Ethics and the Difficult Person: What the New PDM Can Teach Us All Presenter: Robert M. Gordon, Ph.D.

1. Ethics and the Difficult Person: What the New PDM Can Teach Us AllPresenter: Robert M. Gordon, Ph.D.  Learn to recognize clients who can be a risk management problem and/or create ethical dilemmas. Learn how the adult Axis P of the PDM can help with a deeper understanding of difficult clients. Learn the ‘Borderline’ is a level of personality organization that can be at the basis of any personality disorder. Reference: Gordon, R.M., (2007d) PDM Valuable in Identifying High-Risk Patients. The National Psychologist, 16, 6, November/December, page 4. Can be found at www.mmpi-info.com

2. Job consultant's against the grope in $10M suit BY BARBARA ROSS?DAILY NEWS STAFF WRITERMonday, July 9th 2007, 4:00 AM   “A former model who claims that a prominent job consultant grabbed her bottom during a 2002 job interview will finally get her day in Manhattan Supreme Court this week as a jury starts to hear evidence in her $10 million lawsuit.” Let me begin by discussing two frivolous suits against psychologists. These are both examples of revenge by people at the borderline level of personality organization.

3. Case of sex & the shrinkJob hopeful says doc wanted her to strip - and that ain't allBY JOSE MARTINEZ ?DAILY NEWS STAFF WRITERWednesday, July 11th 2007 “An ex-model suing a Manhattan psychologist for allegedly groping her ?testified yesterday the shrink went from professional to pervert in a ?very hands-on job interview.” It took 5 years for this case to go to trial. During that time the psychologist was humiliated by the press and lost his job.

4. Spacy site haunts NYC shrink's accuser NEW YORK, July 12 (UPI) -- “The New York Post said psychologist Robert Gordon testified… "She holds herself out to be an indigo child from another planet who is made of light," Gordon told the Manhattan jury, adding, "this is a very unstable person… Gordon also said examination records indicated a level of paranoia and bipolar disorder.” She had presented herself as a therapist in the job interview with the psychologist. She claimed at the second 20 minute interview he groped at her and almost touched her genitals. She clamed to have been raped by her grandfather. She stated that she doesn’t trust men, even her 8 year old son. Her web site stated that she is from another planet and has special healing powers. In her deposition she stated that she didn’t need a license,that god told her to heal. Her PAI had her in the psychotic range.  She lost in court, but the psychologist had been fired from the university due to the publicity. He spent most his savings defending himself.

5. PDM valuable in identifying high-risk patients “I have often served as an expert witness in malpractice cases where psychologists had missed the psychopathic or borderline traits in patients. They were naively trying to help and before they knew it, they were defending themselves in court, with their professional careers at risk. The DSM classifies antisocial and borderline personality disorders by precise and narrow symptoms. This is often misleading. Psychopathy can be a complex personality pattern that combines with or is obscured by other personality patterns, and borderline can be viewed as an entire level of personality organization that can be applied to the various personality disorders. For example, a patient may have a dependent personality disorder that is organized at either the neurotic or borderline levels of severity.  If it is at the borderline level (no matter how sweetly the patient initially seems), the patient will most likely use splitting (splitting reality into extremes so that you suddenly go from a great therapist to an all bad, rejecting or abandoning therapist) and projective identification (project his own manipulateness and hostility on to you and then treats you accordingly). The Psychodynamic Diagnostic Manual (PDM Task Force, 2006) makes these distinctions and so much more. You will less likely to be blind sided by a victimizing patient if you are familiar with the PDM formulation of personality.” Gordon, R.M., (2007d) PDM Valuable in Identifying High-Risk Patients. The National Psychologist, 16, 6, November/December, page 4.

6. “My Psychologist Abandoned Me!” Middle age woman, with no history of psychiatric or psychological problems seeks out help after her husband commits suicide. Psychologist does gives Beck Depression Inventory, it shows depression and the psychologist does CBT. A CBT therapist will have more insight into patients with a psychodynamic formulation. If one only looks at the surface symptoms, the underlying personality dynamics will be missed.

7. Complaint to Licensing Board and Civil Suit for Damages At first the patient is sweet and appreciative. Calls psychologist frequently between sessions. Begins to stalk him and insist on an outside relationship with him At his rejection, she becomes suicidal and requires hospitalization Psychologist refers her to other psychologists for treatment and does a termination session with her. Later she sues for abandonment. This psychologist did nothing wrong, but practiced poor risk management. He did not manage her as someone with a dependent personality disorder at the borderline level personality organization.

8. 10.10 Terminating TherapyAvoid claims of abandonment and know this standard! (a) Psychologists terminate therapy when it becomes reasonably clear that the client/patient no longer needs the service, is not likely to benefit, or is being harmed by continued service. (b) Psychologists may terminate therapy when threatened or otherwise endangered by the client/patient or another person with whom the client/patient has a relationship. (c) Except where precluded by the actions of clients/patients or third-party payors, prior to termination psychologists provide pretermination counseling and suggest alternative service providers as appropriate.

9. A diagnostic framework that attempts to characterize the whole person--the depth as well as the surface of emotional, cognitive, and social functioning The PDM could be the most important source of information to help you spot people who are most likely to create ethical dilemmas and risk issues.

10. Developed by leading researchers and five psychoanalytic organizations: American Psychoanalytic Association International Psychoanalytical Association Division of Psychoanalysis (39) of the American Psychological Association American Academy of Psychoanalysis and Dynamic Psychiatry National Membership Committee on Psychoanalysis in Clinical Social Work

11. The New York Times Book ReviewFor Therapy, a New Guide With a Touch of Personality  January 24, 2006 By BENEDICT CAREY “The encyclopedia of mental disorders known as the Diagnostic and Statistical Manual is built on a principle that many therapists find simplistic: that people's symptoms are the most reliable way to classify their mental troubles.”

12. The New York Times Book Review The most striking proposal in the new manual is its insistence that personality be evaluated first, and symptoms considered secondary. The first section of the book describes 14 different personality patterns. It also restores others that were dropped from recent editions of the D.S.M., like sadistic, masochistic and passive-aggressive personality patterns. "The D.S.M. is a taxonomy of diseases or disorders of function. Ours is a taxonomy of people,“ the new manual declares.

13. Financial Ties between DSM-IV Panel Members and the Pharmaceutical IndustryLisa Cosgrovea, Sheldon Krimskyb, Manisha Vijayaraghavana, Lisa Schneidera Psychotherapy and Psychosomatics 2006;75:154-160 Of the 170 DSM panel members 95 (56%) had one or more financial associations with companies in the pharmaceutical industry. One hundred percent of the members of the panels on 'Mood Disorders' and 'Schizophrenia and Other Psychotic Disorders' had financial ties to drug companies. Or why there was no ‘Depressive Personality Disorder.’Or why there was no ‘Depressive Personality Disorder.’

14. The PDM is a superior system for case formulation and psychotherapy Under HIPAA, insurance companies who accept and process insurance claims electronically are only required to accept the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). The International Classification of Diseases is published by the World Health Organization. Use the ICD-9-CM for reimbursement and the PDM for case formulations

15. Basis The PDM is based on current neuroscience, treatment outcome research, and other empirical investigations.

17.  Conceptual and Research Foundations of a Psychodynamically Based Classification System for Mental Health Disorders  Historical and Conceptual Foundations Psychoanalytically Based Nosology: Historic Origins R. S. Wallerstein Suitability and Indications for Psychoanalytical Psychotherapy A. Braconnier, N. Guedeney, B. Hanin, F. Sauvagnat, J. M. Thurin, and D. Widlöcher A Developmental Framework for Depth Psychology and a Definition of Healthy Emotional Functioning S. I. Greenspan and S. G. Shanker The Contribution of Cognitive Behavioral and Neurophysiological Frames of Reference to a Psychodynamic Nosology of Mental Illness H. Shevrin

19. Unbeknownst to most students of psychology, Pavlov’s first experiment was to ring a bell and cause his dog to attack Freud's cat.

21. Psychodynamic View of Consciousness

22. “O.K. What part of ‘malignant regression and pathogenic reintrojection as a defense against psychic decompensation’ don’t you understand?” Psychoanalytic theory is threatening to many. It is intellectually challenging, demands a high degree of psychological mindedness and self-reflection. It stirs up repressed material that people would rather avoid by shooting the messenger (rejecting the theory). Int J Psychoanal. 2000 Aug;81 ( Pt 4):651-66. Hypochondria: a tentative approach. By Nissen B. Catastrophic states resulting from earlier traumas are here fused with more mature psychic elements owing to earlier traumas. The author shows how instability in these structures, together with the failure of important ego and superego functions, may lead to a malignant regression and the consequent pathogenic reintrojection of projections. When the psyche is threatened by a dynamic of this kind, hypochondriacal symptoms may ensue as a last-ditch attempt by the patient to defend against psychic decompensation. Int J Psychoanal. 2000 Aug;81 ( Pt 4):651-66. Hypochondria: a tentative approach. By Nissen B. Catastrophic states resulting from earlier traumas are here fused with more mature psychic elements owing to earlier traumas. The author shows how instability in these structures, together with the failure of important ego and superego functions, may lead to a malignant regression and the consequent pathogenic reintrojection of projections. When the psyche is threatened by a dynamic of this kind, hypochondriacal symptoms may ensue as a last-ditch attempt by the patient to defend against psychic decompensation.

23. "Look, call it denial if you like, but l think what goes on in my personal life is none of my own damn business."

24. 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.”

26. Most of what goes on in our brain is unconscious and it affects our emotions, thoughts, perceptions and motives. Most of what goes on in the brain is unconscious that affects our subjective feelings, perceptions and behaviors Psychology has been stuck in the study of the conscious, but most of the brain is about unconscious functioningPsychology has been stuck in the study of the conscious, but most of the brain is about unconscious functioning

27. Split Brain Experiments Roger Sperry (who won the Nobel prize in 1981) and Michael Gazzaniga are two neuroscientists who studied patients who had surgery to cut the corpus callosum. Their research demonstrated that since the corpus callosum was cut, the two sides of the brain could not communicate. The patient would smell a rose, pick a rose from several objects behind a screen, but deny any smell of the rose. It demonstrated unconscious perception and motivation.

28. Split Brain Studies of Unconscious Perception

29. Bruyer, R. (1991). Covert face recognition in prosopagnosia: A review. Brain and Cognition, 15, 223-235. Individuals with prosopagnosia, who lose the capacity to discriminate faces, unconsciously show differentiated electrophysiological responses to familiar versus unfamiliar faces Prosopagnosia (sometimes known as face blindness) is a disorder of face perception where the ability to recognize faces is impaired, while the ability to recognize other objects may be relatively intact. The term usually refers to a condition following acute brain damage, but recent evidence suggests that a congenital form of the disorder may exist. The specific brain area usually associated with prosopagnosia is the fusiform gyrus.[1]One particularly interesting feature of prosopagnosia is that it suggests both a conscious and unconscious aspect to face recognition. Experiments have shown that when presented with a mixture of familiar and unfamiliar faces, people with prosopagnosia may be unable to successfully identify the people in the pictures, or even make a simple familiarity judgement ("this person seems familiar / unfamiliar"). However, when a measure of emotional response is taken (typically a measure of skin conductance) there tends to be an emotional response to familiar people even though no conscious recognition takes place[8]This suggests emotion plays a significant role in face recognition, perhaps unsurprising when basic survival (particularly security) relies on identifying the people around you.Prosopagnosia (sometimes known as face blindness) is a disorder of face perception where the ability to recognize faces is impaired, while the ability to recognize other objects may be relatively intact. The term usually refers to a condition following acute brain damage, but recent evidence suggests that a congenital form of the disorder may exist. The specific brain area usually associated with prosopagnosia is the fusiform gyrus.[1]One particularly interesting feature of prosopagnosia is that it suggests both a conscious and unconscious aspect to face recognition. Experiments have shown that when presented with a mixture of familiar and unfamiliar faces, people with prosopagnosia may be unable to successfully identify the people in the pictures, or even make a simple familiarity judgement ("this person seems familiar / unfamiliar"). However, when a measure of emotional response is taken (typically a measure of skin conductance) there tends to be an emotional response to familiar people even though no conscious recognition takes place[8]This suggests emotion plays a significant role in face recognition, perhaps unsurprising when basic survival (particularly security) relies on identifying the people around you.

30. Emotions in mammals are all similar and evolved for functional reasons. They may be affected by thoughts, but they are not created by thoughts- as in the assumption of CBT. PAG=Periaqueductal gray;AC = anterior commisure for sure.BN likely basal nucleus PAG=Periaqueductal gray;AC = anterior commisure for sure.BN likely basal nucleus

32. HarlowHarlow

34. Mickelson, K. D., Kessler, R. C. & Shaver, P. R. (1997). Adult attachment in a nationally representative sample. Journal of Personality and Social Psychology, 73, 1092-1106. In a non-clinical sample of 5,000 adults a history of parental loss and separation was associated with higher ratings of insecure attachment and lower attachment security Mickelson, K. D., Kessler, R. C. & Shaver, P. R. (1997). Adult attachment in a nationally representative sample. Journal of Personality and Social Psychology. 73:1092-1106. -In a non-clinical sample of 5,000 adults a history of parental loss and separation was associated with higher ratings of insecure attachment and lower attachment security Mickelson, K. D., Kessler, R. C. & Shaver, P. R. (1997). Adult attachment in a nationally representative sample. Journal of Personality and Social Psychology. 73:1092-1106. -In a non-clinical sample of 5,000 adults a history of parental loss and separation was associated with higher ratings of insecure attachment and lower attachment security

35. 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. Our unconscious attachment history remains with us and affects our intimacies. This can not be reached at a cognitive-behavioral level, but only within an empathic therapeutic relationship.

37. Helen Fisher found that the area of the brain known as the caudate is associated with passion. Did you notice it in the lover’s brains in the previous slide?

38. Eagle, M. (1959). The effects of subliminal stimuli of aggressive content upon conscious cognition. Journal of Personality, 27, 678-688Eagle, M. (1959). The effects of subliminal stimuli of aggressive content upon conscious cognition. Journal of Personality, 27, 678-688

39. 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.

41. Delusional mother alleging child sex abuse against the father in a custody case. There was no evidence of abuse. She lied about me in her Board complaint claiming I was abusive to her. She expressed the same paranoia about me as she did with the father. Her MMPI-2 is similar to the Alienating Parents in the study in the previous slide. She sees no fault in herself and projects her pathology on to others. The investigator never brought her claim to the board.

42. Empirical Support for Psychoanalytic Theory 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 Freud’s 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.

43. The functional anatomy of a hysterical paralysis.Marshall, John C.; Halligan, Peter W.; Fink, Gereon R.; Wade, Derick T.; Frackowiak, Richard S. J., Cognition. 1997 Jul Vol 64(1) B1-B8 Neuropsychologists studied the fMRI of a woman with conversion hysteria. When the woman tried to move her "paralyzed leg," her primary motor cortex was not activated as it should have been; instead her right orbitofrontal and right anterior cingulate cortex parts of the brain that have been associated with action and emotion were activated. Authors reasoned that these emotional areas of the brain were responsible for suppressing movement in her paralyzed leg.

44. Figure 1. Higher scores on hysteria as psychoanalysis begins are related to more concerns with sexual conflicts six to twelve months into psychoanalysis. Rosemary Cogan and John H. Porcerelli, presented at the American Psychoanalytic Assoc. New York, 1.19.07 Rosemary Cogan and John H. Porcerelli, presented at the American Psychoanalytic Assoc. New York, 1.19.07 Used the SWAP-200 on 6 men and 6 women in psychoanalysis Rosemary Cogan and John H. Porcerelli, presented at the American Psychoanalytic Assoc. New York, 1.19.07 Used the SWAP-200 on 6 men and 6 women in psychoanalysis

45. Figure 2. Higher scores on obsessiveness as psychoanalysis begins are related to more concerns with hostile conflicts twelve months and longer into psychoanalysis.

46. Gordon, R.M. (2001) MMPI/MMPI-2 Changes in Long-Term Psychoanalytic  Psychotherapy. The MMPI is very stable and does not react to low dose treatment. It did react to high dose long term psychoanalytic psychotherapy with patients with personality disorders. It took years to get to the level of structural changes- reduced symptoms and more emotional maturity.

47. Now that you have seen some examples of psychodynamic research- back to the PDM. The PDM adult nosology begins with a classification of personality patterns and disorders, then offers a "profile of mental functioning" covering in more detail the patient's capacities, and finally considers symptom patterns, with emphasis on the patient's subjective experience.

48. P Axis This dimension has been placed first in the 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 mental life of the person who has the symptoms.

49. Dimension I: Personality Patterns and Disorders P Axis The PDM classification of personality patterns takes into account two areas: the person's level of severity by personality organization, and the characteristic personality pattern or personality disorder.

50. Kernberg’s Differentiation of Personality Organization Preceded the PDM Neurotic Borderline Psychotic Identity +integrated - diffused - Integration Defensive +higher - primitive - Operations Reality + + - poor Testing

51. Borderline Personality Disorder DSM IV Criteria is a Collection of Symptoms A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5. 2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. identity disturbance: markedly and persistently unstable self-image or sense of self. 4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5. 5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior 6. affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). 7. chronic feelings of emptiness 8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) 9. transient, stress-related paranoid ideation or severe dissociations

52. Level of Personality Organization (Severity of Personality Disorder)Note that “borderline” in the PDM is a level of severity Healthy Personalities (Absence of Personality Disorder)(favoring defenses such as suppression, humor, sublimation, altruism) Neurotic-Level Personality Disorders(favoring defenses such as repression, intellectualization) Borderline-Level Personality Disorders(favoring defenses such as splitting, projective identification, denial)

53. 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).

54. Once the level of Personality is Determined (neurotic or borderline), then Consider the Type of Personality Disorder P101. Schizoid Personality Disorders P102. Paranoid Personality Disorders P103. Psychopathic (Antisocial) Personality Disorders  P103.1  Passive/Parasitic   P103.2  Aggressive  P104. Narcissistic Personality Disorders  P104.1  Arrogant/Entitled  P104.2  Depressed/Depleted P105. Sadistic and Sadomasochistic Personality Disorders  P105.1  Intermediate Manifestation: Sadomasochistic Personality Disorders P106. Masochistic (Self-Defeating) Personality Disorders  P106.1  Moral Masochistic  P106.2  Relational Masochistic

55. P107. Depressive Personality Disorders  P107.1  Introjective  P107.2  Anaclitic   P107.3  Converse Manifestation: Hypomanic Personality Disorder P108. Somatizing Personality Disorders P109. Dependent Personality Disorders  P109.1  Passive-Aggressive Versions of Dependent Personality Disorders  P109.2  Converse Manifestation: Counterdependent Personality Disorders P110. Phobic (Avoidant) Personality Disorders  P110.1  Converse Manifestation: Counterphobic Personality Disorders P111. Anxious Personality Disorders

56. P112. Obsessive-Compulsive Personality Disorders  P112.1  Obsessive  P112.2  Compulsive P113. Hysterical (Histrionic) Personality Disorders  P113.1  Inhibited  P113.2  Demonstrative or Flamboyant P114.  Dissociative Personality Disorders (Dissociative Identity Disorder/Multiple Personality Disorder) P115.  Mixed/Other

57. The P Axis- Personality Disorders Considers the Following Factors:  Temperamental, Thematic, Affective, Cognitive, and Defense patterns

58. For Example: 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

59. 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

60. 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

61. Beware of the “Quiet” Borderline According to the PDM, borderline is a level of personality organization. It can be lurking under ‘neurotic’ symptoms or a seemly mild personality disorder. Until… The borderline patient demands magic or love and if you do not provide it, you are viewed as rejecting or abandoning. The borderline patient may have a psychotic transference to you. The borderline patient may manipulate you into boundary violations that will get you in trouble.

62. The PDM May be Your Best Friend in Spotting Difficult Patients Learn from it! Thank You.