, 207 Psychological mindedness, and assessment, 89–90 Psychological testing clinical interviews and, 87–88 histrionic and hysterical personality disorders and, 553 Psychopathy definition of, 516–517 hysterical personality disorder and, 552 use of term, 515–516, 518 Psychopathy Checklist—Revised (PCLR), 516, 527 Psychosocial treatments, for schizophrenia, 200, 205–206 Psychotherapy See also Brief psychotherapy; Cognitive-behavioral therapy; Combined treatment; Confrontation; Individual psychotherapy; Long-term psychotherapy; Psychodynamic psychotherapy; Termination adjunctive for bipolar disorder, 236 Alzheimer’s disease and, 392–393 avoidant personality disorder and, 594–597 borderline personality disorder and, 445–464 dependent personality disorder and, 601–604 obsessive-compulsive personality disorder and, 584–591 paraphilias and, 325–329 posttraumatic stress disorder and, 283 substance-related disorders and, 355–356 Psychotic depression, 225 Psychotic phase, of schizophrenia, 189 Purpose in life, and Alzheimer’s disease, 391–392 632 PSYCHODYNAMIC PSYCHIATRY IN CLINICAL PRACTICE Race and racism countertransference and, 80–81 unconscious and, 11 Rapaport, David, 40 Rapprochement, as phase of development, 60 Rationalization, 38, 227 Reaction formation definition of, 38 depression and, 227 obsessive-compulsive personality disorder and, 587, 590 panic disorder and, 266 Reading the Mind in the Eyes Test (RMET), 439–440 Reality, and paranoid personality disorder, 401 Recovery phase, of schizophrenia, 189 Reflective Functioning Scale, 436 Refrigerator mothers, and autistic spectrum disorder, 385 Regional cerebral blood flow (rCBF), and social phobia, 270 Regression definition of, 37 pedophilia and, 321, 322 Relapse See also Prevention bipolar illness and, 235 paraphilias and prevention of, 324 substance-related disorders and, 351 Relaxation training, and panic disorder, 266 Reparation, and Oedipus complex, 42 Repetitive dimension, of transference, 19 Reporting laws, and psychotherapy for paraphilias, 326 Repression definition of, 38 denial and, 49 dissociative disorders and, 287–288 Resistance as basic principle of psychodynamic psychiatry, 22–23 depression and, 238, 239 expressive-supportive psychotherapy and, 112–113 family/marital therapy and, 146 free association in psychotherapy as, 103 group therapy and, 140 histrionic and hysterical personality disorders and, 558, 565–568 obsessive-compulsive personality disorder and, 585, 586, 587– 588, 590–591 pharmacotherapy and, 154 social phobia and, 272 Resistant attachment, 63–64 Responsibility, and treatment of suicidal patients, 248 Risk factors for Alzheimer’s disease, 391 for schizophrenia, 192–193 for substance-related disorders, 349 for suicide, 230–231, 244–245 “Role suction,” and group therapy, 137 Rorschach test, 87 Sacher-Masoch, Leopold von, 318 Sadism, 317–319, 584 Safety See also Violence attachment theory and, 64 erotic transference and, 571 treatment of suicidal patients and plan for, 248 Saks, Elyn, 202–203 Sandler, Joseph, 64 Scapegoating, and group therapy, 137, 470, 507 Schema-focused therapy, and borderline personality disorder, 446 Schizoid fantasy, 38 Schizoid personality disorder group therapy for, 419–422 individual psychotherapy for, 416– 419, 420 introduction to concept of, 411, 412 psychodynamic understanding of, 412–416 Index Schizophrenia case managers and, 212 discrete psychopathological processes in, 188–189 environmental factors in, 187–188, 193 family interventions and, 203–205 genetics and, 187, 192 group therapy for, 203 hospital treatment for, 206–212 individual psychotherapy for, 195– 203 noncompliance with neuroleptic regimes and, 150, 154 pharmacotherapy for, 193–195 psychodynamic models of, 189–193 psychosocial skills training and, 205–206 schizotypal personality disorder and, 411–412 Schizophreniform disorder, 192 Schizophrenogenic mother, 191 Schizotypal personality disorder group therapy for, 419–422 individual psychotherapy for, 416– 419, 420 introduction to concept of, 411–412 psychodynamic understanding of, 412–416 Seating arrangement, and treatment of paranoid personality disorder, 410 Secondary maturational failures, 417 Secure attachment, 63, 64, 92 Selective serotonin reuptake inhibitors (SSRIs) See also Antidepressants borderline personality disorder and, 445 social phobia and, 271 Self See also Identity; Self-esteem American relational theory and, 50 anorexia nervosa and, 361 assessment and, 91–92 borderline personality disorder and, 460 633 concept of person in definition of psychodynamic psychiatry and, 6–7 deficit model of illness and, dissociation and, 288, 293 mania and lack of continuity of, 234 narcissistic personality disorder and, 491, 492, 496 neurocognitive disorders and, 388, 389 object relations theory and, 44–45 obsessive-compulsive personality disorder and, 583–584 paranoid personality disorder and, 403 risk factors for suicide and, 245 self psychology and, 50–55 Stern on discrete senses of, 61 Self-destructive behavior borderline personality disorder and, 459, 466–467 in dissociative identity disorder patients, 291–292, 303 Self-esteem Alzheimer’s disease and, 393 assessment of, 92 autistic spectrum disorder and, 285– 287 depression and, 226 narcissistic personality disorder and, 486 obsessive-compulsive personality disorder and, 580, 590 paranoid personality disorder and, 402, 403, 405, 409 schizoid personality disorder and, 416 self psychology and, 51, 54, 55 substance-related disorders and, 349, 353 Self-exposure, and avoidant personality disorder, 594 Self-medication borderline personality disorder and, 443 634 PSYCHODYNAMIC PSYCHIATRY IN CLINICAL PRACTICE Self-medication (continued) substance-related disorders and, 352, 353 Selfobject assessment and, 92 as dimension of transference, 19 family/marital therapy and, 147 self psychology and concept of, 52, 54, 55 Self-organization, and borderline personality disorder, 436–437 Self psychology anorexia nervosa and, 360–361 family/marital therapy and, 147–148 masochistic behavior and, 318 narcissistic personality disorder and, 495, 504 paraphilias and, 314, 315 theoretical framework of psychodynamic psychiatry and, 50–57 Separation anxiety borderline personality disorder and, 440–441 forms of anxiety and, 258 histrionic personality disorder and, 550 panic disorder and, 264 Separation-individuation, as phase of development, 60–61, 368 Serotonin, impact of psychodynamic psychotherapy on, 24 Serotonin transporter gene (5HTT) influence of stressful life events on depression and, 220 primate research on development and, 16, 18 Sexism, in psychotherapy training, 560–561 Sex therapy, 331, 336–337 Sexual abuse borderline personality disorder and, 434 brain function and biological effects of, depression and, 221, 226 dissociative disorders and, 286, 291, 292, 294 hysterical personality disorder and, 557 panic disorder and, 264–265 pedophilia and, 320, 321 risk factors for suicide and, 230–231 sadism and masochism, 317 sexual dysfunctions and, 333 Sexual dysfunctions development of concept, 330–333 psychodynamic understanding of, 333–336 treatment considerations for, 336– 339 Sexuality, and histrionic and hysterical personality disorders, 549, 550– 551, 554, 555–556, 560–572 See also Homosexuality; Neosexuality; Sexual dysfunctions Sexualization, as defense mechanism, 38 Sexual offenders, and paraphilias, 324, 325 Shame avoidant personality disorder and, 592, 594 narcissistic personality disorder and, 486, 487, 497 Shedler-Westen Assessment ProcedureII (SWAP-II), 487–488, 547 Short-term psychodynamic psychotherapy (STPP) See also Brief psychotherapy for depression, 231–232, 233 for generalized anxiety disorder, 273 Side effects, of medications, 153, 325 Signal anxiety, 261, 264 Sildenafil citrate, 331, 336 Social behaviors, and autism spectrum disorders, 384 See also Interpersonal relationships; Social skills training Social phobia avoidant personality disorder and, 592 Index case example of, 268–269 treatment of, 270–272 Social skills training, and schizophrenia, 206 Sociopath, use of term, 516 Somatization, 37, 266 “Spacing out,” and dissociative disorders, 285 Specific phobias, 272 Splitting borderline personality disorder and, 430–431, 437, 441–442, 460, 467–468, 469 combined treatment and, 180 definition of, 37 dissociation and, 292–293 hospital settings and, 166, 167, 171– 176 object relations theory and, 45–46 paranoid personality disorder and, 401–402 Spokesperson, and group therapy, 137 Staff meetings, in hospital settings antisocial personality disorder and, 533–534 borderline personality disorder and, 466 countertransference and, 169, 170, 533–534 splitting and, 175–176 Staff members, of hospitals anorexia nervosa and, 363 antisocial personality disorder and, 530 borderline personality disorder and, 464, 466, 467 countertransference and, 167, 169, 170–171, 464, 467 dissociative disorders and, 303 paraphilias and, 329, 330 splitting and, 172–173, 174–176 Stern, Daniel, 61–62 Strange Situation, 64, 92 Stress anniversary reactions and, 84 635 depression and, 219–220, 222, 237 panic disorder and, 263 posttraumatic stress disorder and severity of, 283 schizophrenia and, 187–188 Stress-diathesis model, for mood disorders, 221 Structural interview, 81 Structural model, of unconscious, 35 Subjective self, 61 Subjectivity American relational theory and, 49– 50 family/marital therapy and, 147–148 value of subjective experience in psychodynamic psychiatry and, 8–9 Sublimation, 39 Suborganizations, and object relations, 41 Substance abuse See also Substancerelated disorders antisocial character pathology and, 518 antisocial personality disorder and, 530 group therapy and, 142 histrionic personality disorder and, 548 paraphilias and, 324 risk factors for suicide and, 245 Substance-related disorders See also Substance abuse development of concept, 345–346 genetic factors in, 346–347 models of, 346, 347 treatment of, 351–357 Substance use disorder, 345 Subthreshold symptoms, of schizophrenia, 189 Successful psychopath, 526–527 Suicide, and suicidal ideation anorexia nervosa and, 366 antisocial personality disorder and, 534 636 PSYCHODYNAMIC PSYCHIATRY IN CLINICAL PRACTICE Suicide, and suicidal ideation (continued) borderline personality disorder and, 433, 443, 453, 456, 466, 467 mental status examination and, 86 obsessive-compulsive personality disorder and, 582 posttraumatic stress disorder and, 284 psychodynamic understanding of, 228–231 substance-related disorders and, 350 treatment of, 243–249 Sullivan, Harry Stack, 190–191 Superego antisocial personality disorder and, 523–524 assessment of, 90 Freud’s theory of, 34–35, 41 obsessive-compulsive personality disorder and, 582, 590 substance-related disorders and, 354 Supervision, and treatment of Alzheimer’s disease, 392 Support groups for caretakers of Alzheimer’s patients, 395 for families of borderline personality disorder patients, 467 Supportive psychotherapy See also Expressive-supportive psychotherapy borderline personality disorder and, 450–451 brief therapy and, 126 expressive-supportive continuum in, 100 narcissistic personality disorder and, 499–500 schizophrenia and, 198–199 Suppression, 39 Symbiosis, and development, 60 Systemic desensitization, and posttraumatic stress disorder, 284 Systemic family therapy, 143 Systems Training for Emotional Predictability and Problem Solving (STEPPS), 446 Tape-recording, of manic episodes, 234 Task assignment, and avoidant personality disorder, 595 Temporal splitting, 460 Termination, of psychotherapy erotic transference and, 566–567 expressive-supportive psychotherapy and, 118, 119–121 Testosterone-reducing medications, 325 Thematic Apperception Test, 87–88 Theoretical framework, of psychodynamic psychiatry American relational theory and, 49– 50 attachment theory and, 63–65 clinical practice and, 65–67 developmental considerations in, 57–63 ego psychology and, 34–40 family/marital therapy and, 143–145 object relations theory and, 40–49 psychodynamic formulation and, 93–94 self psychology and, 50–57 Theory of mind, and mentalization, 65, 442 Therapeutic alliance See also Patients; Therapist(s) anorexia nervosa and, 364 bipolar disorder and, 236 borderline personality disorder and, 446, 450, 451–452, 460–461 bulimia nervosa and, 372 depression and, 236–237 dissociative disorders and, 294 expressive-supportive psychotherapy and, 111, 115 group therapy and, 140 narcissistic personality disorder and, 500–501 Index paraphilias and, 326 pharmacotherapy and, 154–157 posttraumatic stress disorder and, 283, 285 schizophrenia and, 200–202 Therapist(s) See also Boundaries; Countertransference; Interpretation; Therapeutic alliance co-therapists in group therapy and, 139 issues for in treatment of suicidal patients, 245–249 suicide of patient and distress of, 243–244 unilateral termination of psychotherapy by, 120–121 Therapist providing treatment as usual (TAU), and outcome studies of depression, 232 Thinking and thought See also Cognition and cognitive style anorexia nervosa and, 361 antisocial personality disorder and, 534 borderline personality disorder and, 429–430 cultures and paranoid forms of, 399 obsessive-compulsive personality disorder and, 581, 591 paranoid personality disorder and, 401 psychodynamic psychiatry as way of, 4–5 Thoreau, Henry David, 422 Time magazine, 482 Time-limited dynamic psychotherapy, for dependent personality disorder, 602 Time-managed group psychotherapy, 138 Topiramate, 445 Topographic model, of unconscious, 9– 10, 34 Transference abstinence and, 105–106 637 borderline personality disorder and, 451–452 brief psychotherapy and, 125–126 clinical interview and, 78–81 dependent personality disorder and, 602, 603 depression and, 238 developmental theory and, 18–20 dissociative disorders and, 300 expressive-supportive psychotherapy and, 110–111, 120 family/marital therapy and, 143, 144 frequency of sessions and, 102–103 group therapy and, 139–140, 177 hospital settings and, 169 histrionic and hysterical personality disorders and, 560–572 narcissistic personality disorder and, 498–499, 502, 503, 507 obsessive-compulsive personality disorder and, 586–587, 589 paranoid personality disorder and, 402 pharmacotherapy and, 151–153 posttraumatic stress disorder and, 285 resistance and, 112 self psychology and, 51 Transference-focused therapy (TFP), and borderline personality disorder, 446, 447–448, 453–454 Transsexuals, and transvestism, 323 Transitional object, body as in bulimia nervosa, 368 Transitional phase, of schizophrenia, 189 Transvestism, 322–323 Trauma See also Microtraumas attachment and, 291 borderline personality disorder and, 434, 436, 443 brain function and biological effects of, depression and, 221, 226 dissociative disorders and, 286, 289, 290, 291 638 PSYCHODYNAMIC PSYCHIATRY IN CLINICAL PRACTICE Trauma (continued) hospital settings and, 167 spectrum of accuracy in memory of, 298 Trauma- and stressor-related disorders, in DSM-5, 281 See also Posttraumatic stress disorder Treatment See also Combined treatment; Family and marital therapy; Group therapy; Hospitals and hospitalization; Individual psychotherapy; Management; Pharmacotherapy; Psychodynamic psychotherapy of alcoholism, 347–351 of anorexia nervosa, 362–366 of antisocial personality disorder, 527–538 assessment of ego functions and, 89 of autistic spectrum disorder, 386– 387 of borderline personality disorder, 444–470 of bulimia nervosa, 369–373 of dissociative disorders, 294–304 of generalized anxiety disorder, 273–276 of histrionic and hysterical personality disorders, 558–573 of narcissistic personality disorder, 495–507 of panic disorder, 262–268 of paranoid personality disorder, 404–411 of paraphilias, 323–330 of posttraumatic stress disorder, 283–285 principles of for depression, 236– 242 of sexual disorders, 336–339 of substance-related disorders, 351– 357 suicidal patients and, 243–249 Treatment of patients with dissociative disorders (TOP DD), 295–296 Tripolar self, 52 Triptorelin, 325 True self, 44 Trust, and borderline personality disorder, 442 Twelve-step programs, and substancerelated disorders, 346, 348 Two-person model, for combined treatment, 179–180 Two-person psychology, and American relational theory, 49, 50 Unconscious basic principles of psychodynamic psychiatry and, 9–12 structural model of, 35 Undoing, 38 Unresolved individuals, and attachment patterns, 64, 92 Unspecified personality disorder, 604 Utilization review process, and managed care, 173 Verbal sense, of self, 61 Veterans, posttraumatic stress disorder and suicide in, 284 Veterans Administration-Penn Study, 355 Victimization, and dissociative identity disorder, 291–292, 300 Violence See also Aggression; Domestic violence; Safety treatment of antisocial personality disorder and fear of by staff members, 533 treatment of paranoid personality disorder and prevention of, 409–411 Virginia Twin Registry, 222 Voyeurism, 317 Weight gain, and treatment of anorexia nervosa, 362, 363 Wilderness programs, and antisocial personality disorder, 529 Index Winnicott, D W., 20, 43, 44, 55, 62, 415, 416, 449, 454 Work group, and group therapy, 135– 136 Work history, and narcissistic personality disorder, 483 Working alliance, 115 639 Working hypothesis, and generalized anxiety disorder, 276 Working through expressive-supportive psychotherapy and, 113 transference in group therapy and, 140 ... memory in criminal and civil cases Int J Clin Exp Hypn 42: 411–4 32, 1994 310 PSYCHODYNAMIC PSYCHIATRY IN CLINICAL PRACTICE Spiegel D, Lowenstein RJ, Lewis-Fernandez R, et al: Dissociative disorder in. .. an intimate part- 29 0 PSYCHODYNAMIC PSYCHIATRY IN CLINICAL PRACTICE ner One in seven had experienced severe violence at the hands of their partner, according to the survey (Rabin 20 11) It is... outcomes from 28 0 patients with DID or dissociative 29 6 PSYCHODYNAMIC PSYCHIATRY IN CLINICAL PRACTICE disorders not otherwise specified using 29 2 therapists from 19 countries at four time points over