Psychopathology week 4

1. Review a bit of on last quiz and diagnoses Early attention towards threat relevant material. anxiety as an organizing human experience How we defend against anxiety A whirlwind tour of analytic thinking with focus on modern ego/self psychologists A few genetic thoughts case example Psychopathology week 4

2. How do we show that disorders ‘truly exist’? When we know disorders are consensus constructs. And are thus vulnerable to various contextual biases (gender, race, politics…) They are more less useful (predicting behavior, explaining, advancing theory, conducting research, etc.) ‘usefulness’ is not verifiable ‘truth’ –diagnoses are more like emotions than they are like goats and puppies. DSM diagnoses

3. Attentional Processes in Psychopathology • Can we find experimental evidence for biases in attention to specific kinds of clinically relevant information? • MacLeod- • do attentional biases towards negative information cause increased reactivity to frustrating/upsetting events and, in turn, cause greater distress? • or, do high N folks create more unhappiness by their tendency to focus on negative information around them. • lots of empirical evidence (see also Lundh et al.,1999 when we read about anxiety)

4. Freud (and others)confront anxiety

5. Reality Anxiety Most basic form: reality  e.g., dog bites, impending accidents Reduce tension by immediate behavioral action Neurotic Anxiety anxiety arising from irresolvable conflicts—id desires clash with internalized prohibitions or can arise from unconscious fear that (id) impulses will take control at an inopportune time can be driven by fear of punishment or threats to self esteem Moral Anxiety Results from fear of violating moral or societal codes Appears as guilt or shame (irrational responsibility) Lady Macbeth experienced moral anxiety (after plotting the death of the King) and engaged in undoing to ward it off. Anxiety

6. We all need to manage/reduce anxiety helps reduce drive conflicts helps protect self esteem Defense mechanisms distort, transform, or falsify reality (internal or external) allow individual to reduce dissonance and minimize sudden changes in internal and external environments by altering perception of events Conflicts and reality reality has inevitable frustration of desires, and of course lots of real pain, loss, disappointment… Why Defense Mechanisms?

7. Processes are (by definition) unconscious we are unaware when we employ defense mechanisms conscious mechanisms are thought of as coping styles (avoidant coping, information gathering, etc.) but defensive maneuvers are observable/ measurable clues are often felt/cues revealed to the careful observer during interpersonal interactions the transference/ counter- transference matrix of therapy can be elicited in interviews, probing questions “How do you handle anxiety?” use of initial interpretations Defense Mechanisms where? how?

8. Relative in their adaptiveness help manage affect safety evokes more primitive defenses/greater range Differ substantially from cognitive/behavioral models of adaptation are seen as motivated/compromise adaptations rather than deficit states or learned voluntary strategies. more on defense mechanisms

11. Why Parapraxis? • Frued was a positivist who believed complex behavior could be explained by rules: Psychic determinism • All psychic events have a psychic cause, even mistakes • All parapraxes have at their root unconscious (Id) desires

12. Rush of pleasure from release of tension Allows expression of repressed impulses Does not require substantial distortion of reality but still provides a buffer against inner/outer reality as in, jokes and silliness are fun because: Escape from reality Having always to deal with reality is no fun death, loneliness, meaninglessness etc. Thus: escaping reality is endemic to humanity! Humor

13. Sexual Humor

14. Aggressive Humor

15. Elimination Humor

16. psychoanalytic character diagnosis • Seeking to expand/enrich the domains of relevant information beyond symptom presentation. • Drive vs. Ego Psychology • Drive theory: • biologically based, nomothetic (basic rules of development constant across people), positivitistic (assumes a knowable solution is available). • oral, anal, phallic. rooted in biological/psychosexual concerns and linked to later pathology. e.g., the anal personality of the obsessive, aggressive orality of borderlines (biters). “where is the fixation?” • shares with behaviorism the key assumption the behaviors are determined by knowable rules.

17. psychoanalytic character diagnosis • Ego Psychology • more ideographic (focus on unique attributes of the individual’s developmental context) in accounts of pathology. • grew out of Freud’s structural model (Id, Ego, Superego). This model emphasized dynamics of internal struggle. • but ego psychology is process/defense. Focus is on how we: • 1) defend against unacceptable impulses and • 2) protect our self esteem

18. Linked to personality disorders not surprising as personality is often described as one’s characteristic ways of behaving across situations in relatively low situational constrained situations that allow for range of behavioral responses anxiety provoking situations are often such situations interpersonal conflicts internal distress Shapiro (1964, 1999) argued characteristic ego functioning/defensive styles arepsychopathological personality the patient is the embodiment of the problem—it is not a separate entity/symptomatic cluster visited upon the patient hence, clinical material is present in all of the patient’s behaviors. defense mechanisms as style

19. McWilliams distinction between concordant and complementary counter transferences: concordant- you feel what the patient felt in relation to an important other. (e.g., passive-aggressive patients can leave you feeling impotent). complementary- you feel like the important other in relation to the patient. (e.g., hating the passive-aggressive patient). Defense mechanisms seen in the relationship

20. psychoanalytic character diagnosis • Object-Relations • emphasize the importance of the socio-emotional aspects of development. quality of relationships with care givers provides ground work for internalized representations • shift in focus from reality of developmental life to importance of representation in mental life. • opened the way for additional appreciation of in the room dynamics with therapist—as in, the ways patients’ recreate dramas from early life, scripts, expectations (blends with repetition compulsion).

21. some defense mechanisms • repression removal of threatening thoughts from awareness • projection the attribution of unacceptable impulses to others; • denial refusal to recognize a threatening situation or thought; • rationalization giving a reasonable explanation for an event; • regression return to a less mature, anxiety reducing behavior; • reaction formation the expression of the opposite of disturbing ideas; • displacement substituting a less threatening object for impulses; • sublimation channeling of impulses into socially acceptable outlets.

22. Ego Defenses • label the defense mechanism with the situation • _____Felix doesn't deal with his three pack/day cigarette habit, claiming that "I'll probably die from an accident before cancer gets me." • _____After some especially frustrating and unfair criticism from her professor, Erin starts an argument with her roommate during lunch. • _____Kevin has no memory of his seventh grade class play which was marred by his forgetting his lines and leaving the stage in tears. • _____Michael explains his bad grade on the final by noting that he had a long phone call from his parents the night before the exam. • _____Jessica, who was quite the "party animal" only a few months earlier, writes the university president arguing for the mandatory expulsion of alcohol-using students. • _____Meagan uses her anger over a disagreement with a friend to set a school record in the 100 meters. • _____Matt, who ordinarily keeps his anger under wraps, sees every other driver's breach of automotive etiquette as a personal criticism. • _____After an especially traumatic day, in which she failed three different exams, Hina curls up in a blanket and rocks herself to sleep.

23. Character/DevelopmentalLevel • Developmental Levels: • Symbiotic: psychosis • Separation-individuation: borderline • Oedipal: neurotic • symptom vs. character neurosis • not reflected well in DSM • example of obsessive ‘worker’ who wants help developing a program of self-improvement.

24. Developmental Levels of Personality Organization • character neurosis— • gradual improvement, nature of relationship may be more important in treatment, rigidity is prominent • symptom neurosis— • more rapid improvement, more trust of therapist, greater working alliance, flexibility of defenses, etc. • Borderline pathology—not seen as a category by analysts but as a level of severity.

25. Developmental Levels of Personality Organization • neurotic level— • use of mature defenses (intellectualization, suppression) assessment questions to help sus out level: • is there an identifiable precipitant vs. long standing? • has there been dramatic increase in anxiety or gradual? • self referred or other referred? • symptoms ego alien or ego syntonic? • can person have perspective on problems (agent and victim)?

26. A few genetic thoughts types of studies (Schaffner, 2001). • epidemiological and molecular • epidemiological—focused on large sample, statistical modeling of variance accounted for by known and unknown influences (shared and non-shared environment, shared genes, etc.). • gold material are identical twins reared apart. molecular—focus is on identifying candidate genes. polygenic—sets of genes influence the phenotypic manifestation of the disorder. • sadly, we are much better (though still in relative infancy) in identifying genetic influences compared to environmental influences. • movement towards mixed models of population, gene mapping, and developmental appreciation of environmental stressors is afoot.

27. Betsy • Presents as an attractive, vivacious, verbal, flirtatious 23 year old mother of 2 (1 and 3 year old boys) moderately distressed in the wake of separation and pending divorce from verbally and psychologically abusive husband. • Long standing self esteem concerns dating back to psychological abuse at the hands of step-mother. Most of abuse occurred ages 4-5. prior to the birth of ½ sister. Older siblings (2 brothers) spared the abuse. (fabricate bad behaviors to ‘tell your father when he gets home’, put baking soda in her cereal, etc.) • Socially conservative family, parents divorced but didn’t want betsy to. Bio-mother was alcoholic and having an affair with a police man. She later cleaned up and married the cop and became successful in the family business (in same office with ex—betsy’s father). Step mother at home; does arts/crafts.

28. Betsy • Betsy’s ex routinely abuses verbally (currently; swearing alternating with overtures) during low points of marriage he would kick her out of bed and make her sleep on the floor. He was paranoid and possessed by jealousy. • She told family who ‘liked him’ and wanted her to stick it out. Father still has a photo of her with ex on his wall at work. She playfully covers up his face with post its. • She is the repository of dirty family secrets…went to psychiatrist ~age 15 who called father at work to tell him about his wife’s abusive behavior during betsy’s childhood. He rejected the charges and later told betsy ‘don’t make me choose between the two of you’

29. Betsy • She doesn’t meet criteria for any dsm diagnosis. Closest would be histrionic pd (flirty, sexualized, attention seeking,…) but she has been able to maintain some long term meaningful relationships with friends and is not particularly fickle in her affections. • She deeply wants affirmation from men. Creates a dynamic with them in which she is flirtatious and lively and knows she can affect a bar full of men. Excited, they sense her lack of self-protective boundaries and are inappropriately intimate-e.g., grab her ass, buy her meals, soldier boy who moved across the country… so she complains she can’t take men seriously, they are easily manipulated and foolish.

30. Betsy • Seeks out the unavailable-emotionally distant men who often see her as superficial and weak. ‘I want the ones that don’t want me.’ seeking the elusive, hard won affirmation/love from men unable to provide it. • Suffers from an impoverished self. Sees her emotional reactions (especially negative feelings) as dangerous and likely to cause others to abandon her. Fears her father will cast her out of the family if she presses him or step-mother on the abuse. Has undeveloped sense of self protective anger. Rationalizes/minimizes/represses • a bit like gloria in that she does not demand respect. She wields her power in seduction of the masses and pursuit of the damaged/unavailable--controlling/jealous assertive men who don’t see her (as her father and mother don’t) or abuse her (as her step mother/husband did).

31. Betsy • Last interesting note on the Freud’s notions that behavior is multi layered in its symbolism: • She applied for entry into the police academy. • Meaning of being a cop—powerful (when she feels weak) • Themes of dominance/submission (role established boundaries involving control/assertion) • Manifest way of negating her experience of powerlessness at the hands of step-mother/husband. • a compromised attempt at mastery—forced to be powerful. an abdication of self: selflessly giving by becoming a symbol of power/authority without having to change internal structures • identification with step-father whom she has fond feelings for (he is a retired cop)