Psychopatology Gabbasrd

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Psychopatology Gabbasrd

Post  counselor on Sun Nov 30, 2014 10:47 am

schizophrenia
Genetic factors play a very important role in the development of schizofrenia.Tuttavia, as with almost all psychiatric disorders, it is not a clear mode of transmission of Mendelian. It is likely that there is some genetic heterogeneity - in other words, it is likely that the defective genes involved are more than one and that several paintings underlie genetic disorder. Even environmental factors appear to be involved in the development of schizophrenia, although there is still no consensus on the specific nature of these insults. Among the possible factors include perinatal damage, viral infections during pregnancy, problems of blood perfusion intrauterine factors related to diet, evolutionary accidents and certain types of childhood trauma. None of the discoveries of biological research, however, mitigates the impact of uri irreducible fact - schizophrenia is a disease that affects a person with a particular psychological configuration. Although genetic factors were responsible for 100 percent of the etiology of schizophrenia, clinicians would find themselves increasingly faced with an individual dynamically complex that reacts to a disease deeply disturbing. Sophisticated psychodynamic approaches to the management of the schizophrenic patient will always be an essential component of the therapeutic armamentarium of the clinician. Probably no more than 10 percent of schizophrenic patients is able to adequately respond to a therapeutic approach that consists only of antipsychotic drugs and a brief hospitalization. I1 remaining 90 percent require treatment approaches dynamically oriented psychotherapy that include pharmacotherapy, individual therapy, group therapy, family approaches and hospital treatment psychodynamically oriented as crucial ingredients for effective management of their disease. There is no such thing as the treatment of schizophrenia. All interventions should be tailored to the specific needs of each patient. Schizophrenia is a heterogeneous disease with protean clinical manifestations. A useful structuring of the descriptive symptoms of the disorder is the division into three groups: 1) positive symptoms, 2) negative symptoms, 3) personal relationships disturbed (Andreasen et al., 1982; Keith, Matthews, 1984; Munich et al., 1985; Strauss et al., 1974). Proposed for the first time since Strauss and colleagues (1974), this model identifies three distinct psychopathological processes observed in schizophrenic patients. Positive symptoms include disorders of thought content (such as delusions), disorders of perception (such as hallucinations) and behavioral manifestations (such as catatonia and agitation) that develop in a short time and are often accompanied by a acute psychotic episode. While the positive symptoms are undeniable flourishing "presence", the negative symptoms of schizophrenia can be characterized as an "absence" of functions. These symptoms include negative affectivity constricted, poverty of thought, apathy and anhedonia. Carpenter and coworkers (1988) have suggested a further distinction of negative symptoms. they have shown that certain forms of social withdrawal, flattened affect and apparent impoverishment of thought may actually be secondary to anxiety, depression, deprivation or environmental effect of psychotropic substances. These events should therefore not be labeled as negative symptoms are secondary and of short duration. Carpenter and co-workers have proposed the definition deficit to indicate clearly the primary negative symptoms that persist over time. the duration of the negative symptoms is prognostically significant. While once thought that their presence would imply a worse prognosis, recent research suggests that negative symptoms are reliable predictors of poor outcome only when persist beyond the initial phase of the disease. As the negative symptoms, disturbed personal relationships tend to develop in a significant period of time. Prominent manifestations of disturbed interpersonal relationships include withdrawal, inadequate expression of aggression and sexuality, lack of awareness of the needs of others, the excessive demands and the inability to have meaningful contact with other people. In fact all three categories overlap extensively, and the same schizophrenic patient may move, in the course of the disease, from one group to another. 179-81 many psychodynamic models have been proposed to help clinicians in understanding the schizophrenic process. The dispute between the model of the conflict than the deficit (as described in Sec. 2) is a prominent feature in the discussions on the theories of schizophrenia. Freud himself wavered between a model of conflict and a deficit model for schizophrenia gradually evolved that his conceptualizations (Arlow, Brenner, 1969; Grotstein, 1977a, b; London, 1973a, b; Pao, 1973). Much of Freud's conceptualization (1910, 1914, 1915, 1923, 1924) developed from its notion of cathexis (charge, energy investment) with which indicated the amount of energy tied to any intrapsychic structure or object representation. He was convinced that schizophrenia was characterized by disinvestment energy (decathexas) objects. Sometimes used to describe this concept of disinvestment detachment of emotional investment or libidinal object representations from intrapsychic, and sometimes used it to describe the social withdrawal by the real people of the surrounding environment (London, 1973a). Freud defined schizophrenia as a regression in response to intense frustration and conflict with other people. This regression from object relations in an evolutionary stage autoerotic occurred in parallel with a withdrawal of emotional investment from object representations and external figures, thus explaining the appearance of autistic withdrawal in schizophrenic patients. Freud postulated then that the energy charge for divestment was reinvested on the self or ego (1914). After processing the structural model, modified, consequently, their conception of psychosis (1923, 1924). While believed neurosis a conflict between the ego and 1'Es, psychosis considered a conflict between the ego and the outside world. Psychosis involved a disregard and a consequent remodeling of reality. Despite this revision, Freud went on to talk about the withdrawal of the investment of energy and its reinvestment in the ego. Harry Stack Sullivan thought first that 1'eziología disorder was to trace in early interpersonal difficulties (particularly in the child-parent relationship), and the treatment conceptualized as an interpersonal process in the long term, trying to identify those issues early. Inadequate maternal care, according to Sullivan (1962), result in the newborn a self load of anguish and prevent the child to receive satisfaction for his needs. This aspect of self-experience is then dissociated, but the damage to self-esteem remains deep. Disease onset schizophrenic, in the conception of Sullivan, is a revival of the Self dissociated, leading to a state of panic and then the psychotic disorganization. Sullivan believed that there was always, even in schizophrenics more withdrawn, a capacity of interpersonal relationship. His pioneering work with schizophrenic patients was carried out by his pupil, Frieda Fromm-Reichmann (1950), which showed that the subjects with schizophrenia are not happy in their withdrawal. People are fundamentally alone, who can not overcome their fear and their distrust of others because of adverse experiences lived early. While Sullivan and collaborators were developing their interpersonal theories, the early ego psychologists observed as a defective ego boundary is one of the main deficits in schizophrenic patients. Federn (1952) dissented from Freud that in schizophrenia there is a withdrawal of the investment object. Conversely, Federn emphasized the withdrawal of energy investment than ego boundaries. He noted that schizophrenic patients are characteristically devoid of barrier between what is inside and what is outside, because the borders of their invested psychologically it is not (as it is in neurotic patients). Children who end up developing schizophrenia have an aversion to the object relationships that makes it difficult to bond. Hypersensitivity to stimuli and difficulties in concentration and attention are common traits of personality preschizofrenica. Recent research has suggested that widespread losses, at the level of certain areas of the normal sensory filter in the central nervous system may be characteristic of schizophrenia (Freedman et al., 1996; Judd et al., 1992), so that patients find it difficult to shield the irrelevant stimuli and experience a chronic feeling of sensory overload. In a comprehensive synthesis of the literature, Olin and Mednick (1996) have identified premorbid characteristics that seem to be risk markers for future psychosis. These features fall into two categories: 1) early etiological factors, including a family history of schizophrenia, perinatal complications, maternal exposure to influenza virus during pregnancy, neurobehavioral deficits, parental separation during the first year of life, family dysfunction and growth within an institution; 2) behavioral and social precursors of mental illness, identified by clinicians and teachers, and personality variables revealed by interviews and questionnaires. In other words, there is an interaction between genetic vulnerability, environmental characteristics and individual traits. a psychodynamic understanding is important for the therapy of schizophrenia, regardless of its etiology. Some issues are common to many of the psychodynamic theories that influence the clinical approach to the patient. First of all, the psychotic symptoms have meaning (Karon, 1992). Hallucinations or delusions of grandeur, for example, often appear immediately after an affront to the self esteem of the schizophrenic patient. The content of the grandiose thought or perception is the patient's attempt to compensate for the narcissistic wound. A second common concept is that interpersonal relationships are a source of terror for these patients. The intense anxieties related to the contact with others are obvious even if you can not clearly making explicit the causes. Concerns about the integrity of ego boundaries and the fear of fusion with the other is an issue of increasing intensity, which is often solved with the insulation. The therapeutic relationship is a challenge for the patient to be able to believe that from his relationship with others will not derive a catastrophe. Finally, a third point concerns the common belief of all the authors of a psychodynamic approach that psychodynamic therapeutic relationships with clinical sensitive can fundamentally improve the quality of life of patients with schizophrenia. In a study of patients in complete remission (Rund, 1990), 1'80 per cent had received a long-term psychotherapy attributing to it a great importance. Even when it was not achieved a complete remission, the therapeutic relationship could be considered of extraordinary importance in adapting to the patient's overall life. 181-5 control well-designed studies have amply demonstrated that antipsychotic drugs are highly effective in treating the positive symptoms of schizophrenia. The accessibility of the schizophrenic patient to all other forms of therapeutic intervention is greatly enhanced by the judicious use of neuroleptics. Keith and Matthews (1984) have even claimed that "freedom from positive symptoms is almost a prerequisite for psychosocial treatments" .I negative symptoms and disturbed interpersonal relationships, however, are much less affected by the drugs and therefore require approaches psychosocial. It seems that some of the new atypical antipsychotic agents (such as clozapine, risperidone and 1'olanzapina) have a better impact on the constellation of negative symptoms. The new atypical antipsychotics that have become widely used in the last decade have revolutionized the treatment of schizophrenia. These agents, including risperidone, clozapine, olanzapine, quetiapine and ziprasidone, are effective as the least common antipsychotic drugs compared to positive symptoms, while they are more effective than conventional antipsychotics against negative symptoms. Furthermore, these drugs often avoid to patients across a range of troublesome side effects, so that they are more willing to take the therapy and to participate in psychosocial treatments. It was found that treatment with risperidone exert a more favorable effect on verbal working memory compared to therapy with a conventional antipsychotic agent, thus making collaboration in psychotherapeutic treatment or psychosocial something more of a chance (Green et al., 1997) . The advent of atypical antipsychotics has resulted in new challenges for clinical psychotherapy. Some chronically ill patients for many, many years because of a failure to respond to traditional drugs have suddenly found themselves in a state of remission. Some observers (Degen, Nasper, 1996; Duckworth et al., 1997) have compared these dramatic remissions in what Oliver Sacks (1973) has described as "awakenings". Psychosis can fulfill a defensive function for many patients, so that they can avoid dealing with the uncertainties of the relationships, the complexity of work situations and the meaning of existence. The totality of the identity of the individual can be absorbed by the awareness of having a chronic disease. When you finally realize a remission of symptoms, there is often a grieving process related to what has been lost and the disconcerting feeling of not knowing who you are in a state of mind not psychotic. As noted Degen and Nasper (1996), "despite the improvement unambiguous, for some individuals the sudden absence of symptoms becomes at least as painful psychosis". The psychotherapeutic intervention can help the patient to integrate the old and the new self. Patients with chronic psychosis may also have been protected from the risks of intimacy. The remission of psychotic symptoms makes it possible, for the first time in many years, romantic entanglements and sexual. Faced with this prospect several patients may experience intense anxiety. The risks of loss and rejection that are connected need to be addressed when these patients start to get close to others (Duckworth et al., 1997). Finally, the emergence from psychosis may expose patients to an existential crisis about the purpose and meaning of life. They recognize that a good portion of their lives has been lost because of chronic illness and are now forced to redefine their personal values and spiritual. Those who become part of the working world are confronted with the integration of the meaning of work in a sense of purpose and identity after being unable to carry out a professional activity for a long period of time. In addition to training for skills development, rehabilitation and other interventions, patients who respond well to the atypical antipsychotics also need a human relationship of support in which to explore these adaptations. 185-7 After the patient's symptoms have stabilized, the main challenge for the therapist is to start building a therapeutic alliance. Due to the lack of insight of these patients towards their illness, this is often a particularly difficult task. It follows that therapists must be creative in finding some common ground. Selzer and Carsky (1990) have stressed the importance of finding an object organizer - a person, an idea or an object - which allows the patient and the therapist to talk about what happens between them. In this initial phase of treatment, patients are often not able to recognize that they are sick and need care, and 1'obiettivo main must be to establish a relationship. For example, Mills (1997) warns clinicians so that they avoid challenging the delusional beliefs of patients. He points out the fact that when patients have delusional beliefs, they assume that they are true even if put before the evidence to the contrary. Frese, who suffered from schizophrenia for many years while carrying out a successful career as a psychologist, advises clinicians to think of patients as if they were speaking in a poetic and metaphorical. He suggests that it is useful to help patients see how others regard their beliefs, so that they learn to avoid actions that may be due to their hospitalization in a psychiatric ward. Allying with the patient's need to avoid hospitalization, the therapist can gain his cooperation and his willingness to participate in other times of the treatment plan, such as that of pharmacotherapy. Much of the initial work will be aimed at steering and repair the deficit of the patient that prevent the development of a therapeutic alliance (Selzer, 1983; Selzer, Carsky, 1990; Selzer et al., 1989). The work dedicated to building an alliance can come later rewarded. When Frank and Gunderson (1990) examined the role of the therapeutic alliance with respect to the course and outcome of 143 schizophrenic patients involved in the study of Boston, found that this factor was an important predictor of successful treatment. 1 patients who formed a good therapeutic alliance with their psychotherapists remained in psychotherapy, taking prescribed medications and could achieve better results at the end of two years most likely. The development of a therapeutic alliance can be facilitated by supporting and restoring the patient's defenses, focusing its resources and trying to provide a safe haven. McGlashan and Keats (1989) have pointed out that psychotherapy should especially offer asylum. Feelings and thoughts that others do not understand are accepted by the psychotherapist. Similarly, the withdrawal or bizarre behavior are received and understood without the patient is in no way required to change to be acceptable. Much of this aspect of the technique consists in '' being with '(McGlashan, Keats, 1989, p. 159), or the willingness to be constantly in the company of another human being without making undue demands. As noted Karon (1992), the terror is the primary affection of the schizophrenic patient. Therapists must be able to accept the feelings of terror when they are projected into them, and avoid retiring and being overwhelmed at the power of these emotional states. When the alliance becomes more solid, the therapist can begin to identify individual-specific factors that favor to relapse, and help the patient to accept the fact that he suffers from a serious illness. The therapist must also act as the auxiliary for the patient. When you highlight profound weaknesses of the ego, as a reduced ability to critique, the therapist can help the patient to anticipate the consequences of his actions. II therapist must try to be open and frank with the patient. If in the therapeutic relationship all the negative feelings are denied and split, the patient will feel the therapist as unreal. Moreover, the apparent ability of the therapist to transcend all the feelings of anger, boredom, frustration and hatred will increase simply the envy of the patient against him (Searles, 1967). This attitude does not imply that the therapist should open up excessively; he can decide whether to share topics of personal interest with the patient and may want to validate the perception that the patient has feelings such as irritation, sadness, boredom and other unpleasant sensations. The therapist must pay particular attention to any deficit. Some patients will have substantial limitations neurocognitive, the therapist can highlight with caution. When these deficits are identified, the therapist may also decide to tell the patient the possible strategies to compensate, so that the patient does not feel desperate because of them. For example, in discussing the hallucinations of a patient, the therapist can try to explore the quality idiosínerasica perception. May be asked questions like: "Is there anyone else who can listen to what is being said?" and the therapist might deepen our convictions that the patient has the origin of the items. Working on delusions, the therapist might gently ask if there are other possible explanations for the facts described by the patient. It is possible that the patient take things too personally, or see in the behavior of the other things that are not there? You should also explore the chain of inferences. For example, if the patient believes that his brain is on a silicon chip, the therapist might ask how much electricity it consumes. The experience of the patient in general must be accepted, and you should build a positive atmosphere for the analysis which can lead the patient to critically examine alternatives. Only after you have established a solid alliance, which are identified and discussed the specific factors that induce relapses, which were dealt with problems related to any deficit and that the patient has reached a stable housing situation with family or others, the therapist might groped an expressive approach where 1'insight or interpretation are central. Some patients never reach this point. When the supportive and rehabilitative strategies are sufficient, the therapist may feel that this is enough. Should be avoided imagination to save patients from schizophrenia - the worst possible psychological attitude for a therapist. Therapists must accept the possibility that patients choose "evil known" rather than face the uncertainty of change and improvement. Effective psychotherapy requires from the therapist an attitude that allows the patient to want to remain patient as an acceptable alternative to the psychotherapeutic change (Searles, 1979). Nevertheless, a substantial subset of individuals with schizophrenia want to collaborate with a therapist to come to understand their disease and the way in which it has shattered their sense of identity. In recent literature, patients with schizophrenia have spoken eloquently about the benefits of individual psychotherapy (Anonymous, 1986; Ruocchío, 1989). These patients emphasize the importance of having had a constant shape in their lives, present before any adversity for a period of many years. Illustrate how their subjective experience has been greatly modified during a psychotherapeutic relationship long term 187-95 The studies that have been made on the group psychotherapy with schizophrenic patients suggest that this therapeutic modality can be utille, but highlight the problem to determine the extent to be undertaken. The optimum time appears to be after the positive symptoms have been stabilized by means of a pharmacological intervention (Kanas et al., 1980; Keith, Matthews, 1984). The patient in the acute phase of disorganization is not able to select the environmental stimuli, and the multiple inputs of a group setting can overwhelm the ego beset just when it is trying to recover. After it has been brought under control the positive symptoms, groups can be a great support for patients with schizophrenia who are reorganizing and see others who are preparing for discharge. For the patient stabilized pharmacologically, weekly sessions of 60-90 minutes can be used to build the trust and can offer a support group in which patients can freely discuss their concerns on issues such as how to deal with auditory hallucinations or live with the stigma of mental illness. 195 Numerous studies have shown that treatment of the family associated with antipsychotic drugs is three times more effective than the single drug therapy to prevent relapse. These studies have used a factor known as expressed emotion (EE), identified for the first time by Brown and co-workers (1972). This term was coined to describe a style of interaction between family members and the patient characterized by hyper-intense and excessive criticism. Although this concept is not accuse parents of being the cause of schizophrenia of their children, acknowledges that the families themselves are to be affected by the disease, and that they can become secondary factors that contribute to the impact through increased interactions with the patient. In short, the families with high index of EE induce a higher frequency of relapses in schizophrenic member of those with low index of EE. A meta-analysis of twenty-seven studies on the relationship between EE and outcome in schizophrenia has confirmed that compared to recurrences 1'EE is a reliable and significant predictor (Butzlaff, Hooley, 1998).


The relationship between high EE and relapse appears to be stronger for patients with forms of schizophrenia characterized by a greater chronicity. Extensive research on EE led to a sophisticated psychoeducational approach with families of schizophrenics. Family members are prepared to recognize prodromal signs and symptoms that presage a relapse, they are taught to reduce criticism and 1'ipercoinvolgimento and are helped to understand how a program can maintain constant pharmacological optimal operation. Other areas of education include information on the side effects of the drugs and their management, the long-term course and prognosis of schizophrenia, and the biological and genetic bases of disease. Clinicians using this approach can actually rely on the cooperation of the family in the prevention of recurrence. recent research suggests that the two components of EE-1'ipercoinvolgimento emotional and excessive criticism - should not be considered in the same way (King, Dixon, 1996). In this study, conducted on 69 patients and 108 family members, hyper-emotional appears associated with a better social outcome of patients, indicating that excess criticism could be the factor that favors the fallout. 195-8 Psychosocial rehabilitation, commonly defined as a therapeutic approach that encourages the patient to fully develop their skills through environmental support and learning procedures (Bachrach, 1992), currently expected to be a very important part of therapy for all people with schizophrenia. This approach, tailored to the individual, is based on strategies to capitalize on the strengths and skills of the patient, to give him hope, to optimize its employment potential, to encourage their active involvement in therapy and to help him develop social skills. All of these objectives is often summarized by the English term psychosocial skills training (education in psychosocial skills). Hogarty and colleagues (1991) found that recipients of psychosocial skills training interventions showed substantial improvements over yardsticks of social adaptation, and had, according to an audit carried out after a year, a relapse rate lower than that found in a control group. However, these positive effects scemavano within two years of therapy. Even cognitive rehabilitation has been incorporated in these strategies. By repeated application of related techniques, various cognitive deficits are changed. In social skills training interventions, patients participating in the role-playing (role-play) and other exercises designed to improve their functioning in interpersonal settings. there is a general consensus that the teaching of specific skills and modification of cognitive deficits can be useful in a more comprehensive treatment plan. For the schizophrenic patient who has an acute psychotic breakdown, a brief hospitalization offers a "pause", a chance to regroup and acquire a new direction for the future. Antipsychotic drugs provide relief to the majority of positive symptoms. The structure of the hospital department offers a safe place that prevents patients from harming themselves or others. The members of the nursing staff carry out, to the patient, the auxiliary functions of the ego. Can be initiated an effort psychoeducational family and the patient to establish an environment post ottonale hospital. They should be prepared for the fact of having to deal with a disease that lasts throughout life and the fact that (goal is to minimize the invalidity, to operate a permanent cure. It is put in evidence the importance of a constant intake of drugs, and can also be explained by the concept of expressed emotion. at the same time, the treatment team must be able to instill a sense of hope. If the patient is not already in psychotherapy, the hospital can be used to prepare the patient to an outpatient psychotherapeutic process (Selzer, 1983). the omnipotence of the patient is challenged by the need to adapt to the needs of others. Introducing the lives of patients a routine program, it is inevitable that some of their needs and desires are frustrated. This optimal level of frustration helps the patient to improve reality testing and other ego functions (Selzer, 1983). If psychotherapy can begin during hospitalization, the patient can maintain a sense of continuity pursuing the therapeutic relationship after discharge. When the positive symptoms of the patient was partly alleviated can be undertaken group therapy, which can also continue in the outpatient external in relation to the availability of the patient. For some outpatients isolated group meetings may be the only meaningful social contact. For patients with predominantly negative symptoms, diagnosis and drug prescriptions may be reconsidered. There are secondary reasons, such as depression, anxiety and drug side effects, which may be the cause of negative symptoms? Similarly, the psychotherapeutic process, if in progress, can be re-evaluated with the help of the therapist to determine if you need a change of strategy. The work with the family can proceed in a manner psychoeducational interventions, and family members may be called to seek the possible presence of stress factors that prevent the patient to respond to current therapy. The set of negative symptoms requires above all a social rehabilitation and aptitude. Groups of skill training that focus on improving behavior in simple daily acts like eating, talking, walking and be educated with others can be extremely valuable in respect of negative symptoms. Similarly, a careful assessment of behavior in a situation in which they are taught and supervised practical work skills developed can be an essential component. Investigations on adaptation post hospital and the rates of rehospitalization show that patients are most likely out of the hospital when they were taught their skills and adaptive behaviors, and when they learned in the course of hospitalization, to control maladaptive behaviors and symptomatic (Mosher, Keith, 1979). Although the focus behavior of this kind of environmental programs may seem antithetical to psychiatrists in psychodynamic orientation, in reality, this focus may work synergistically with dynamic approaches. Patients who, thanks to training in behavioral orientation in work skills, improve their interpersonal relationships will begin to feel the changes in their object relations, which then provide material for discussion in the context of psychotherapy. Schizophrenic patients refractory to treatment may also present a predominant disturbed interpersonal relationships. These patients often have serious difficulty character that coexist with schizophrenia. Clinicians sometimes tend to forget that each schizophrenic patient also has its own personality. These behavioral problems can therefore lead to a rejection of the drug prescriptions, compared to a sale to family members and other people to support the environment, the denial of the disease and an inability functional within aptitude. A psychiatric ward or a day-hospital setting may be ideal to deal with aspects of character that accompany schizophrenia and to examine the reasons soggiacerti to patient noncompliance. Through projective identification, patients try to restore their internal object world in the hospital. Staff members contain these projections and provide new relationship models from reinteriorizzare. In addition, patients are informed of the models maladaptive patterns of interaction when they arise in the here and now of Settino hospital. In summary, patients with schizophrenia who need therapeutic figures in their lives. They need help to navigate through the complicated reality of the mental health system. They also need someone to help them understand the fears and fantasies that prevent them to follow the various aspects of the overall treatment plan. Undoubtedly, a central role of the psychotherapist is the exploration of the compliance problems that arise in other areas of treatment. 198-206 Affective disorders Affective disorders are strongly influenced by genetic factors and biological. individuals predisposed to major depression tend to place themselves in high-risk environments. For example, individuals with a temperament characterized by neurotic aspects can keep out the other and thus be the cause of the rupture of a significant relationship. Stressful events more powerful seemed to be the death of a loved one, violence, serious marital problems and divorces or separations. However, there are a lot of data that indicate how early experiences of abuse, neglect or separation can create a sensitivity neurobiological that predisposes individuals to respond to stressors in adulthood with the development of a major depressive episode. For example, Kendler and colleagues (1992) found an increased risk of major depression in women during childhood or adolescence had been separated from the mother or the father. A prospective study (Bifulco et al., 1998) found that women with a history of abuse or neglect of a child have twice as likely than those who have not experienced similar experiences, to have adult relationships and negative a low self esteem. In addition, women who have suffered in childhood behaviors of abuse or neglect (neglect) and have negative relationships as adults, and low self-esteem have a ten times greater likelihood of getting depression. the impact of childhood trauma or abandonment can be crucial in psychodynamic therapy of depressed patients. These stressors related to the early separation, abandonment or abuse children appear to make individuals more vulnerable to stressors slightly later in adulthood can lead to depression. However, based on a psychodynamic perspective, the clinician should always consider the meaning of a particular stressor: what to an outsider might seem a relatively mild stressor can play powerful meanings for the patient conscious and unconscious, which amplify enormously 'impact. Hammen (1995) noted that "there is considerable consensus that the crucial element is not the mere occurrence of an event existential negative, but rather the individual's interpretation of the meaning of the event and its effects within the context in which it occurs. "In a longitudinal study on the relationship between depressive reactions and stressors, Hammen and his collaborators revealed that stressors content focused on the area of the definition of the self of the patient were more likely to trigger depressive episodes (Hammen et al., 1985 ). In other words, in an individual in which the sense of self is partially defined by social ties, the loss of a significant interpersonal relationship can precipitate a major depression. On the other hand, a person whose self-esteem is related primarily to the achievement of results and successes has a greater chance of experiencing a depressive episode in response to a perceived failure at school or at work. These advances in research on mood disorders suggests that drugs that psychotherapy may be necessary in the treatment of major affective disorders. The psychodynamic exploration of the meaning of the stressors can be of particular importance. Depressed patients may also benefit from a dynamic psychotherapy. Some do not adhere to the prescribed drug therapies for a variety of reasons, including the fact that they feel they are not worthy to improve or that take these drugs stigmatizes them as mentally ill. In addition to being indicated for patients with problems of noncompliance, psychotherapy should be used with those who can not take antidepressants for pre-existing physical conditions of medical interest, with patients who can not tolerate the side effects, and those that are refractory or in part entirely in every somatic treatment. You must also remember that depression encompasses the entire spectrum of the disease and mental health, and that at times stressful may appear in lighter forms even in individuals basically healthy. Individuals with a minor depression, which does not fall within the criteria of the DSM-IV (American Psychiatric Association, 1994) for a major depressive episode or dysthymia for a live a greater number of days of discomfort in society than those with major depression (Broadhead et al., 1990) .1 physicians provide more assistance to individuals with depressive symptoms than those with a depressive disorder formally defined (Johnson et al., 1992). It follows that these forms averages of depression, even when they do not have the characteristics required to be classified as major disorders according to DSM-IV, are not necessarily benign. Drug therapy is often ineffective in minor depression, and these patients may need psychotherapy to be returned to normal operation. For many patients, the combination of psychotherapy and pharmacotherapy seems to be particularly useful. A psychodynamic approach to treatment is also extremely useful in dealing with the relationship between personality and depression. This report can be divided into three distinct categories: 1) major depressive disorder complicated by the coexistence axle i axis 2 of personality disorders, 2) depressive personality, 3) characterological depression in the context of personality disorders on axis 2 . a summary of the literature provides ample evidence that personality disorders complicate the treatment of depressive disorders on the axis 1. These studies suggest that certain personality disorders can help keep depression already in place, and that the factors may characterological also be responsible for a poor compliance to drug therapy. To effectively treat these patients may require a psychotherapy in combination with medication. The second category, the depressive personality, has been a subject of controversy despite a long history of psychoanalysis. Appendix B of the DSM-IV criteria for depressive disorder personality emphasize a constellation of personality traits, in contrast to the criteria for dysthymia that focus on somatic symptoms. These traits include a mood dominated by unhappiness, dejection, sadness; a self-concept centered on the devaluation and low self-esteem; and a tendency to self all'autocolpevolizzazione; ease the feelings of guilt or remorse; a pessimistic attitude; a way negativistic and judgmental of yourself to others; Finally a tendency to brood and worry. Many disputes have centered on whether the depressive personality disorder is really distinct from dysthymia. However, recent data indicate that the distinction between the two disease entities is valid and clinically useful. The third category includes patients with severe personality disorders, particularly borderline, suffering from "depression" though lacking the DSM-IV for a disorder axle i. Many of these patients describe feelings of loneliness or emptiness pervasive, accompanied by the perception that their emotional needs are not reflected in the other. There may also be a conscious feeling of anger and frustration that sets them apart from the typical patients axis 1. The psychiatrist that combines a psychodynamic approach and psychopharmacological measures will be equipped to best to treat the broad spectrum of patients with affective disorders seen in clinical practice. 211-16 We can summarize the different theoretical formulations on depression and concluded that, whatever there may be biochemical component, the patients they experience depression psychologically as a disorder of self-esteem in the context of interpersonal relationships bankruptcy. These relationships are internalized childhood and may subsequently, in adulthood, be reactivated with the onset of major affective disorders. Harrowing internal object relations is then externalized also in the relations existing in the world of the patient. Depression shows the close connection between the intimate relationships of an individual and the maintenance of self-esteem (Strupp et al., 1982). In terms of self psychology, depression can be seen as desperation resulting from the failure on the part of the self-objects in gratify the needs of the Self of mirroring, twins or idealization. Blatt (1998) has suggested that from a psychoanalytic point of view these various theoretical perspectives describe two types of underlying depression. The anaclitic depression is characterized by feelings of helplessness, loneliness and fragility related chronic fears of abandonment and lack of protection. Individuals with this type of depression have an intense desire to be cared for, protected and loved. Introiettava depression, on the other hand, is characterized by feelings of worthlessness, failure, guilt and inferiority. Individuals with this variant are particularly self-critical and suffer from a chronic fear of criticism and disapproval from others. They are perfectionists and overly competitive and constantly feel pressured to achieve optimal results at the school level or professional. The anaclitic depression is characterized by vulnerability to rupture of interpersonal relationships, and depression is manifested mainly as dysphoric feelings of abandonment, loss and loneliness. Introjective depression involves a vulnerability to the absence of a positive sense of self and efficient; occurs mainly with dysphoric feelings of guilt, worthlessness and failure, and with the feeling of not having more of their autonomy and their power. 216-20 Several psychiatric disorders may culminate in the tragic outcome of suicide. However, suicide is mainly associated with major affective disorders aspects emerged from psychodynamic psychotherapeutic work with patients who have attempted suicide may be secondary to any neurochemical changes; Therefore, in the context of a psychotherapeutic approach, will have to be massively used all available modes of somatic treatment. In many cases psychotherapy alone is insufficient with patients who experience severe suicidal tendencies. The reasons of the suicide are highly diversified and often obscure. 220-21 In line with the general denial of the disease, these patients typically claim that their symptoms manic or hypomanic not part of a disorder but rather a reflection of their way to be. Patients with bipolar disease known to lack of awareness. Often related to this denial, there is another issue that concerns psychodynamic division or discontinuity psychic. Many bipolar patients continue to deny the significance of previous manic episodes when they are under euthymic. They can argue that their behavior was simply the result of a poor self-care, and frequently insist so adamant that what happened will not happen ever again. In this form of splitting the representation of self involved manic episode is considered completely unrelated to the self respect of the euthymic phase. This lack of continuity of the self does not seem to bother the patient, while family members and doctors can be very exasperated. The clinical management of the patient requires a level work psychotherapy to try to patch up the fragments of the self in a narrative continuum in the life of the patient, so that the need to follow drug therapy becomes more important for the patient. There is a strong association between childhood physical trauma and addiction in adulthood 225-6 The first step in therapy, regardless of whether the patient is hospitalized or not, must be the construction of a therapeutic alliance. So that will also establish the necessary relationship, the clinician must simply listen to the patient, empathizing with his point of view. Perhaps the most common mistake, is that of family members of mental health professionals inexperienced, is to try to comfort the patient, focusing on what is positive. Comments like "She has no reason to be so depressed - has so many good qualities," or "Why should he commit suicide? There are so many things for which it is worth living" will manifest easily the opposite effect. These comments "encouraging" are experienced by depressed patients as complete failures of empathy, which may lead them to feel more misunderstood and only thus increasing their suicidal tendencies. Therapists who work with these patients should instead talk to understand that there are certainly reasons to be depressed. Can empathize with the pain of depression, but asked, at the same time, the cooperation of the patient to a search for the causes that underlie the disease. The initial approach should be supportive but firm (Rams, 1977; Lesse, 1978). Premature interpretations, such as "In reality she is not depressed - is angry", will feel is not as empathetic as it centered. The therapist will be more help just listening and trying to understand how the patient interprets the disease. During the early stages of the history taking, the clinician will develop a formulation explaining the patient's depression. What events have apparently triggered the depression? What is the aspiration, high value narcissistic, that the patient has failed to achieve? What is the dominant ideology of the patient? Who is the other dominant for which the patient is experiencing and which is not receiving the desired responses? There are feelings of guilt associated with aggression and anger, and if so, who is angry with the patient? The attempts of the self to get answers from the object-self are frustrated? The patient has primarily an anaclitic depression type, in which the therapeutic change affect interpersonal relationships? Or the patient has a predominantly introjective depression, for which will be central to the definition of the self and of its value? For the psychodynamic approach to depressed patients is crucial to establish the context and interpersonal meaning of their depression. Unfortunately, patients often resist tenaciously to such interpersonal implications (Betcher, 1983). Often prefer to see their depression is their desires of suicide as if they develop in a vacuum, insisting that no one should be blamed fervently but themselves. Careful attention to developments in the transference-countertransference may allow to penetrate into this form of resistance. Both in psychotherapy in the hospital, patients recapitulate their internal object relations and also their relational models with external figures. Depressed patients arouse feelings particularly intense. During treatment, the therapist will try despair, anger, desires to get rid of the patient, powerful fantasies of rescue and a myriad of other feelings. All these emotional responses can reflect how other people in the life of the patient can feel. These interpersonal dimensions of depression may be involved in causing or perpetuating the pathological condition. To examine the impact of the condition of the patient on the other, the therapist must request the cooperation of the patient using such feelings constructively within the therapeutic relationship. Many cases of refractory depression have come to a situation of impasse in the repetition of a model of object relations characteristic that has strong foundations of character and it is therefore difficult to change. The literature on families of depressed patients clearly shows that the frequency of relapses, the course of depression and suicidal behavior are all influenced by family functioning (Keitner, Miller, 1990). In one study (Hooley, Teasdale, 1989) the best predictor, taken individually, relapse was the perception of the depressed patient that the spouse was particularly critical. Addition to research on families of schizophrenic patients, several studies have shown that high expressed emotion in the relatives of depressed patients may adversely affect the risk of relapse (Hooley et al., 1986; Vaughn, Leff, 1976). Depressed patients elicit a significant proportion of hostility and sadism in their family members, and clinicians need to help families overcome their feelings of guilt for such reactions, so that they can accept them as comprehensible answers. 227-32 First, clinicians should keep in mind an incontrovertible fact - patients who are truly willing to kill themselves will eventually do so. No amount of physical restraint, careful observation and clinical skills can stop the patient really determined to suicide. After a suicide accomplished, clinicians often feel guilty for not having identified the warning signs that would allow him to predict an imminent suicide attempt. Despite an extensive body of literature on risk factors for suicide in the short and long term, our ability to predict the suicide of a patient is still greatly limited. The primary means of assessing an imminent risk of suicide in a clinical setting is the verbal communication of the patient with respect to his intentions, or action clearly suicidal in its intent. Clinicians can not read minds and should not reproach themselves for their failures when there are no clear indications, verbal or not, suicide risk. One study (Isometsà et al., 1995) found that in 571 cases of suicide, only 1136 percent of patients who were in psychiatric therapy communicated a suicidal intent. The treatment of depression suicidal must start with the prescription of an antidepressant drug that is not suitable lethal when taken in overdose. Must be evaluated several other risk factors, such as: feelings of hopelessness, severe anxiety or panic attacks, substance abuse, presence of adverse events recently, financial problems or unemployment, male, age sixty or well, and the fact of living alone or being widowed or divorced (Clark, Fawcett, 1992; Hirschfeld, Russell, 1997). If the patient has a clear plan and seems willing to put in place soon, is required urgent hospitalization in a psychiatric ward. If the risk of suicide is substantial but not imminent, should be involved a family member or another person close. Should be considered the presence of firearms in the home or elsewhere. Summary of literature (Cummings, Koepsell, 1998; Miller, Hemenway, 1999) reveal that the availability of a gun significantly increases the risk of suicide. Clear communication is essential in such circumstances, and must be sought also a possible substance abuse. In case of intense anxiety or panic should be considered the use of a benzodiazepine (Hirschfeld, Russell, 1997).
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Re: Psychopatology Gabbasrd

Post  counselor on Sun Nov 30, 2014 10:52 am

Psychotherapy can also be extremely important to understand why the patient wants to die, and what do you expect will happen after death. Clinicians with psychodynamic training tend to agree in believing that therapists who fall prey to the illusion of being able to save their patients from suicide are actually reducing their ability to do so (Hendin, 1982; Meissner, 1986; Richman, Eyman, 1990; Searles, 1967; Zee, 1972). One concern psychological salient in patient suicide is the desire that an unconditionally loving mother to take care of him (Richman, Eyman, 1990; Smith, Eyman, 1988). Some therapists are wrong in trying to gratify this fantasy going to meet every need of the patient. Can accept calls the patient at any time of day or night and during holidays. They can see the patient in their study seven days a week. Some have even had any sexual involvement with their patients in a desperate attempt to gratify the demands inexhaustible associated with depression (Twemlow, Gabbard, 1989). This kind of behavior exacerbates what Hendin (1982) has described as one of the most lethal of patients with suicidal tendencies - that is, their tendency to assign to others the responsibility of their stay alive. Trying to gratify these ever increasing demands, the therapist collude with the fantasy of the patient, according to which there is actually somewhere in the world a mother unconditionally loving, different from anyone else. Therapists can not possibly sustain this illusion infinity; those who seek to do so would lead the patient to a crushing disappointment, which could increase the risk of suicide. 1 clinical patients with suicidal are dragged into the role of savior often operate on the assumption, conscious or unconscious, of being able to offer the love and attention that others are not able to give, transforming , magically, the patient's desire to die in a desire to live. This fantasy is however a trap because, as noted Hendin (1982): "The hidden agenda of the patient is trying to prove that nothing will make the therapist will be sufficient. The desire of the therapist to see himself as the savior of the patient with suicidal tendencies can make the therapist blinded to the fact that the patient has assigned the part of the executioner. "Therapists are most useful to patients suicidal when diligently seek to understand and analyze the origins of suicide rather than become slaves desires of patients. Some therapists openly acknowledge that they can not restrain the patient from committing suicide and instead offer the opportunity to understand why the patient think that suicide represents the only choice (Henseler, 1991). Often this admission has a calming effect and can lead to greater collaboration in psychotherapeutic work. It is useful to distinguish between therapy and management of patients with suicidal intentions. The second relates to measures such as continuous, physical limitations and the removal of sharp objects from the environment. Although these measures are useful to prevent the patient puts in place suicidal impulses, management techniques do not necessarily reduce the future vulnerability of the patient with respect to the use of suicidal behavior. The treatment of patients with suicidal tendencies - which consists of a psychotherapeutic approach aimed at understanding the factors internal and external stressors that make the patient potential suicide - is necessary to change the radical desire to die. Suicide is also the ultimate narcissistic injury for the therapist. The anxiety of the clinician about the suicide of the patient may also arise more from the fear that others can charge him for the death of the patient because no concern for the benessere- individual patient. Therapists who treat patients with serious suicidal at some point begin to feel tormented by repeated denial of their efforts. In such situations can easily emerge hatred countertransference, and therapists will hatch often an unconscious desire that the patient will die to end the torment. Maltsberger and Buie (1974) noted that feelings of animosity and hate are among the most frequent countertransference responses associated with the treatment of patients with severe suicidal tendencies. The inability to tolerate their sadistic desires toward the patient can lead the therapist to implement countertransference feelings. The authors caution that while the feelings of ill will are more unpleasant and unacceptable, those of aversion are potentially more lethal, because it can lead the therapist to neglect the patient and offer the opportunity for a suicide attempt. In a hospital, this form of countertransference may occur simply "forgetting" to check the patient, as the rules provide for the management of potential suicides. Hatred countertransference must be accepted as part of the therapeutic experience with suicidal patients. It emerges often in direct response to aggression of the patient. Threats of suicide can hang on the head of the therapist as the mythical sword of Damocles, and haunt him day and night. Similarly, the family of the patient will be afflicted by the concern that a false move or a nasty comment on their part may be the cause of suicide. If the therapist splits and disclaims hatred countertransference, this will be projected on the patient, which in addition to its existing suicidal impulses will also have to face the murderous wishes of the therapist. Clinicians can also treat their aggressive feelings through a reaction formation, which can lead to fantasies of salvation and exaggerated efforts to prevent suicide. Psychotherapists who have patients in therapy with suicidal tendencies should help them reach an agreement with their dominant ideology (Rams, 1977) and with their fantasies rigidly maintained (Richman, Eyman, 1990; Smith, Eyman, 1988). When there is disparity between the reality and the narrow view that the patient has of what life should be, the therapist can help the patient to mourn the loss of such a fantasy. This technique can paradoxically lead the therapist recognizes the desperation of the patient in such a way that it can be mourned for the broken dreams and they can be replaced with more realistic. To effectively treat patients with suicidal tendencies, clinicians must distinguish the responsibility of the patient from the responsibility of the therapist. Physicians in general, and especially psychiatrists, are by character prone to an exaggerated sense of responsibility (Gabbard, 1985). We tend to blame ourselves for negative outcomes that are outside of our control. We must ultimately accept the fact that there are psychiatric illnesses terminals. Patients should take the responsibility to decide whether to commit suicide or actively work with their therapist to understand their desire to die. Fortunately, the vast majority of patients look to suicide with a certain ambivalence. The part of the individual potential suicide who doubts the solution suicide can lead these patients to choose life rather than death. 232-37 Anxiety disorders Panic attacks usually last only a few minutes, but cause considerable distress to the patient. Besides alarming physiological symptoms, such as choking, dizziness, sweating, tremor and tachycardia, patients with panic disorder often experience a feeling of impending doom. The majority of patients with panic disorder also suffer from agoraphobia (fear of being trapped in a place or situation from which escape may be difficult or terribly embarrassing). Since panic attacks are recurring, patients often develop a secondary form of anticipatory anxiety, worrying constantly about when and where the next attack will occur. Patients with panic disorder and agoraphobia often reduce their trips to try to control the dreaded situation of having a panic attack in a place from which he can not go easily. The disorder panic attacks may seem devoid of psychological content. In some cases the attacks seem to come "out of nowhere", with no apparent precipitating factors environmental or intrapsychic. Consequently, the role of the psychiatrist in psychodynamic orientation is often - and unfortunately - considered irrelevant in the treatment of these patients. A significant percentage of people who suffer from panic disorder has such attacks because of psychodynamic factors, and could therefore respond to psychological interventions (Mibrod et al., 1997; Nemiah, 1984). Clinicians in psychodynamic orientation should thoroughly examine the circumstances in which attacks occur and the history of each patient, to determine whether there are psychological factors relevant. Although the data demonstrating the involvement of neurophysiological factors in disorder panic attacks are irrefutable, these observations are most persuasive in explaining the pathogenesis rather than etiology. No data neurobiological is able to explain what triggers the onset of a panic attack. A more thorough analysis of the respondents showed the presence of a pattern of anxiety than the socialization with others during childhood, relationships with parents are supportive and the feeling of being trapped. The rage and aggression were difficult to handle for most of these patients. It is found that, compared with control subjects, patients with panic disorder have a higher incidence of stressful life events, particularly losses, in the month before the onset of the disorder (Faravelli, Pallanti, 1989). In another controlled study of patients with panic disorder (Roy-Byrne et al., 1986), the experimental group had not only experienced a significantly higher number of stressful events in the year preceding the beginning of the disorder, but also felt a greater degree of discomfort with such events compared with control subjects. In a study of 1018 pairs of twins (Kendler et al., 1992a), the disorder panic attacks was associated in a decisive and significant is the separation that with the death of their parents. A pathogenetic theory with a certain degree of empirical support claims that patients with panic disorder have a vulnerability neurophysiological predisposing that can interact with specific environmental stressors to produce the disorder. Kagan and co-workers (1988) have identified a characteristic innate temperamental in a number of children, who have defined behavioral inhibition to what is not known. These children tend to be easily frightened by all that is foreign to them in the environment. To adapt to this fear, rely on the protection of parents. Growing up, however, they learn that parents will not always be available to protect them and reassure them. They can then outsource their inadequacy projecting it in the parents, who consider unreliable and unpredictable. They may be angry for their inconsistent availability, but such anger creates new problems, because they worry that angry fantasies end up by destroying and removing the parents, leaving them with no figures to depend to acquire security (Busch et al., 1991; Milrod et al., 1997). The result is a vicious circle in which the child's anger threatens the bond with the parent, and so accentuates the dependence hostile and frightened child. Understanding the pathogenesis of the disorder panic attacks depending on the perspective of the theory is also useful in a psychodynamic approach to therapy (Shear, 1996). A small preliminary study on attachment style of 18 women with anxiety disorders showed that all had problematic attachment styles (Manassís et al., 1994). Of the 18 patients, 14 were diagnosed suffering from panic disorder; many of the latter had a preoccupied attachment. 1 patients with panic disorder often see the separation and attachment as mutually exclusive. Have difficulty in modulating the normal oscillation between separation and attachment as they have heightened sensitivity to both the loss of freedom that the loss of security and protection. These difficulties result in an operate within a very narrow spectrum of behaviors that attempt, at the same time, to avoid both the separation, which is too threatening, both the attachment, which is too intense. This limited area of tranquility often manifests itself in a style of interaction with others ipercontrollante. Milrod (1998) suggests that those who develop a disorder with panic attacks are subject to feelings of fragmentation of the self, and may need a therapist or other important figures that help them feel they have a stable sense of identity. In female patients another etiological factor related to problems of attachment is the sexual and physical abuse in childhood. Since childhood trauma interferes with the child's attachment to parents, sexual abuse could explain some of the difficulties that patients with panic disorder have in feeling safe and secure with objects significant in their lives. The internalization of violent representations of parents also interferes with the development of trust in adult life. Patients who suffer from a poorly developed object constancy can not, in times of difficulty, to appeal to an internal image of their therapist to quell anxiety. On long weekends or during the holidays of the therapist, these patients may have severe panic attacks induced by the thought of losing their therapist. They may fear that he is dead or about to reject them or to abandon them. In such circumstances, the mere fact of hearing the voice of the therapist on the phone can completely eliminate the panic in a matter of seconds. Patients who suffer from lack of constancy of purpose are often able to develop a picture of their therapist internalized in the long-term course of psychotherapy, supportive-expressive. As a result of this process of internalization, and separation anxiety that panic attacks can improve considerably. It is usually desirable that the therapist explores the fears of the patient to become completely addicted to it with the progress of therapy. Similarly there may be excessive anxiety over the loss of the therapist, either temporarily for the holidays that definitively by the end of therapy. In many cases fantasies of uncontrollable rage, or even murder, may be central to the therapy. The anger of the parents may have been so intense that any explosion of anger is seen as potentially destructive. Some children may have lived parents abandoned them as figures from a emotional point of view when they expressed their anger. Psychotherapists may need to help patients become aware of their anxiety of expressing anger and the related need to defend themselves from this emotion. The defenses of somatization and outsourcing often act synergistically to prevent internal reflection. Somatization in the patient's attention is focused on physical phenomena rather than on causes or psychological meanings. In outsourcing problems are attributed to other people, who are considered somewhat adverse to the patient. Used in combination these defenses can create a specific form of object relationship in which others (family, friends, doctors) are seen as healers who is credited with the ability to remedy something wrong in the body of the patient. This mode of object relationship is frequently elicits even in the transference. Patients with panic disorder often require a combination of medication and psychotherapy (Nemiah, 1984). Even when their symptoms are controlled by medication, patients with panic disorder and agoraphobia are often reluctant to venture back into the world and may be in need of psychotherapeutic interventions to overcome this fear (Cooper, 1985; Zitrin et al., 1978). At least one study has suggested that the combination of dynamic therapy and drug therapy can help reduce relapses in patients with panic disorder. Some patients have a higher resistance to the drugs, often because they believe that the fact of taking drugs stigmatizing them as mentally ill, and a psychotherapeutic intervention is needed to help them understand and eliminate their reserves on pharmacotherapy. Others decide to discontinue drug therapy for their inability to tolerate the side effects. So that the treatment plan is complete and effective, these patients need psychotherapeutic approaches in addition to appropriate medications. In all patients with symptoms of panic attacks or agoraphobia, careful evaluation psychodynamic help you weigh the contributions of biological and dynamic. 247-54 Anxiety disorders, taken together, are the most prevalent among all major groups of mental disorders (Regier et al., 1988), and between anxiety disorders phobias are by far the most common. In DSM-IV phobias are divided into three categories: 1) agoraphobia (without history of panic disorder), 2) specific phobia, 3) social phobia. The psychodynamic understanding of phobias illustrates the mechanism of neurotic symptom formation described above. When prohibited sexual or aggressive thoughts that could lead to a retaliatory punitive threaten to emerge from the unconscious, a signal is triggered anxiety that leads to the deployment of three defense mechanisms - displacement, projection and avoidance (Nemiah, 1981). These defenses eliminate anxiety removing again the forbidden desire, but the price of anxiety control is the creation of a phobic neurosis. Phobias fit perfectly in a model of genetic diathesis-constitutional interacting with environmental stressors. Kendler and colleagues (1992b) studied 2163 female twins and concluded that the best model for the disorder is a hereditary disposition to the phobia that require specific environmental etiological factors to produce a full-blown syndrome phobic. In their studies on the population, one of the obvious environmental stressors associated with an increased risk of phobia was the death of a parent before the age of seventeen (Kendler et al., 1992a). Although they observed that children with this temperament present at birth a lower threshold for limbic-hypothalamic activation in response to changing environmental contingencies, Kagan and colleagues conclude also that a certain form of chronic environmental stress must act on temperamental predisposition original to give rise to two years of age, to a behavior bashful, shy and taciturn. They postulated that stressors such as humiliation and criticism from an older brother, arguments between parents, the death of a family member or separation from an important figure are probably among the environmental factors that make the greatest contribution. behaviorally inhibited children who come to develop obvious anxiety disorders are exposed to parents more anxious, which can communicate to children the feeling that the world is a dangerous place. Social phobia is a condition with a high rate of comorbidity. Clinical work with socially phobic patients revealed the presence of some internal object relations characteristics. In particular, these patients have internalized representations of parents, brothers or care agents that induce shame or embarrassment, criticize, ridicule, humiliate, abandon (Gabbarti, 1992). These introjects are established early in life and are repeatedly screened in the environment that people are subsequently avoided. Although such patients may be genetically predisposed to experience others as threatening, positive experiences can partially mitigate these effects. It is as if from birth was present a program genetically determined. If those who take care of the child behave in accordance with this program, the individual will become increasingly fearful towards others and develop a social phobia. If agents of care are sensitive to the child's fears and compensate, introjects will be more benign, less terrifying, and will produce less likely syndrome of adult social phobia. Although many patients with social phobia respond well to selective serotonin reuptake inhibitors (ssxi) c / or cognitive therapy, also the dynamic therapy may be helpful. Some patients are particularly resistant to treatment because they fear any situation in which they could be judged or criticized. Because the therapeutic setting is considered a situation of this kind, the fear of being humiliated or judged transference can lead patients to skip frequently appointments or stop altogether therapy. In fact, due to the high percentage of comorbid disorder, social phobia can sometimes be discovered only when a patient seeks help for other reasons. The embarrassment and shame are the predominant affective states and the therapist that you tune these emotions can have a better chance of forming a therapeutic alliance with the patient in the initial sessions. Explore fantasies about how the therapist and others might react help these patients also begin to realize that their perceptions of how others are placed against them may be different from what others actually feel for them. The resistance to therapy should be approached with the decision because without treatment these patients often avoid school or work, and many end up living on social assistance or disability pensions (Schneier et al., 1992). The ramifications interpersonal phobias often benefit also from a psychodynamic approach. By virtue of their being confined indoors, individuals severely agoraphobic often need someone to take care of them, as a spouse or parent. It is common, for example, that a woman agoraphobic and her husband have adapted to the condition of her in the course of many years. The husband can actually feel more secure knowing that his wife is always at home. If agoraphobia is treated, the balance of the pair will become destabilized. The husband may become more anxious for fear that his wife, leaving the house, can search for other men. A diagnostic evaluation and appropriate treatment of phobias should include a careful assessment of how the phobia fits into the network of relations of the patient. A psychodynamic understanding of the interpersonal context of a phobia may therefore be crucial in dealing with resistance to conventional treatments such as medications and behavioral desensitization. 254-8 Obsessions are defined as recurring ego-dystonic thoughts while compulsions are ritualized actions that must be performed to relieve the distress. The complaints of these patients may fall into five main categories: 1) rituals involving checks, 2) rituals that involve cleaning, 3) are not accompanied by obsessive thoughts compulsions, 4) obsessive slowness, 5) rituals mixed (Baer, Jenike, 1986). Patients who are engaged in cleansing rituals or obsessive thoughts about germs and contamination present considerable similarities with phobic patients. Obsessive-compulsive disorder is often complicated by depression and a severe impairment in work and society, such that even family members and colleagues of the patients can be significantly affected by the disease. DSM-3 riclassificò OCD as an anxiety disorder, because the primary function of an obsession or a ritual seems to be to regulate anxiety. It is also well known that the symptoms grow and diminish in relation to the presence or absence of stress in the patient's life. You may experience an improvement with reduced voltage, while an increase in stress and restoration of the original situation precipitating the symptoms worsen (Black, 1974). However, the improvements observed in these studies were almost always incomplete, and the combination of SSRIs and behavioral therapy is then generally considered the optimal therapeutic approach. Nevertheless psychodynamic strategies can be of great help in many situations. Many patients with OCD seem to cling to their symptoms, resisting tenaciously to therapeutic efforts.
The symptoms themselves can serve to protect certain patients from a psychotic disintegration, thus fulfilling a very useful function in terms of psychological homeostasis. Many family members described the feeling of "being forced" by the patient to do things that would fit his obsessions or compulsions. Similarly, this relationship model is internalized and reproduced frequently when patients are hospitalized. An attitude characterological legitimacy often accompanies the tendency of some patients with OCD in insisting that all - without exception - must adjust to their illness. The symptoms of OCD usually lead to serious relationship problems, and this disorder is associated with a higher risk of divorce or separation (Zetin, Kramer, 1992). In particular, can help in this area a dynamic psychotherapy group or family. Another useful contribution of clinical psychotherapy in the treatment of OCD can be derived from the analysis of the factors that trigger or worsen the symptoms. Helping patients and their families to understand the nature of these stressors, the symptoms can be managed more effectively. 258-63 the most common precipitating event reported among individuals with PTSD was the sudden and unexpected death of a loved one, suggesting that the emphasis of rapes, assaults and violent wars focuses on only a portion of the population that suffers of this disorder. He observed that the victims of trauma range from the denial of the event and its repetition compulsion through flashbacks or nightmares. The mind endeavors to develop and organize stimuli overly oppressive. Horowitz identified eight common psychological issues which result in severe trauma: 1) pain or sadness, 2) guilt for their impulses of anger or destructive, 3) fear of becoming destructive, 4) feelings of guilt for having survived, 5) Fear to identify with the victims, 6) shame compared to a feeling of helplessness and emptiness, 7) fear of repeating the trauma, Cool intense anger directed towards the source of the trauma. Despite the recommendations of the Advisory Committee that it would create a new category for the response to stress, PTSD has been maintained in the treatment of anxiety disorders. However, the criterion of the stressor has changed significantly, so that both of the following conditions are required: "1) the person experienced, witnessed or has faced one or more events that relate to the death, whether real or feared, a serious harm or a threat to the physical integrity of their own or another; 2) the person's response is characterized by an intense fear, helplessness and horror from. in children, this can be expressed by a disorganized or agitated behavior. "These changes take place so this is more subjective factors is the fact that the prevalence of traumatic events in the general population is higher than previously thought. This revision in the DSM-4 reflects the importance of a careful assessment of both psychodynamic meanings the patient assigns to the event, as well as specific psychological vulnerability of the patient in the evaluation of various environmental precipitants (Ursano, 1987; West, Coburn, 1984). One study (Breslau et al., 1991) has shown that the risk of developing PTSD could be associated with an early separation from parents, with nervousness, with a family history of anxiety and with a pre-existing anxiety or depression. The authors concluded that it was necessary, for the emergence of symptoms, a personality predisposed to the development of PTSD. Aspects of subjective perception that have been most extensively documented relate the experience of extreme fear, the subjective experience of powerlessness, the perception of a threat to life and the perception of a potential physical violence (March, 1993). Most people do not develop PTSD even when confronted with horrific injuries. In some individuals events that seem to be of relatively low severity may instead trigger a PTSD because of the subjective meaning assigned to them. Old traumas can also be evoked by the current circumstances. According to Davidson and Foa (1993), one predisposing factors to a particular vulnerability that influence the development of PTSD are: 1) genetic-constitutional vulnerability to psychiatric illness; 2) negative or traumatic experiences in childhood; 3) certain personality characteristics (such as those found in antisocial patients, employees, paranoid and borderline); 4) recent stress or existential changes; 5) a support system compromise or inappropriate; 6) a serious and recent alcohol abuse; 7) the perception that the locus of control is external rather than internal. Paintings of PTSD symptomatically more severe were associated with lower IQ scores, suggesting that cognitive variables can affect an individual's ability to adapt to trauma. these individuals suffer from alexithymia - the inability to identify and verbalize affective states. Because of these considerations, the dynamic psychotherapy of patients with PTSD must maintain a balance between a hands-off approach and observant, that allows the patient to conceal content painful, and a benevolent attitude that encourages the patient to reconstruct a complete picture of the trauma. Integrating the memory of the trauma within the continuity of the sense of self of the patient may be an unrealistic goal, as the patient should not be forced to proceed with rhythms that become excessive and disorganizing. The construction of a solid therapeutic alliance in which the patient feels safe is crucial to the success of therapy. Education about common reactions to trauma may facilitate the development of such an alliance, which can be further reinforced by a confirmation empathic that patients have the right to feel how they feel. The therapist, with the intention of saving the patient-from the terrible trauma that has lived, may develop fantasies of omnipotence. Alternatively, the therapist may feel overwhelmed, angry and powerless in the face of apparent resistance of the patient to overcome the trauma. When the patient is particularly tenacious nell'aggrapparsi to the memories of the trauma, the therapist may lose hope and become indifferent. In most cases these patients with the objectives of psychotherapy should be modest - healing or the complete disappearance of the symptoms are probably too ambitious. More reasonable ambition is to arrest further decline, to support the areas of proper operation and to re-establish the integrity of the patient as a person (Lindy et al., 1984). The acute stress disorder (ASD) has, compared to the stressor, the same criteria of PTSD - the individual must have lived an event that involved a threat of death or serious injury, to which he responded with intense feelings of helplessness, horror or fear. However, the symptoms caused by the traumatic event must begin within four weeks and last from a minimum of two days to a maximum of four weeks. In other words, this category takes into account the syndromes similar to PTSD that may appear before this disorder, last for a shorter time, or constitute the beginnings of a more typical case of PTSD. In addition to the criteria that reflect the symptoms of PTSD (like reliving the event, avoiding the stimuli that reactivate memories of trauma, manifesting hyperactivation), the diagnosis of an acute stress disorder also requires at least three of the following dissociative symptoms: amnesia for important aspects of the trauma; depersonalization; derealization; decreased awareness of the surrounding environment; a subjective feeling of detachment, numbness or lack of emotional sensitivity. 263-9 The criteria of the DSM-IV criteria for generalized anxiety disorder (GAD) have sought to clarify the boundary between this disorder and a normal concern. The anxiety must be excessive, difficult to control and for a period of at least six months, the number of days in which it is present should be greater than that of the days in which it is absent. It must also be a cause of significant stress from the clinical point of view or interfere with work and social activities, or other important areas of functioning. The diagnosis requires that the focus of the anxiety will not remain limited to the features of other disorders of axis 1, as the concern of having a panic attack, to be contaminated, the fear of being embarrassed in public, and so on. The anxiety must be so pervasive that the patient focuses on a series of activities or events which targets anxiety. The quality of life of these patients is materially affected by their perpetual apprehension about the future, the current life circumstances, their financial situation, the possibility that something happens to the family's painful, and various other aspects of life. Can experience physical tension and mild symptoms of activation of the sympathetic nervous system, but nothing that approaches the level of disorder panic attacks. Anxiety emerges in response to many situations along the course of life. If patients had to resort to medication every time you feel anxious, this would be particularly worrisome for psychiatrists. With medication can eliminate the physiological components of anxiety without affecting the cognitive aspects of concern that remains. When you embark on a psychodynamic therapy with patients with GAD, it is necessary that the therapist demonstrates tolerant patient who focuses his attention on somatic symptoms and other concerns that appear rather superficial. A working hypothesis about the function of the fact that defense is to focus attention on these concerns distracts the patient from deeper problems and disturbing. This characteristic pattern of defensive avoidance can be linked to a confrontational insecure attachment in infancy, as well as to early trauma (Crits-Christoph et al., 1995). After listening empathically the concerns presented by the patient, the therapist can begin to ask questions about family relationships, any interpersonal difficulties and work situation of the patient. The therapist can then associations between the various situations that are cause for concern, so that the way of nuclear conflict in relationships begin to emerge. 269-73 dissociative disorders Forms pathological dissociation are identified in disorders or abnormalities of the functions normally integrative memory, identity and consciousness (Putnam, 1991). The DSM-IV (American Psychiatric Association, 1994) includes the following entities within the diagnostic category of dissociative disorders: dissociative identity disorder (multiple personality disorder), depersonalization disorder, dissociative disorder not otherwise specified, dissociative amnesia and dissociative fugue. In its essence, the dissociation is the result of a lack of integration of aspects of perception, memory, identity and consciousness. Less important examples of dissociation, as the "highway hypnosis" or temporary feelings of alienation and "distancing" are common in the general population. An extensive empirical evidence indicates that the dissociation occurs in particular as a defense against trauma. The same trauma can be considered as an abrupt interruption of the continuity of experience (Spiegel, 1997). The dissociation during trauma also leads to a process of storing memories discontinuous. A common defensive response to trauma is the dissociative detachment, understood as a way to ward off intense emotional content. Allen and colleagues (1999) have stressed because this detachment greatly narrows the field of consciousness of the individual, so that a small recognition of the environment can interfere with the process of recording and processing of memories. Without reflective thought necessary for the storage, the memory is not integrated in the autobiographical narrative. The dissociative amnesia, dissociative fugue, dissociative identity disorder and acute stress disorder (ranked among the anxiety disorders, see Chapter 9) have a common psychodynamic basis. The dissociative amnesia involves one or more episodes of inability to recall an important personal trauma; dissociative fugue involves a sudden and unexpected departure from the house which is associated with the inability to remember their past and some confusion about personal identity. The dissociative identity disorder (DID), formerly referred to as multiple personality disorder, is the presence of two or more distinct identities or personality states, each with its own mode, relatively stable, of perception, of relationships, of thought than environment and self. At least two of these identities or personality states should periodically take control of the behavior of the individual. The DID is also characterized by a lack of memories that relate to important personal information that is too extensive to be able to be interpreted as a normal form of forgetfulness. Kluft has proposed a theory of etiology based on 4 factors: 1) the ability to implement a dissociation of defense against trauma must be present; 2) overwhelming traumatic life experiences, such as a physical or sexual abuse, are beyond the capacity of adaptation and the usual defensive operations of the child; 3) the precise forms assumed by dissociative defenses in the process of formation of the other personalities are determined by influences plasmatrici and substrates available; Finally, 4) contacts reassuring and restructuring with parental figures or significant others are not possible, so the child feels a profound inadequacy of the ability to protect themselves from the stimuli. One clear implication of the model of the four etiological factors is that the trauma is because necessary but not sufficient to develop a DID. At the risk of asserting what is obvious, not all those who are abused as children develop a DID. The dissociation may also occur in the absence of trauma in individuals strongly suggestible and brought to fantasize (Brenneis, 1996; Target, 1998). Therefore the presence of the dissociation is not in itself confirmation of a history of early childhood trauma. The therapist should make clear to the patient that the recovery of traumatic memories is not the purpose of psychotherapy. The memory dysfunction typical of patients with dissociative disorders actually makes them the subjects less than ideal for a therapy that aims to recover the memories. A more reasonable goal is to help to restore normal mental function, in particular as regards the capacity of reflection and mentalisation, so that they can develop a representation of themselves and other more consistent. In the context of a strong attachment relationship to the therapist, the trauma patient can benefit from the therapist's ability to reflect on what is happening between them. Eventually, patients may internalize the processes of reflection of the therapist and become able to bring their dissociated aspects to awareness, and thus acquire a greater sense of continuity. The integration of the other persons is only possible for some patients suffering from DID. When patients with DID evoke sexual abuse suffered in childhood, often are ashamed to events that have happened them. It is for example very common to hear women talk about themselves as "sluts" and "whores", you deserve what happened to them. From small stick frequently to the conviction of having received such punishment because they were naughty children who had misbehaved. Although to some extent this sense of shame and guilt can be explained by introjective identifications with parents "bad", the self-accusation can also be understood as a desperate attempt to make sense of a terrifying situation. If you retain some ability to mentalizing, may explain this situation, trying to convince himself that parents are basically good people who care about their well-being. If parents treat them well means that were bad and that they deserved. When clinicians try to convince these patients that what happened is not their fault, patients often do not feel understood. This attitude of the victims of abuse may be an adaptive aspect of incest even if the event can not be canceled, a pc can get to the knowledge that his only way to survive was to submit to his father's amorous approaches. Effective psychotherapy recovers much of what has been lost and helps the patient to build a chronological narrative or an autobiography which provides the basis for the formation of a new self (Putnam, 1990). When a patient with DID has different personalities in the clinical setting, the therapist must treat them effectively as aspects of the same person. Moreover, it should be ready in the time of transition from one personality to another and try to explore with the patient what triggers the transition. The dissociation in the context of therapy is usually a defensive escape from something that produces pain or anxiety. This need to escape at the end can be brought to the awareness of the patient. Psychodynamic therapy of patients with severe dissociative disorders is often compromised by their lack of reflective capacity. Their thinking may be overly concrete, and they may be unable to sustain the feeling of "as if" typical of transference. In other words, patients with DID may be unable to distinguish between a perception of the therapist as representation and the mode of being of the therapist in reality. Have tended to believe that their perceptions are absolute facts instead of ideas that can be shared and understood. Even the experience that they themselves can be just as real. Patients who have been abused as children often feel that everyone will abuse them because they have no reason to think otherwise. According to this perspective, these patients are inherently suspicious of the assurances given by therapists, who claim that there never will abuse them. Assurances can make people feel better therapists, but rarely do patients feel better. The professions of benevolence are inherently suspicious for patients who have been exploited by people who claimed to love them. Most patients suffering from DID has not had the advantage of growing with generational boundaries and limits set by parents is good and loving, and often live professional boundaries of the therapeutic context as a cruel form of rejection. These patients may require demonstrations of real interest on the part of the therapist involving extensions of the sessions, physical contact, the expectation that the therapist reveal personal aspects and the claim of its total availability. If therapists begin to "jump through hoops" to gratify these demands, their efforts are doomed to failure. Attempting to become a substitute parental goes beyond the need for the patient to express his pain, and raises false hopes that a parental relationship may be available as long as the patient can find the right person. In most cases of DID treatment sooner or later reveals that patients have the tacit belief that they have the right in this in compensation for abuses lived in the past (Davies, Frawley, 1992). With the gradual increase in demand, the therapist can quickly develop a sense of being tormented. The third act of the drama is revealed in certain instances where the growing demands of the patient is accompanied to the efforts of the therapist gratificarle. At the height of exasperation at the failure of all therapeutic efforts, therapists can get with the patient in a dramatic cross boundaries therapeutic proposing in fact the abuse of children. The therapist then became the abuser of the patient who is once again in the role of victim. The most tragic - and unfortunately all too frequent - manifestation of this third paradigm is a sexual manifesto between therapist and patient. Other common examples include a sadistic verbal abuse against the patient's attempts to comfort the patient making him sit on his lap and to recur as its "parents", bring the patient in trips with his family, and so on. In such circumstances the anger of the therapist in response to frustration is often completely disregarded. What began as an attempt to aid ends up as a re-enactment of exploitation and abuse. Many patients with DID suffer from a kind of learned helplessness that feel they can not do anything to change their fate. They assume that, once trapped, there is no way out. They have no sense of operability and efficiency they will use. In this sense the patients, according to the definition of Kluft (1990), the "perching ducks" against all forms of abuse and violation of limits by therapists who use their patients to gratify their own needs. Patients with DID who are hospitalized in the departments of general psychiatry often found in the role of the classic patient "special" (Burnham, 1966; Gabbard, 1986). Both staff members that other patients believe that they have privileged relations with their psychotherapist and often the result is that they end up becoming scapegoats. At the beginning of the stay in the hospital with the patient should be entered into a contractual agreement that enshrines his consent to respond according to the legal name when called in the department. The patient should be informed that they can not expect that the staff is able to respond to other personalities in different ways as they emerge during his stay in the ward. Only the individual therapist called by name other separate personalities. A patient who is unable to make a contract on behalf of all other personality should be structured to the level of the personality more dangerous and self-destructive. This arrangement avoids the inevitable confusion among staff members on the privileges and responsibilities given the variability of operation of several other personalities. Kluft (1991d) also suggested that nursing staff should constantly explain the rules and guidelines to patients because some personality might not know them. Kluft (1991d) warned that patients with a DID may have considerable difficulty with group psychotherapy unstructured hospital wards. If a patient is unable to establish a contract that allows them to contribute as another personality that adapts to the rules of the group, according Kluft should be excluded from the group work. 282-301 The depersonalization disorder differs significantly from other dissociative disorders. It is usually characterized by persistent or recurrent experiences in which there is a feeling of detachment from your body or by their mental processes, as if these were observed from the outside. Reality testing remains intact, but these experiences cause significant discomfort and interfere to some extent with the occupational and social functioning. Derealization typically part of depersonalization disorder and specifically refers to the feeling of being alienated from their environment. Depersonalization may be in different forms, including the feeling that your body is numb or lifeless, the feeling that certain parts of the body (such as the feet or hands) are not connected to the rest of the body, the feeling of being detached from their self-image to the point of seeing a stranger, or the feeling of observing from a distance (Gabbard, Twemlow, 1984). The subjective experience of real detachment from their body is actually quite uncommon in depersonalization, were encountered only in 19 percent of psychiatric patients with this disorder (Noyes et al., 1977). Although the experience of déjà vu are often associated with depersonalization, they are in fact the opposite of the depersonalization and should be maintained as separate entities (Nemiah, 1989). In other words, in the déjà vu that is new is experienced as if it were familiar, while in depersonalization what is familiar is experienced as if it was new or unreal. occurs in women twice as often as men, and its wider dissemination among individuals under the age of forty (Nemiah, 1989). A transient depersonalization can also occur in response to situations involving danger of death, such as accidents, illness, and the like (Gabbarti, Twemlow, 1984; Noyes et al., 1977; Steinberg, 1991). There can be a sense of survival in the division that is created between a self that looks and a self that is involved in a crisis situation, so that an individual is able to acquire the necessary detachment to think about how to juggle to take off from a dangerous context. Depersonalization that occurs in normal people exposed to dangers not significantly different to the episodes that occur in the context of a psychiatric disorder (Noyes et al., 1977). Among psychiatric patients, depersonalization disorder is the third most frequently complained, after depression and anxiety (Cattell, Cattell, 1974). Depersonalization is in fact relatively uncommon disorder as pure, and is more often a symptom associated with another disease like schizophrenia, dissociative identity disorder, depression or anxiety disorders (Nemiah, 1989). The experience of depersonalization with or without a disease, is typically unpleasant affective and active content such as anxiety, panic, feeling empty. It is seen as a disease, an oddity, an experience similar to a. dream and often leads to the research assistance of a doctor (Gabbarti, Twemlow, 1984). Depersonalization has a chronic course in about half the cases, but the degree of limitation that creates the individual can be very variable (Steinberg, 1991). Comorbidity seems to be common in patients with a disorder, depersonalization. In a study of 30 patients, the prevalence of lifetime major depression and social phobia was 53 percent for each disorder (Simeon et al., 1997). It was also detected a prevalence of 37 percent for the disorder panic attacks. They were also common in these patients disorders Axis 2: an avoidant personality disorder was present in 30 percent of cases, a borderline personality disorder in 27 percent and an obsessive-compulsive personality disorder in 23 percent. Overall, 60 percent of those studied had at least one personality disorder. Rosenfeld (1947) considered the depersonalization Count a defense against primitive destructive impulses and persecutory anxieties arising from the paranoid-schizoid position. Blank (1954) saw it as a defense against anxiety and anger generated by primitive deprivazione- oral. Finally, Stamm (1962) agreed with both in considering deeply regressive aspects of depersonalization as a defense. The psychodynamic point of view the most current is to consider the depersonalization as the internalization of conflicting identifications, Jacobson (1959) observed that it is possible to defend against unacceptable identifications through denial and the denial of an undesirable part of the ego. Arlow (1966) considered the depersonalization as a means of defense to control the impulses of self involved in a dangerous situation, which is experienced as alien to that point from the self observant. In this way the dangerous conflict is seen as a process that takes place inside of a stranger rather than within the Self. The role of trauma in the etiology of depersonalization disorder is not entirely clear. The literature suggests that patients with this disorder have a history of childhood trauma with a frequency tends greater than control subjects who do not suffer from psychiatric disorders (Simeon et al., 1997), but are generally less severely traumatized than in patients with other types of dissociative disorders. Nevertheless, a depersonalization is frequently described when patients who have suffered sexual abuse in childhood recall the details of their victimization. Not always depersonalization is a defense against an external threat or internal instinctual impulse. According to a perspective derived from self psychology, depersonalization may also be a reflection of problems in the consolidation of a stable and cohesive sense of self (Gabbard, 1983; Stolorow, 1979). In these patients, the state of depersonalization may reflect the sense of panic linked to the fragmentation of the self when others do not reach answers confirmation and mirroring of self-objects. If depersonalization is secondary to an underlying primary disorder, the clinical improvement of the primary disorder in response to appropriate therapy can also solve the depersonalization. 302-5
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Re: Psychopatology Gabbasrd

Post  counselor on Sun Nov 30, 2014 10:58 am

paraphilias

The definition of paraphilia in the DSM-IV (American Psychiatric Association, 1994), in an attempt to be non-judgmental, suggested the restriction of the term to situations in which they are used nonhuman objects, are inflicted on themselves or their partner a real pain or humiliation, or are involved children or non-consenting adults. To consider the continuum between fantasy and action, the DSM-4 has developed a spectrum of severity. In the forms "mild", patients are troubled by their sexual drives paraphilic, but not put in place. In terms of severity, "moderate", patients translate thrust into action, but only occasionally. In "severe" cases, patients repeatedly put in place their forces paraphilic. Finally, trying to make it more scientific and less pejorative, in the DSM-IV uses the term paraphilia rather than perversion or deviation. 312 Patients with paraphilias are notoriously difficult to treat. Over many years they have developed a well thought out solution to their problems erotica, and are rarely interested to give it up (MeDougall, 1986). Why someone would want to stop a practice that produces great pleasure? Many of perversions are ego-syntonic; only exceptionally patients who are bothered by their symptoms seek treatment voluntarily. People who generally consider their fetishes fetishism as nothing more than a personal idiosyncrasy, certainly not as a psychiatric symptom (Greenacre, 1979). Typically seek treatment for other reasons, and fetishism emerge during therapy or analysis. The majority of patients paraphilic is in therapy as a result of pressure exerted by others. A marital crisis can bring a transvestite attention clinic under the threat of divorce. In cases of voyeurism, exhibitionism and especially pedophilia, legal provisions often require therapy as necessary to obtain parole as an alternative to prison. There may be a court case pending, and the patient can then undergo the treatment only to "look good" in court and push the national proscioglierlo of all charges. In all cases of paraphilia, first be clarified the legal situation of the patient. The clinician may decide to postpone a possible long-term therapy until after the case has been discussed in court. Patients seeking treatment even after all the legal issues are resolved can have a more favorable prognosis (Reid, 1989). We are filled with disgust, anxiety and contempt. Our natural impulse is to respond in a punitive - to moralize, to reprove, to preach, to do what we can to "choke" this perversion. We also filled with horror to the idea that someone can give free rein to such impulses ourselves while we check them carefully. Finally, another trend countertransference is to collude with 1'evitamento put in place by the patient than the perversion talking about other aspects of his life. Clinicians can avoid their own feelings of disgust and contempt avoiding the whole area of sexual pathology. With certain patients - pedophiles, in particular - some therapists may feel simply not be able to be effective due to an intense hatred countertransference. In these cases, it is better to refer the patient elsewhere. A final reason for difficulties in the treatment of subjects suffering from perversions is associated psychopathology. The perverse fantasies and behavior are difficult enough to change, but when the patient's condition is complicated by a disease of the antisocial, borderline or narcissistic, the prognosis is even more unfavorable. If treatment of paraphilias, and in particular those involving pedophilia and other forms of criminal violence, to be truly effective it remains a very controversial issue. Because, for example, an observation day and night of pedophiles is not possible, the researchers can not know for sure whether or not they continue to act impulses to molest children. Associated with the use of psychodynamic approaches, are commonly used also the cognitive behavioral therapy, reconditioning and behavioral relapse prevention techniques that have proven useful in certain patients. Treatment goals usually include the fact of helping patients overcome their denial and develop some empathy for their victims; identification and treatment of sexual deviant; the identification of social deficits and poor adaptability; modification of cognitive distortions; Finally, the development of a comprehensive plan for the prevention of recurrences that includes 1'evitamento of situations in which the patient may be "induced into temptation." In general, patients with organizations of the character of the highest level have a better outcome than those with borderline levels of organization (Persoti, 1986). Similarly, it is likely that patients who possess a psychological mindset, that have some degree of motivation, they feel some discomfort for their symptoms and are curious about the origins of these symptoms derive greater benefits than those who do not have these characteristics. These patients rarely want to focus on perversion and often brightly assert that for them it is no longer a problem. Although psychotherapists should treat disorders associated with paraphilia, should also be compared with patients that denial from the start. A task of therapy is to integrate the perverse behavior with the core of the operation of the patient's personality so that it can be harmonized with the rest of his life. Goldberg (1995) suggests that the therapist must recognize that the perverse behavior is essential to the emotional survival of the patient but also consider such behavior as something that must be understood and resized. Even beyond the legal and ethical considerations, the perverse behavior therapists in easily evokes strong responses of disapproval. Patients may also avoid discussing the symptom instead professing feelings of shame, embarrassment and humiliation. If the patient is able to overcome his initial resistance to form a therapeutic alliance in the service of understanding of the symptom perverse, then both patient and therapist can start looking for the unconscious meanings of the symptom and its function within the patient's personality. Most paraphilias operates in a context of object relationship outside the patient's awareness. Many individuals with paraphilia they experience their fantasies and their behavior as essentially not psychological, and are unaware of any connection between their symptoms and emotional states, or between the symptom and events in their lives that can increase the need of the symptom. Many of the efforts of the therapist must therefore turn to the explanation of these connections. The couple's therapy can be crucial to the success of the treatment of paraphilias. A marital crisis can primarily cause the patient to seek assistance, and a couple therapy can often help them understand how the activity reflects perverse sexual and emotional difficulties in the marital dyad. It can also relieve the wife unfounded feelings of guilt and responsibility for the behavior of her husband and can make the woman feel to participate in its resolution rather than being responsible for its cause (Kentsmith, Eaton, 1978). The exploration of a marital discord can also reveal that the paraphilia is a container or a "scapegoat" that shifts the focus from one or more problem areas in marriage (Reid, 1989). Clinicians must therefore be creative in using the patient's wife as an additional therapist in refractory cases of paraphilia. Patients paraphilic that more easily are hospitalized are pedophiles and, to a lesser extent, the exhibitionists who are simply unable to control their behavior when treated on an outpatient basis. Many of countertransference problems described above also arise in the hospital. The refusal of the patient with respect to his perversion can lead hospital staff to collude with him, focusing on other issues. In general, patients with paraphilias are contrary to discuss their problems in group meetings or meetings in the community of a hospital ward. However, when staff members acquiesce to the request to avoid the sexual themes in therapy meetings, in fact collude with the patient's tendency to cross the entire length of stay without addressing the perversion that led to hospitalization. Furthermore, those with overt antisocial personality traits may simply lie, so that their perverse behavior is never examined during hospitalization. Other pedophiles can convince the staff members that are actually following the treatment, building the whole charade that the case involves. They seem to use the insights that reach in psychotherapy from the origin of their impulses and desires but secretly have no interest in changing. "They're in the game" because the hospital treatment is far preferable to the prison, where pedophiles are often raped. Some pedophiles may therefore be treated in much better correction facilities in which they are applied specialized programs for sex offenders approaches that involve comparison within a group. The psychodynamic understanding of pcs male or female who has no desire for sex, or pc male desire but that test is not able to get an erection, start with a thorough understanding of the situational context of the symptom. If the patient is involved in an intimate relationship, the clinician must determine whether the problem of desire or excitement manifests itself specifically with the partner or if it is generalized to all prospective sexual partners. Sexual difficulties that are specific torque must be read in the context of the interpersonal dynamics of the dyad, while those that occur with each partner reflect essentially intrapsychic problems. Clinicians must remember, however, that the problems of desire, like all other psychological symptoms, are overdetermined. The nationwide study mentioned earlier (Laumann et al., 1999) found that the presence of problematic relationships, both at present and in the past, is strongly associated with sexual dysfunction. All types of sexual dysfunction reported by the women involved in this investigation showed in fact a close association with unhappiness and poor physical satisfaction. and emotional. The problems in reaching a state of sexual arousal were significantly related to sexual victimization due to contact adult-child or forced sexual relations. Males who had been victims of child-adult contacts instead had a chance to be suffering from erectile dysfunction, three times greater than those who had not been abused, and twice as likely to suffer from premature ejaculation and low sexual desire compared to control subjects who had no history of childhood trauma. Laumann and colleagues have pointed out that in both sexes sexual trauma seemed to give rise to profound and lasting effects on sexual functioning. Levine (1988) has outlined three different elements of sexual desire that must work in sync so that there is a proper desire and excitement: drive, desire and motivation. The drive is rooted in biological and can be affected by physical factors such as hormone levels, diseases and drugs. The element of desire is more intimately associated with conscious factors cognitive or ideational. For example, in the presence of a normal component of drives, an individual may wish to not have sex for religious prohibitions or for fear of contracting AIDS. The third element, the motivation, is intimately connected to the unconscious needs of object relationship and is the component most likely will be the focus of therapeutic intervention. According to Levine, the clinician should consider all three elements, and try to understand why they are not integrated in a functional unit. Several factors can interfere with the motivation of an individual. One spouse may have an extramarital affair and simply do not feel any interest in the partner. Or one spouse may feel so chronically resentful and angry towards others that sexual relations are out of the question. The problems of the couple without sexual relations are probably the cause of most cases of inhibition of sexual desire. Even distortions transference of a partner can play a key role in disturbing the motivation. In many couples who embark on a sex therapy or conjugal partners unconsciously relate to each other as if it was the parent of the opposite sex. When this occurs intercourse may be unconsciously felt as incestuous, and the members of the pair then attempt to master the anxiety associated with this taboo avoiding sex altogether. 311-34 Disorders substances and disorders of the AA approach to the problem of alcoholism has proved extremely effective in the treatment of many individuals. Although the organization promotes the model of the disease, its methods have turned to psychological needs and facilitate a lasting structural change of personality (Mack, 1981). Abstinence is reached in an interpersonal context in which alcoholics can bring a community of fellow sufferers who cares and takes care of them. Clinical experience has repeatedly demonstrated, however, that the approach of AA is not suitable for all patients suffering from alcoholism. Most experts would agree in considering alcoholism a heterogeneous disorder with a multifactorial etiology (Donovan, 1986). No type of therapy is constantly reveals more effective than all the others. Alcoholism is not a monolithic entity. In fact, it would be more appropriate to speak of "alcolismi" (Donovan, 1986). Numerous studies show that there is no single "alcoholic personality" that predisposes patients to alcoholism alcoholics have problems with self-esteem, to the modulation of the affection and the ability to take care of themselves. Scholars of borderline personality disorder have noticed that among alcoholics and patients with borderline personality disorder are similarities in particular, they share traits such as poor tolerance of anxiety, poor emotional and checked using the split as a defense predominant (see Sec. L5). This link between alcoholism and borderline personality disorder has been further confirmed by empirical studies (Nace et al., 1983; Vaglum, Vaglum, 1985) indicating that 39 percent of alcoholics have a coexisting borderline pathology. An analysis of twelve studies of alcoholic patients, conducted with the specific purpose of verifying the presence of personality disorders, found that the prevalence of comorbid conditions for axis 2 ranged between 14 and 78 percent (Gorton , Akhtar, 1994). Other diagnoses that commonly accompany alcoholism are those of depression (Weissman, Myers, 1980) and sociopathy (Schuckit et al., 1970). An individual can develop alcoholism as a culmination of a complex interaction between structural deficiencies, genetic predisposition, family influences, cultural contributions and other various environmental variables. When these people stop drinking and look back at the wreckage caused by their existence of alcoholics, are generally faced with some degree of depression, which arises from the painful recognition of having done harm to others (often those who represented to them the the most important figures). They must also mourn for everything (for example, relationships, assets) that have lost or destroyed because of their addictive behavior. Although antidepressant medications can relieve this depression, psychotherapy can provide help in the process of developing these painful aspects. The assessment and treatment of suicidal risk should be part of the overall treatment plan of alcoholic patients. 25 percent of all suicides occurs between alcoholics and the probability that an alcoholic is suicide is from 60 to 120 times higher than that of an individual not suffering from psychiatric disorders (Murphy Wetzel, 1990). When depression and alcoholism coexist, seem to have additive or synergistic effects that result in disproportionately high levels of suicide risk (Cornelius et al., 1995; Pages et al., 1997). Another implication of the observation that alcohol addiction takes place in a person is that each person will prefer and accept different treatment options. For many alcoholics the approach used by the AA does not work because of their embarrassment at having to speak in front of a group. 345-48 A considerable amount of research supports the existence of an association between personality disorder, depression and the development of an addiction. Studies of people addicted to drugs have detected other psychiatric diagnoses in a percentage between 1'80 and 93 percent (Khantzian, Treece, 1985; Rounsaville et al., 1982). The frequency of co-morbidity is high even among individuals who use cocaine. Other surveys of high school students who used hard drugs identified depression as the strongest predictor of all personality variables Compared to alcoholics, drug addicts are much more easily and significant coexisting psychiatric disorders. One study found that relations deteriorated with parents and depression are highly significant predictors for the possible abuse of illicit drugs, anxiety disorders, antisocial personality disorder and attention deficit disorder usually precede the onset of the abuse of cocaine, while affective disorders and alcoholism typically occur after the onset of the abuse (Rounsaville et al., 1991). The researchers stressed that a unified approach to treatment of drug addicts is not appropriate because those with a personality disorder require different therapeutic approaches. Drug addicts with personality disorders tend to be more depressed, more impulsive, more isolated and generally less satisfied with their lives compared to addicts without such disorders. Researchers contemporary psychoanalytic see addict behavior more as a reflection of the lack of the ability to take care of themselves than as a self-destructive impulse (Khantzian, 1997). This reduced ability to take care of yourself is the result of early developmental disorders that lead to inadequate internalization of parental figures, leaving the addict unable to protect themselves. Therefore, the majority of drug addicts. Chronic shows a fundamental lack of judgment about the risks that substance abuse poses. Equally important in the pathogenesis of drug addiction is the failure of the functions delegated to affect regulation, impulse control and the maintenance of self-esteem (Braids, Khantzian, 1986). These deficits create problems in the corresponding object relations. The use of multiple drugs was put in direct relationship with the addict's inability to tolerate and regulate interpersonal closeness (Nicholson, Braids, 1981; Braid, 1984). These relationship problems also contribute a narcissistic vulnerability to the risks inherent interpersonal and inability to modulate associated affects intimacy. Dodes (1990) noted that drug addicts have a tendency to feel helpless because of a specific narcissistic fragility. The addict behavior reduces the sense of helplessness and despair through the control and regulation of their affective states. Narcissistic rage and humiliation shall require such persons to use drugs as a tool to re-establish a sense of power. Taking a drug can therefore be seen as a desperate attempt to compensate for the shortcomings in the functioning of the ego, self-esteem and interpersonal problems related. specific substances are chosen for specific psychological and pharmacological effects, depending on the needs of each addict. cocaine seems to alleviate stress related to depression, hyperactivity and hypomania, while narcotics appear to reduce feelings of anger. heroin addiction is plurideterminata by: 1) a need to contain aggression, 2) a desire for gratification of the desire for a symbiotic relationship with a mother figure, 3) a desire to alleviate suffering depression. These individuals struggle with feelings of worthlessness, guilt, self-criticism and shame. Their depression seems to intensify when they try to get close to others, so that they retreat into a "bliss" isolated reached through heroin or other drugs that size is regressive and defensive. The nucleus of depressive opiate addicts was further confirmed by a study comparing (Blatt et al., 1984a, b), which took over as opiate addicts are generally significantly more depressed of politossicomani, and has identified self-criticism as a major component of this depression. 349-57 Anorexia nervosa and bulimia nervosa appear to be the disorders of our time. The means of mass communication bombard the audience with images of slender women who "have everything". In many Western countries there is plenty of food, a necessary precondition for a behavior characterized by "binge eating" food. Individuals with these disorders tend to be Caucasian, educated, female, economically advantaged and rooted in Western culture (Johnson et al., 1989). Anorexia nervosa is virtually unknown in countries where thinness is not considered a virtue (Powers, 1984). The images of women provided by the mass media also suggest that the outward appearance is much more important internal identity. Although intra-psychic and biological factors should not be minimized in the etiology and pathogenesis of eating disorders, these factors clearly interact with a particular sociocultural period of Western civilization in producing a syndrome that reflects the culture. The incidence of anorexia nervosa and almost doubled from the 60s, while the prevalence of bulimia nervosa found among teenage girls and young adult is around 1 per cent (Fairburn, Beglin, 1990). These disturbing figures show that eating disorders can be a solution increasingly common for a variety of stressors intrapsychic, family and environmental. 357 What the diagnostic plan characterizes anorexia nervosa is actually a fanatical pursuit of thinness related to an overwhelming fear of gaining weight. To make the diagnosis is often used the arbitrary criterion of a reduction in body weight below 85 per cent of the normal minimum value with respect to age and height. Amenorrhea is a prominent feature of anorexia nervosa in women. Although the 5-10 percent of individuals with this disorder is male, their clinical and psychodynamic are very similar to those of their female counterparts. The Bruch noted that the concern I about food and weight is an event, relatively late, emblematic of a deeper disorder of self-concept. In most cases, patients with anorexia nervosa have the firm conviction of being completely powerless and ineffective. The disease often manifests itself in "good girls" who have spent their whole lives trying to please his parents, and suddenly become stubborn and negativiste during adolescence. The body is often experienced as separate from the self, as if it belonged to the parents. These patients lack any sense of autonomy, to the point of not even feel able to control their bodily functions. The defensive posture premorbid being a perfect little girl usually hides a deep sense of worthlessness. Anorexia nervosa is produced, said the same words of Bruch (1987), as "an attempt to self-care, to develop through the discipline of the body a sense of individuality and interpersonal effectiveness. Anorexics transform their anxiety and their psychological problems through the manipulation of the quantity and size of the food taken. "The Bruch indicated the evolutionary origins of anorexia nervosa in a disturbed relationship between the infant and the mother. Specifically, the mother seems to take care of her daughter as a function of their own needs rather than those of the child. If its signals are not receiving answers confirmation and validation, the child can not develop a healthy sense of self. It feels like an extension of the mother, rather than as an independent entity in its own right. The child is not perceived as a separate individual, but rather as the "right arm" of the mother. Minuchin and co-workers have described a pattern of enmeshment in the families of anorexic patients, characterized by a general lack of personal and generational boundaries. Each member of the family is ipercoinvolto in the life of all the others, to the point that no one experiences a sense of separate identity beyond the family matrix. Even the Palazzoli (1963) noted that patients with anorexia nervosa have not been able to separate psychologically from the mother, with the result that he never acquired a stable sense of one's body. The body is therefore perceived as if it were inhabited by poor maternal introject, and fasting may be an attempt to stop the growth of this internal object hostile and intrusive. Similarly, Williams (1997) pointed out that the parents of an anorexic patient tend to project their anxiety in the child rather than contain it. These projections may be experienced by the child as foreign bodies enemies. To protect themselves from the experiences not metabolized and fantasies projected by the parents, the young girl can develop a system of defenses from "forbidden to enter", which is concrete in food refusal. Boris conceptualized anorexia nervosa as an inability to get good things from others because of an unlimited desire to possess. Any act of receiving food or love puts these patients directly compared with the fact that they can not have what they want. Their solution is not to receive anything from anyone. Envy and greed are often closely linked in the unconscious. She envies the good things owned by the mother - love, compassion, nurturing but receive them would increase simply envy. Give up these claims unconscious fantasy of ruining what is envied, in a manner not unlike that in Aesop's fable, does the fox with the grapes. The patient sends the following message: "There is nothing good that I can have, so just give up all my wishes." This waiver makes the anorexic patient the object of others' wishes and, in his imagination, the object of their envy and admiration, because they are "impressed" by his self-control. Most formulations evolutionary origin of anorexia nervosa is focused on mother-daughter. Bemporad and Ratey (1985), however, have observed a pattern characteristic of paternal involvement with daughters anorexic. The father was typical superficially interested and supportive but emotionally abandoned his daughter whenever he really needed him. In addition, many fathers of anorexic patients seek emotional nourishment in daughters - rather than give it. Both parents often experience a big disappointment compared to their marriage, which leads them to seek emotional support in the daughter. The anorexic girl seriously doubts that the parents or significant others in his life can put aside, even temporarily, their interests and needs to meet its needs for reassurance, confirmation and mirroring (Bachar et al., 1999). It can then gradually increase fasting and restrictions in a desperate attempt to force parents to pay attention to his suffering and to recognize his need for help. These psychodynamic factors are also accompanied by some cognitive traits characteristic, including an erroneous perception of body image, all-or-nothing thinking, magical thinking, and thoughts and obsessive compulsive rituals. Clinicians who have treated patients with anorexia nervosa are in agreement that treatment goals should not be focused strictly on weight gain (Boris, 1984a, b; Bruch, 1973, 1978, 1982, 1987; Chessíck, 1985 ; Giving, 1995; Hsu, 1986; Hughes, 1997; Powers, 1984).
An approach "two-way", supported by Garner and colleagues (1986), provides a first step of refeeding to buy weight. Once this is achieved, it can begin the second step of the psychotherapeutic. The anorexic patients showed improvement more remarkable when the therapeutic approach includes a combination of family psychotherapy and psychodynamic psychotherapy individual, than when they are treated simply with educational measures aimed at weight control weight. Until you have examined the underlying disorder of the self and the related distortions of the internal object relations, the patient will follow a path of repeated relapses and hospitalizations continues. The hospital can be an addition effective than individual psychotherapy. Although there is unanimous consensus on the indications for the treatment of in-patients, a weight loss of 30 percent compared to normal body weight is a good rule to determine the need hospitalization. staff members of a department should pay particular attention to the patient's unconscious attempts to reenact the battles in the hospital family. They must be able to convey their interest in the patient and help her regain weight without worry excessively, and ask no requests similar to those that would do the parents. The patient can be helped to deal with the fear of losing control by establishing frequent meals but low abundance, in the presence of a member of the nursing staff that is willing to discuss with the patient his anxiety about eating. The patient sees anorexia nervosa as the solution to an internal problem. Psychotherapists that define it immediately as a problem that must be solved reduce their ability to form a viable therapeutic alliance. The behavior associated with anorexia nervosa raises demands and expectations of change of the parents of the patient. Just as the patient causes their parents by refusing to eat, try to provoke the psychotherapist refusing to talk (Mintz, 1988). Initiating therapy may therefore be useful to clarify that the main goal of treatment is to understand the underlying emotional disorder of the patient rather than the problem of food refusal (Bruch, 1982; Chessick, 1985). according to Bruch (1982) psychotherapy is not feasible unless the patient does not weigh around forty pounds. The Bruch explains to his patients that their ability to think and communicate improve if you will be able to carry their weight at least at that level. the patient is an autonomous person who is entitled to have his own ideas about his illness. It is crucial to help the paziento to define their own affective states. The actions and decisions that arise from these feelings must be legitimized and respected. The therapist can help the patient to explore various options but should avoid telling her what to do (Chessick, 1985).
The anorexic patients often believe that parents want to make them gain weight so that others do not see them as failures (Powers, 1984). It is likely that the terpeuta become anxious about similar issues. In particular, the therapists who work within the therapeutic team will begin to feel that colleagues judge negatively their job if their patients do not gain weight. This concern countertransference can lead the therapist to fall into the trap of identifying with the parents of the patient. The ideal situation for individual psychotherapy is that another therapist to take care of the weight problem, leaving the psychotherapist free to explore the underlying psychological issues of the patient. When to weight control is needed hospitalization, the treating psychiatrist can manage food intake while the psychotherapist continues psychotherapeutic work at the hospital. In this frame, the psychotherapist can work productively with the team. Patients try to give the therapist the same role that give parents, looking for help to get attention but repeatedly frustrating their attempts. Often show themselves willing and ready to cooperate and then sabotage the work of the therapist. With patients with anorexia typically the therapeutic alliance is much more tents than it appears, and the therapist has to adapt to the frustration of feeling cheated by the patient. To manage countertransference is useful to remember that these patients interpret progress as synonyms for growth and separation from family, perspectives that are both a source of great anxiety and fear. The anxiety of the therapist is further fueled by the fact that the anorexic patients are actually "playing" with the death, and the situation is made even more frustrating because they frequently deny having suicidal desires. Misperceptions of the patient about his body and cognitive illogical beliefs should be explored with the patient in a non-judgmental (Powers, 1984). The distortions of body image, which often assume delusional proportions, may be particularly refractory to educational and therapeutic efforts. 361-5 The patients with bulimia nervosa are generally distinct from those with anorexia nervosa on the basis of a relatively normal weight, and the presence of binge eating and the use of purgatives. The emaciated patients who stuff themselves and purge are often classified as anorexic, bulimic subgroup (Hsu, 1986). According to Bruch the two syndromes have little in common: the rigid self-discipline and awareness of severe anorexic patient are in stark contrast to the impulsive behavior, irresponsible and undisciplined person bulimic. The opinion of Bruch, however, is not supported by the data indicate that more and more numerous as between the two disorders exists a considerable binding (Garner et al., 1986). At least 40 to 50 percent of all patients is also bulimic anorexics (Garfinkel et al., 1980; Hall et al., 1984; Hsu et al., 1979). The results of long-term follow-up suggests that with the passage of time anorexia nervosa can give way to bulimia, while the reverse mode is very rare (Hsu, 1991). In light of these observations, the DSM-IV (American Psychiatric Association, 1994) classifies anorexia nervosa according to the presence or not of bulimic symptoms, while preclude the diagnosis of bulimia nervosa bulimia if occurs only during episodes of anorexia. One of the reasons to mitigate the boundaries between diagnostic behaviors anorexic and bulimic is the fact that the clinical picture can be very varied. Concomitant psychiatric disorders are common (Yager, 1984), and in more than half of the cases the bulimic patients may suffer from associated personality disorders. Anorexia and bulimia are essentially two sides of the same coin (Mintz, 1988). the bulimic patient may suffer from a generalized inability to postpone satisfaction pulse, due to the weakened and a superego less strong. Binges and the use of laxatives are not usually problems of impulse control blocks; generally coexist with sexual impulsive and self-destructive, and the abuse of various substances. family and environmental factors play a key role in the development of the disorder. In a study of 102 subjects with bulimia nervosa and 204 healthy control subjects (Fairburn et al., 1997), problems between parents, experiences of physical and sexual abuse and self-esteem were all negative factors associated with the development of the disease. According to the authors, a low self-esteem may encourage eating disorders distorting the vision that the girls of their physical appearance. emotional problems in dialogue with parents and a pattern of constant conflicts between contradictory parts of the self, undoubtedly influenced by conflicting identifications with parents. Also according to these authors, many bulimics experience a lack of respect for its borders and gross intrusion into their privacy, which is manifested by physical or psychological abuse. The authors who have studied the evolutionary origins of bulimia revealed significant difficulties with respect to the separation of both in patients in their parents. As mothers of anorexic patients, parents of girls destined to become bulimic often relate to her daughters as if they were - extensions of themselves (Humphrey, Stern, 1988; Strober, Humphrey, 1987). The daughters are often used as self-objects to validate the Self parent. Each member of the family depends on all other members to keep a sense of cohesion. Although this pattern characterizes the families of anorexics, bulimics in families dominated a particular mode of managing quality "bad" unacceptable. Family members bulimic apparently have a strong need that others see them as "all good." The unacceptable quality of parents are often projected in the bulimic girl, who becomes the sole repository of "malice". Unconsciously identifying with these projections, it becomes the bearer of all the greed and impulsiveness of the family. The resulting homeostatic balance keeps the focus on the child "sick" rather than in conflict, or between parents. Bulimia nervosa can be a threat to life. There are known cases of patients who have altered their electrolyte balance to induce cardiac arrest. Repeated blood tests check should therefore be part of the outpatient management of these patients, with hospitalization as a recovery strategy. Since many bulimics also suffer from borderline personality disorder and major affective disorders, hospitalization may be necessary even after a serious suicide attempts or self-mutilation. Hospital treatment should follow a comprehensive treatment plan customized, in addition to pursuing the achievement of a symptom control through measures such as locking the key of the bathrooms, the application of a regular schedule of meals, assistance in psychoeducational interventions by a dietician or encouragement to keep a journal. Hospitalization often provides the psychotherapist opportunity to better understand the internal object relations of the patient; Therefore, it facilitates a more sophisticated understanding of diagnostics and a more precise treatment planning. Therapists may find themselves to be repeatedly caused to accept the "evil" that the patient is trying to expel. They may also feel "vomited on him" when the patient repeatedly spit them all their therapeutic efforts. The reproduction of family patterns in the hospital or in individual psychotherapy helps the clinician to understand the role of the patient within the family system. Since bulimia is often part of a homeostatic balance within this system, it is often necessary to family therapy or intervention on the family associated with individual psychotherapy. Ignoring the family system, the therapist runs the risk that the improvement of the patient is seen as terribly threatening by other family members. Defensive reactions to this threat include an insidious sabotage the treatment of bulimic patient, or the development of a serious malfunction in another family member. The need that the family has the disease of the bulimic patient must be respected, and parents should feel "supported" and considered as they may interfere with treatment (Humphrey, Stern, 1988). Because of their intense ambivalence and their concern to disrupt profoundly the balance family, many bulimics try to avoid intensive psychodynamic therapy. May be considered carriers of defects that exploration psychotherapeutic runs the risk of highlighting (Reich, Cierpka, 1998). Encourage the preparation of a daily journal of food and emphasize the association between certain modes of supply and certain emotional states can be an extremely effective way to build a therapeutic alliance. Even the family interventions in the form of support, education, and possibly family therapy are usually needed to strengthen individual therapy. A brief hospitalization, support groups and group psychotherapy can all help the patient to control the symptoms. A significant subgroup of bulimic patients with severe diseases of the character, or suicidal propensity to severe alterations of electrolytic require psychotherapy in the context of a prolonged hospitalization. These patients frustrate the most diligent efforts of therapists to structure their lives. Seem prone to self-destructive an evolution that could indeed be fatal in the absence of a prolonged hospital treatment. 369-73 The borderline patient Our treatment of personality disorders in group B starts from the borderline patient, because the borderline personality disorder serves as a reference point for the entire group. Personality disorders narcissistic, antisocial and histrionic often end up being defined according to their differences with borderline personality disorder. Also, when borderline is used in the broader sense of a spectrum (Meissner, 1988) or an organization of personality (Kernberg, 1967), all personality disorders in group B, as well as those in group A, can be summarized under the generic category of "borderline conditions." Unfortunately, the growing popularity of the diagnosis of borderline in the last two decades has made it become a kind of "trash" psychiatric - often used too much and hurt. Patients for whom there is a diagnostic confusion can receive the label of borderline by default. Grinker and collaborators- (1968) introduced a certain rigor diagnostic compared to the syndrome in the early 60s with their statistical analyzes relating to approximately sixty patients who had been hospitalized in Chicago. For cluster analysis of data of these patients suggested that there were four subgroups of borderline patients (Tab. 15.1). These patients seemed to fill the entire range along a continuum from "psychotic side" (type 1) to "neurotic side" (type 4). Between the two extremes could be identified a group that had predominantly negative affect and difficulty in maintaining stable relationships (type 2) and another group (type III) characterized by a generalized loss of identity, resulting in a need to borrow identity by others. Grinker and colleagues (1968) also attempted to identify the common denominators in the borderline syndrome that appeared regardless of subtype, identifying four key features: 1) anger as affection main or sole, 2) difficulties in interpersonal relationships, 3) absence of a consistent identity Self, 4) depression pervasive. One of the most significant contributions of this empirical study was the observation that the borderline syndrome was clearly distinct from schizophrenia. Grinker and collaborators found that these patients over time did not deteriorate in a frank schizophrenia. Rather, they were permanently unstable (Schmideberg, 1959) in the course of their disease. This discovery helped to disprove the belief of some skeptics that patients were actually borderline schizophrenic. Many of these criteria are interrelated. Borderline patients are consumed in an attempt to establish exclusive dyadic relationships in which there is no risk of abandonment. Can express the need of such relationship with an arrogance that overwhelms and alienates others. Moreover, once it reaches the intimacy with another person, two types of anxiety are activated. On the one hand, are beginning to fear of being swallowed up and the other to lose their identity in this primitive fantasy of fusion. On the other, they experience anxiety bordering panic in relation to the idea of being able to be abandoned at any time. To prevent loneliness, can cut their wrists or perform other self-destructive acts, in the hope of being saved by the person to whom they are attached. Cognitive distortions, such as thinking quasi-psychotic (characterized by transient, limited, and / or atypical tear in reality testing), can also occur in the context of interpersonal relationships. Are common perceptions quasi-delusional dropout figures by love and when patients bind to their therapists may occur regressions psychotic transference. Clinicians who are witnesses of these kaleidoscopic transitions between different ego states are subject to various and intense countertransference reactions, including fantasies of salvation, feelings of guilt, transgressions of professional boundaries, anger and hatred, anxiety and terror, and deep feelings impotence (Gabbard, 1993; Gabbard, Wilkinson, 1994) Otto Kernberg (1967, 1975) coined the term borderline personality organization to narrow a group of patients showing characteristic pattern of weakness of the ego, primitive defensive operations and object relations issues. Kernberg observed in these patients a variety of symptoms, including free-floating anxiety, obsessive-compulsive symptoms, multiple phobias, dissociative reactions, hypochondriacal concerns, conversion symptoms, paranoid ideas, polymorphous perverse sexuality and substance abuse. He emphasized, however, that the symptoms were not descriptive enough for a definitive diagnosis. Instead that the diagnosis was based on a sophisticated structural analysis revealed that four key characteristics (see Tab. 15.3). I. Events nonspecific weak ego. One aspect of the funzlonamento ego is the ability to delay the fulfillment of the pulses and to modulate affects such as anxiety. Similarly, they are struggling to sublimate intense impulses and to use their conscience to guide behavior. 2. Sliding toward primary thought processes. As Robert Knight, Kernberg noticed that these patients tend to regress to a thought similpsicotico for the absence of structure or under the pressure of intense suffering. These slips still occur mainly in the context of a capacity generally conserved evaluation of reality. 3. Getting defensive specifications. Main defensive operation is the split, which Kernberg described as an active process that can separate introjects and affections between contradictory (see Sec. 2). Demerger transactions in patients with borderline personality disorder are manifested clinically with these features: a) an expression of alternating contradictory behaviors and attitudes that the patient sees with lack of concern and bland denial; b) a division into compartments of all the people who are part of the environment of the patient in a group of "all good" and in a group of "all bad", provided that a given individual can often swing from one to the other ; c) prospects and images of self (self-representations) contradictory that coexist and alternate in their dominance from day to day and from hour to hour. in borderline patient are representations of self contradictory Other defenses, as primitive idealization, omnipotence and devaluation, reflected in a similar way to the splitting tendencies (for example, others are considered in terms of all negative or all positive). According to Kernberg borderline personality organization is another important defense projective identification, in which self-representations or object are split off and projected in the other in an attempt to control them. 4. pathological internalized object relations. For the spin-off, individuals with borderline personality organization do not see in the other a set of positive and negative qualities. Others are instead divided according extreme polarities and are considered, in the words of a patient, "or gods or demons." the inability to integrate positive and negative self-representations generates a severe identity diffusion. The concept of Kernberg's borderline personality organization is different from the current phenomenological characterization, which identifies a specific personality disorder. In other words, he uses the term includes many different personality disorders. According to his point of view, patients with narcissistic personality disorder, antisocial, schizoid, paranoid, childish and cyclothymic, for example, are all characterized by an underlying borderline personality organization. There are considerable controversy about whether the term "borderline" to be applied to a specific personality disorder or to be used, as it does Kernberg, in a broader sense to describe a dimension of personality (Gunderson, Zanarini, 1987). According Grinker and his collaborators (1968) the borderline syndrome included several subcategories that were going to be a ghost. Meissner (1984, 1988) classified the borderline conditions differently than Grinker and collaborators, but also judged it right to restrict the use of the term "borderline" to a specific personality disorder. 429-34 At least three-quarters of patients for which is given a diagnosis of borderline personality disorder (BPD) are women (Gunderson et al., 1991). This figure can be largely due to cultural factors deriving from sex role stereotypes, since male patients exhibit characteristics of BPD are often diagnosed as suffering from a narcissistic or antisocial personality disorder. BPD is by far the most frequently diagnosed disorder axis 2, with a prevalence in clinical populations between 15 and 25 percent (Gunderson, Zanarini, 1987) The borderline personality disorder usually becomes apparent in late adolescence or in early adulthood. Although individuals borderline. chronic patients and may seem difficult in the short term, there are reasons to believe that with continued treatment may occur substantial improvements. 334-7 According to Kernberg borderline patients successfully pass the symbiotic phase described by Mahler, enough to clearly distinguish the self from the object, however, to stop at the stage of the separation-individuation. , Kernberg identified the crucial moment of this crisis in the evolutionary step of rapprochement, approximately between the sixteenth and j thirtieth month of life. At this stage the child is afraid that her mother disappears, and sometimes shows a frantic concern about his movements. From this evolutionary perspective, borderline patients can be seen as people who constantly relive a crisis early childhood in which fear that attempts to separate from the mother cause his death. In a repeat of this crisis, adult child, the individual is unable to tolerate periods of loneliness and fear of being abandoned by figures meaningful for him. Patients! with borderline personality disorder may also be overwhelmed by anxiety in the face of major separations from parents or other people who take care of them. But while most of the children at the age of about three years achieves object constancy sufficiently consolidated to allow a vision of the mother and of the self as whole objects, this does not occur in individuals potentially borderline. At that point, children can generally tolerate better the separation, because they have internalized an image of unity and comforting mother, unable to support them at times when she is physically absent. Deprived of this internal, individuals have a borderline object constancy poor or absent, which contributes significantly to determine their intolerance to separation and loneliness. Even the formulation of Masterson and Rinsley (1975) has focused attention on the rapprochement subphase of separation-individuation, however, putting the emphasis on the behavior of the mother rather than the child's innate aggressiveness. Masterson and Rinsley found that mothers of borderline patients, themselves from their typically considered borderline, are highly conflictual than the growth of their children. As a result, the child from the mother receives the message that the fact of growing up and becoming an independent person will cause the loss of love and maternal support. A corollary of this key message is that the employees remain is the only possibility to maintain the maternal bond. This powerful communication maternal causes a "depression of abandonment" whenever the prospect of separation or autonomy is presented to the child. The setting at this level of fragmentation over the borderline patient to the feeling that there are only two choices: you can feel abandoned and bad or, like Peter Pan, you can feel good only through the denial of reality and not growing ever. 438-40 conception of Adler (1985) of the borderline personality disorder is based on the model of the deficit or dell`insufficienza. "Adler identified the. Because of the inability of the borderline patient to develop an internal object" containing-comforting "in a maternal function inconsistent or insufficient. greatly influenced by the theory of self psychology of Kohut (see Sec. 2), Adler saw the borderline patient as an individual in search of self-object functions from external figures, due to the absence of introjects supportive. Adler put in relief the construct evolutionary Selma Fraiberg (1969) as opposed to that of Mahler. He noted that around the eighteenth month of age, according to Fraiberg, the normal child is usually able to form a 'internal image of the mother figure even in the physical absence of such a figure. this ability to "evocative memory" as the Fraiberg called this cognitive achievement, according to Adler is poorly developed in the borderline patient. In stressful situations, or in the grip of an intense transference borderline patients tend to regress to lose the ability to recall the important figures of their world that are not physically present, unless an object such as a photograph does not act stimulus mnestic. Adler has conceptualized this observation explaining it in terms of a regression to an evolutionary stage between the eighth and eighteenth month, before the development of evocative memory. The fact that the borderline patient lacks an internal object containing-comforting explains many aspects of borderline psychopathology. This lack leads to feelings of emptiness and depressive tendencies. It is also responsible for the dependence adhesive commonly observed in borderline patients. In the absence of answers from people significant to act as self-object, borderline individuals have inadequate internal resources to support them and tend to the fragmentation of the self. This dissolution of the self is accompanied by a deep sense of emptiness, described by Adler as "panic from annihilation." Finally, the absence of an introject containing-comforting induces a chronic oral anger in borderline patients, that is related to their feeling of not having had a mother figure emotionally available during childhood. 440-1 All psychodynamic models were somewhat challenged in the literature based on empirical research. For example, maternal 1'ipercoinvolgimento described in the formulation of Masterson and Rinsley was questioned by a series of studies (Frank, Hoffman, 1986; Frank, Paris, 1981; Goldberg et al., 1985; Gunderson et al., 1980 ; Paris, Frank, 1989; Paris, Zweig-Frank, 1992; Soloff, Millward, 1983; Frank Zweig, Paris, 1991) suggest that overall three main conclusions (Zanarini, Frankenburg, 1997): 1) borderline patients usually consider their maternal relationship distant, very confrontational or uninvolving; 2) in the families of borderline patients the failure of the paternal presence is an even more discriminating of maternal relationship; 3) disturbed relationships with both the mother and the father may be more pathogenic as well as more specific for BPD than they are problematic relations with only one parent. These data suggest that neglect can be an etiological factor most significant dell'ipercoinvolgimento. A prospective study with particular care Gohnson et al., 1999) found that the presence of childhood behaviors of neglect by parents was associated with increased symptoms of borderline as well as those related to several other personality disorders. A study that compared patients borderhne with patients with other conditions of the axis ii, psychotic patients and patients with affective disorders, found that patients had borderline behind a significantly higher proportion of losses and early separations. The figures ranged 37-64 percent and were highly discriminatory for BPD (Zanarini, Frankenburg, 1997). There is now ample empirical support in support of the concept that abuse in childhood is one of the most significant factors in the etiology of the disorder Childhood sexual abuse seems to be an important etiologic factor in about 60 percent of borderline patients. Although the control patients suffering from other personality disorders or depression does not relate sexual abuse with a frequency comparable to that found between the patients with BPD, the situation is different as regards physical abuse, for which the head is roughly the same . About 25 percent of borderline patients have a history of parent-child incest. On the other hand, sexual abuse is neither necessary nor sufficient for the development of BPD, and other early experiences as behaviors of neglect by agents of care of both sexes and the presence of a chaotic family environment or inconsistent, constitute significant risk factors (Zanarini et al., 1997). This view was supported in a prospective study conducted by Johnson and co-workers (1999), who associated the presence of borderline symptoms in adulthood with sexual abuse or neglect, but not with physical abuse during childhood. Cloninger and co-workers have found that patients with BPD are the only ones who have a strong tendency to be in search of novelty is the avoidance of harm. In other words, the borderline patients are impulsive, angry and also extremely anxious. The model of Cloninger suggests the presence of a genetic diathesis organic, which is activated by certain environmental factors to create the combination of a low self-determination and low cooperativity with a temperament characterized by a high harm avoidance and high search of novelty. Figueroa and Silk (1997) proposed a similar model, in which the effects of the trauma they interact with an underlying predisposition to serotonergic dysfunction. Their hypothesis is based in part on the observation that borderline patients have a significantly reduced level of serotonin activity. Given that serotonin exerts an inhibitory action on behavior, impulsivity characteristic of borderline patients may be partly related to this altered serotonergic activity (Coccaro, Kavoussi, 1997; Coccaro et al., 1989; Siever, Davis, 1991). Increased vulnerability secondary to reduced serotonergic tone is accentuated by the effects of the trauma, which also determine alterations in the levels of cortisol and catecholamines. The hypersensitivity of noradrenergic system, related in part to the temperament and partly hyperactivity resulting from trauma, leads to self-destructive behaviors, such as self-mutilation, in an attempt to reduce dysphoric affect and painful. The possible existence of a biological substrate for borderline personality disorder is further confirmed by data suggesting the presence of neurocognitive deficits in these patients.

The possible existence of a biological substrate for borderline personality disorder is further confirmed by data suggesting the presence of neurocognitive deficits in these patients. Andrulonis (1991) noted that a significant number of patients borderline shows slight signs of suffering neurological disorder with a history of attention deficit / hyperactivity, learning problems, poor impulse control and conduct disorders. Neuropsychological studies report that borderline patients generally have a number of signs of neuropsychological deficits significantly higher than normal, but that some of these problems can be very mild and become evident only when individuals with BPD are compared with healthy controls (O'Leary, Cowdry, 1994; Swirsky-Sacchetti et al., 1993; vanReekum et al., 1993). At least one study has also found in patients with BPD a percentage of head trauma before diagnosis significantly higher compared to control subjects (Streeter et al., 1995). Family studies have found that BPD is relatively more common among first-degree relatives of patients with borderline than it is among control subjects (Zanarini, Frankenburg, 1997). All these factors also influence a child's ability to bind to the mother or those who take care of him mainly. As discussed in Chapter 2, according to the theory the bond that is created between the child and the curing agent can be reflected, in adulthood, in attitudes of attachment that can be classified into four general categories : 1) safe / self, 2) distancing, 3) concerned and 4) unresolved / disorganized. Patients with BPD tend to be classified as preoccupied or unresolved / disorganized. In response to the abuse and neglect children who grow develop a BPD can defensively destroy the mental processes necessary to define thoughts and feelings in themselves and in others. This deactivation of mentalizing prevents the development of reflective function that allows the understanding of the inner dimension (see Sec. 2). The loss of the feeling of power and a cohesive sense of self that comes brings these patients to be denied their mastery of their own bodies and their own actions (Fonagy & Target, 1995). Overall, these data indicate that the BPD has a multifactorial etiology. Zanarini and Frankenburg (1997) postulate three main factors. The first is a familiar traumatic and chaotic, which causes early separations, disagreement emotional behaviors of rejection and neglect toward the child, insensitivity to her feelings and needs, and trauma of varying significance. The second is a temperament constitutionally vulnerable. The third factor is related to trigger events, such as the attempt to establish an intimate relationship, the fact of going to live alone, sexual abuse or other traumatic experiences, each of which can act as a catalyst activating the symptoms of borderline condition. Certain types of genetically based temperament may increase the likelihood of negative life events, so that between the effects of genes and environment occurs progressive interaction in the development of BPD (Paris, 1998).
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Re: Psychopatology Gabbasrd

Post  counselor on Sun Nov 30, 2014 11:05 am

One conclusion is that each borderline patient can have a personal etiological involving different extent these three general etiological factors. Some of the conflicting perspectives expressed in psychodynamic theories may reflect different developmental experiences and different patient populations borderline. For example, patients who have experienced a premature loss or that have been neglected during childhood may not be able to develop a introject contenenteconfortante, as described by Adler (1985). The work of Zweig-Frank and Paris (1991) indicates that other patients, subjects in childhood to a hypercontrol by both the mother and the father, can suffer anxiety of abandonment similar to those described by Masterson and Rinsley (1975) and Kernberg (1975). Searches subsidiaries have also documented the existence of a strong correlation between the themes of separation-individuation and borderline psychopathology (Dolan et al., 1992). 441-6 A major problem in the psychotherapy of borderline individuals is the fragility of the therapeutic alliance These patients have considerable difficulties to consider the therapist as a figure that helps them working in partnership with them to achieve the objectives recognized by both. Maintain flexibility. A therapeutic flexible attitude is required for optimal treatment of patients with BPD. As a general rule, patients with borderline high level with a strong ego and a psychological mindset most developed will benefit more from psychotherapy oriented in a meaningful way, while patients closer to the border psychotic emphasis will need supportive. In most cases, you need a flexible attitude on the part of the therapist, using interpretive and not, will from time to time to adapt to the type of relationship that is established between him and the patient. Through his behavior, the patient tries to subtly impose certain mode of response and interaction with others. Therapists must afford sufficient flexibility to respond spontaneously to the type of object relation proposed by the patient. In other words, the therapist participates in a "dance" based on a specific music that comes from the inside of the patient, and which provides a remarkable range of information on the particular difficulties that the patient encounters in interpersonal relationships outside of the situation transferale- countertransference. Such response must be naturally modulated and limited, and the therapist must try to maintain a reflective attitude with respect to this "dance". Establish the conditions that make possible the psychotherapeutic. Because of the chaotic nature of the life of the patient borderline, some stability has to be imposed from outside sources since the beginning of therapy. In prior consultations and in the course of the therapy, the therapist must define and redefine what therapy involves and how it differs from other types of relationships. The topics that should be considered include clear agreements on the payment of land, the definition of an acceptable program of events, the need to conclude the sessions on time even though the patient may wish to prolong and an explicit policy on the consequences of missed appointments. Moreover, with a borderline patient at risk for suicide, the therapist may need to clarify that in a situation of acute suicide risk he is unable to prevent the implementation of the pulses of the patient and which may therefore be needed hospitalization. With a patient who makes use of substances the therapist can insist on participation in self-help groups as a condition for therapy. When there are clear indications for drug therapy, the therapist must emphasize that taking prescription drugs is an essential component of the entire treatment plan. In addition to establishing the conditions that will make it possible to psychotherapy, the therapist must also communicate their limits to the patient. This communication is often at odds with the expectations of the patient, who sees the therapist as an omnipotent savior. This dialogue will then directly to a discussion about what the therapy is or is not. Kernberg argued the opportunity to establish a "contract" with i1 patient during consultations prior therapy (Kernberg et al, 1989). As part of the definition of this contract, the therapist must make it clear that involvement in the life of the patient outside of the sessions is not within the responsibility of the psychotherapist. Consequently, the therapist does not expect to receive phone calls between sessions and the other, and reaffirms the limits of its availability. However, this approach may interfere with the development of a stable investment on the therapist, in particular if the conditions of the "contract" appear unsustainable for the patient. As pointed out by Gunderson (1996), the patient may have recurrent panic reactions due to insufficient development of evocative memory and may feel the need to call from time to time the therapist in order to develop a stable representation that can be internalized. According to Gunderson the therapist should discuss his availability between a seat and the other only after the patient begins to ask questions about that. He suggested, and I agree with him, that patients should be informed that the therapist would like to be contacted in case of emergency. This position avoids a start against the therapeutic process and often causes the patient feels understood and "held together" in Winnicott's sense. If you experience any of the phone calls between sessions, Gunderson recommends that the same phone calls represent the exploratory focus of the therapeutic work. As the practitioner begins to recognize the fear that the patient has of loneliness and its evolutionary significance, in the latter can be facilitated by the development of introjects containing-comforting, as described Adler. If the calls become excessive, may be imposed clear limits while exploring meanwhile the meaning and significance of the contacts between sessions. To be transformed in the object bad. One of the most difficult challenges in the psychotherapy of borderline patients is to be able to tolerate and to contain the intense anger of the patient, his aggression and hatred. It is important to remember that these patients have internalized an introject of hatred and perhaps abuse, who are trying desperately to outsource through projective identification in the size of the transference-countertransference of the dyad. Borderline patients are looking for an "object sufficiently bad" (Rosen, 1993). Paradoxically, patients are predictable, familiar and even comforting the fact of recreating an internal object relationship sadomasochistic derivation child with the therapist. If the therapist resists this transformation, patients can adopt attitudes even more provocative, trying to turn the therapist with even greater commitment (Fonagy, 1998). The therapists who try to curb their growing aggressiveness may strive to respond with patience increasing verbal attacks of patients. Alternatively, the therapist can subtly escape an emotional investment towards the patient, consciously or unconsciously hoping that the patient abandon therapy and find someone else to torment. Another more disturbing possibility is that the therapist begins to make hostile comments or sarcastic, or that it even explosions of anger towards the patient. To be transformed in the object bad does not mean that the therapist should lose all sense of professional decorum. Rather requires that the therapist functions as a container, which accepts the projections and try to understand them and to hold them in place of the patient until it is again able to regain possession of such projected aspects of himself, "the state of the mind optimal for therapists is realized when you leave 'sucked' into the world of the patient while maintaining the ability to observe what is happening before their eyes. in such a state, the therapists are actually 'thinking their own thoughts', even if they are in some way under the influence of the patient. "Often borderline patients do understand that the therapist will be driven to suicide because of his shortcomings (Maltsberger, 1999). Such charges feed the doubts of therapists and activate their fears of abandonment, to the point that in such situations therapists can groped to demonstrate their ability to take care of patients through heroic measures designed to save them. As a result, the patient can get to exercise control on the almighty therapist - what Maltsberger (1999) defined coercive subjugation. In this scenario the therapist assumes full responsibility for the survival of the patient, instead of leaving that he be in charge of most of the responsibility with respect to his life or his death, indispensable condition if we want to end the patient is better . Promote a reflective function. A general objective in psychotherapy of patients with BPD is to help them recover a reflective function, so that they can begin to think about the world inside their own and others. With patients who are not able to mentalize interpret the meaning of their behavioral expressions may be premature. It can be far more useful to help such patients to process the emotional content that may have triggered a certain behavior. Another way to encourage the development of skills mentalizzanti is to follow and comment constantly changes in the sentiments expressed by the patients, so that they can eventually internalize the therapist's observations on their inner contents. The reflective function can also be encouraged by helping the patient to think about the consequences of his self-destructive behavior (Waldinger, 1987). Many of the self-destructive behavior of borderline patients are put in place impulsively, without absolutely consider their possible consequences. Through repeated questions about possible negative effects of these actions, the therapist can make these behaviors become less rewarding in the eyes of the patient. Demarcate the boundaries when necessary. Many borderline patients they experience the normal limits Professional as a cruel and punitive deprivation by the therapist. May require more demonstrations with crete of his interest in them, like hugs, extensions of the sessions, discounts sull'onorario and elasticity of time (Gabbard, Wilkinson, 1994). Therapists who experience feelings of guilt compared to having to set limits with their professional borderline patients can begin to overcome them in the name of flexibility or the prevention of suicide. Most patients receive rewards, the more they become insatiable. Much of the difficulty is due to the fact that the therapist may feel cruel and sadistic when appropriately puts limits on the behavior of the patient. Paradoxically, however, many patients - who demand more freedom may worsen when it is granted to them. Suicide is an ever-present danger with borderline individuals, and therapists must be prepared to admit their patients when they become uncontrollable suicidal impulses. Therapists often find themselves in the untenable position groped heroically to treat these patients maintaining continuous contact with them. A therapist ended up talking on the phone with a borderline patient for an hour each night to avoid that she committed suicide. Establish and maintain the therapeutic alliance. As noted above, the therapeutic alliance is a construct fleeting in psychotherapy of borderline patients. Because of internal object relations chaotic patient during therapy the therapist is often transformed into an opponent or a savior idealized. If the therapeutic process becomes particularly difficult should the therapist stating the patient on the ground of the common objectives with respect to psychotherapy. A recurring message for the patient should be the one that the therapy is not an obligation. It is an evolutionary path chosen by the patient to work on specific goals that can generate suffering. Patients often lose sight of these objectives; the fact of reviewing them regularly helps patients to remember that the therapist is an ally who is working with them. Help the patient to regain possession of the aspects of the self that have been disavowed or screened. Since splitting and projective identification are the primary defense mechanisms in patients with BPD, a sense of incompleteness or fragmentation is a key phenomenon in the borderline psychopathology. Patients may ignore behaviors had a month earlier as if someone else was responsible. This lack of continuity of the self emerges from substantial changes in the way every week, patients present to the therapist. The therapist's task is to connect these fragmented aspects of the self, and to interpret the underlying anxieties connected with the re-appropriation and integration of disparate representations of themselves in a coherent unit. Monitor the countertransference feelings. The importance of paying special attention to countertransference was implicit in all this discussion on psychotherapy of borderline patients. Contain the projected parts of the patient and reflect on the nature of these projections will help the therapist to understand the patient's internal world (Gabbard, Wilkinson, 1994). In addition, through continuous monitoring of their feelings can prevent countertransference enactments. Each therapist has limits than personal animosity or anger is able to tolerate. If the therapist constantly checks his countertransference feelings, this limit can be handled constructively rather than destructively. For example, a therapist might use in a therapeutic sense countertransference feelings by saying to the patient: "I feel that she is trying to make me angry, instead of allowing me to help her. Let's see if we can figure out what's going on." Alternatively, the therapist may decide to place limits on the patient's verbal barriers based on countertransference reactions, saying something like, "I really would not be able to work productively if she continues to yell at me. I think it's important for her to try to control his anger, so he can express it without shouting. "Therapists must be frank and spontaneous with borderline patients, or they will end only to increase the envy that patients have for them, seen as essentially non-human deities (Searles, 1986). 454-67 The hospital treatment is an essential in working with borderline patients. Externalizing their inner chaos in the hospital, patients borderline can undermine the compactness of staff in attendance. Some patients become "special", which create serious countertransference problems related to splitting and projective identification (Burnham, 1966; Gabbard, 1986; Maín, 1957). Others are especially full of hatred and attack with intense envy all those who try to help them (Gabbard, 1989b), resulting in therapeutic staff members a feeling of worthlessness. Still others may have a passive opposition and refuse to participate in every aspect of the therapeutic program (Gabbard, 1989a). Although these patients may seem refractory to therapy, some may eventually be cured through meticulous attention to their individual dynamics and the counter staff therapeutic. Some clinicians think that for borderline patients should not be used in hospital admissions because hospitalization induces regression and dependence. This belief is not supported by any evidence rigorous and convincing; on the other hand, at least one controlled study showed that hospital treatment can be very useful for patients with severe personality disorders. The patient who requires a brief hospitalization during a psychotherapy is usually found in a crisis involving a psychotic regression, self-destructive behavior, or a suicide attempt. Therapists of the department must be able to communicate with these patients that they are able to control their impulses, despite stating the opposite. Although forms of external control, such as surveillance and antipsychotic drugs, can sometimes become necessary, the emphasis must be placed on the fact of helping these patients to take responsibility for their own self-control. The weakened ego of the patient can be supported by a solid and consistent treatment plan characterized by a precise programming, from the clear explanation of the consequences of impulsive acting out and regular individual and group meetings with members of staff and other patients. Normally the borderline patient hospitalized just expect that members of the nursing staff are available to it for endless interviews. If nurses lend themselves to gratify those requests, classically the patient worsens in direct proportion to the length of these sessions of "therapy" individual. Borderline patients generally respond much better to treatment when the nursing staff is able to arrange short scheduled meetings which must not exceed five to ten minutes. 1 staff members of the department and the same hospital work as auxiliaries for borderline patients. Rather than engage in exploration work or interpretation, the task force can help patients identify events that trigger their crises, to delay the discharge of impulses looking for alternatives, to anticipate the consequences of their actions, and to clarify their internal object relations (as described in Sec. 6). Another function of hospitalization brief is to allow a more precise understanding of the patient's internal world. Finally, the department staff can often help the therapist to understand the nature of a crisis or impasse that occurred in the course of psychotherapy. In addition to addressing each splitting process (see Chap. 6), the staff of the department can help the therapist validating its expertise and its value as a clinician (Adler, 1984). Within the staff of the department must also exist an effective mutual communication. All that the patient tells a single member of your treatment team should be shared with others during department meetings. In addition, clinicians and nurses must be able to repeatedly say "no" to the patient firmly but tactfully, demonstrating their interest in him. Otherwise, the patient may not be able to integrate the fact that the figures "good" who care about him are the same that impose restrictive measures (interventions "bad"). This integration of internal representations of self and object is another primary purpose of hospital treatment in the long term. The restrictions prescribed to a patient must always be based on an empathetic understanding of the need for that patient to the limits imposed on the outside, rather than on a sadistic attempt in some way to control it, which is in fact the way in which the patient lives of usually these restrictions. Suicidal behavior and self-mutilating hospitalization is often a significant problem in the long term; with similar behaviors borderline patients attempt to control the entire treatment staff, exactly as they did outside of the hospital and their families and loved ones. Staff members must remember that each patient is ultimately responsible for the control of such behavior and that realistically no one can prevent a patient commits suicide. Borderline patients often inflict superficial cuts with staples, soft drink cans, light bulbs and other items that are usually found in hospital. Although the actual harm caused by these superficial wounds may be minimal, the staff members therapeutic should carefully examine the origins of such a self-mutilating behavior. It is related to episodes of depersonalization or dissociation? There is a history of childhood sexual abuse? It is appropriate for the patient to submit to a therapy with fluoxetine? The behavior is essentially kind of manipulative, tended to get attention from the staff members of the department? The borderline patient with chronic suicidal tendencies can arouse intense countertransference feelings among the staff members, who receive the manipulative aspect of such attempts and of such acts and therefore can react to threats of suicide of a patient with a worry less and less. Hospital staff should keep in mind that people who have attempted suicide are 140 times more likely to commit suicide than people who have never tried (Tuckman, Youngman, 1963), and that approximately 10-20 percent of all those who attempt suicide actually ends up killing himself. 470-2 Changes treatment of internal object world of the borderline patient usually require a process intensive individual psychotherapy. Working with the family is still often an essential complement within the entire treatment plan. The use of formalized family therapy is far less common than in one or more family interventions during treatment (Brown, 1987). Hospital treatment, for example, provides clinicians with the opportunity to meet with the family of the patient and to understand the extent to which family interactions overlap or conflict with the revival of the inner world of the patient in the hospital by means of splitting and of projective (see Chap. 6). In outpatient psychotherapy, the individual process can be undermined by operations controterapeutiche by family members who feel threatened by any change in the patient's condition. Family interventions or, in serious cases, a family therapy, can therefore be required for individual treatment success. The first step in a speech on the family is to identify the role played by the family interactions in the pathogenesis and maintenance of symptoms of borderline patient. As described in Chapter 5, the splitting and projective identification are extremely common mechanisms that serve to maintain homeostasis pathological in the family system. For example, a parent can get rid of bad representations of self and object and project them in a young child or teenager, who later identifies with these projections becoming a member carrier of symptoms of the family. Empirical studies indicate that parents of borderline patients are more often heedless that ipercoinvolti. The negligent parents of these patients tend à themselves be in need of support, and therefore are often not able to provide their children with a guide in the form of rules or "structure". In families where 1'ipercoinvolgimento is a dominant pattern, interventions must respect the needs that each family member has the other. Parents themselves may be suffering from a borderline psychopathology and can be terribly frightened by the prospect of "losing" the borderline child during treatment. Clinicians should give serious consideration to the possibility that a significant improvement in the patient causes a serious failure in a parent, who finds himself in a panic after perceived separation (Brown, 1987). In such circumstances, the therapist should help the family to process the dilemmas generated by the changes that have occurred in the patient and the entire family system. Another crucial principle in working with families of patients with BPD is to avoid colluding with the denigration of the patient towards their parents, as if the story of every atrocity was completely reliable. Even group psychotherapy can be a useful adjunct to individual psychotherapy of borderline patients. As noted Ganzarain (1980) and Horwitz (1977), all groups tend to use borderline defenses of splitting and projective identification. Group psychotherapy offers the individual the opportunity to understand these borderline defenses in their happening within the group context. borderline patients in group psychotherapy need a concomitant individual psychotherapy (Day, Semrad, 1971; Horwitz, 1977; Hulse, 1958; Slavson, 1964; Spotnitz, 1957). The dilution of the transference in psychotherapy group has significant positive effects for both the patient borderline for both therapist. The intense anger that is usually mobilized in borderline patients when they are frustrated in the course of treatment may be so diluted and directed to other figures as well as on the individual therapist. Similarly intense countertransference reactions towards borderline patients can be damped by the presence of other people. Horwitz (1977) pointed out that psychotherapists individual may provide an important supportive function when the patient's anxiety borderline intensifies in response to the comparison to which the patient is in a group setting. The individual therapist and group therapist should be in theory different people borderline patients seem to accept more willingly the comparison and interpretation of these traits from their fellow group psychotherapy rather than the therapist. They can also more easily accept the interpretations of their therapist when they are part of a theme centered on the group, compared to similar interpretations proposed in an individual context. Despite the advantages of working in a group setting, therapists meet some specific difficulties in group psychotherapy of borderline patients. These patients can easily become scapegoats because of their more primitive psychopathology and their greater tendency to express affections directly. When you encounter such situations it may be necessary that the therapist supports the borderline patient. In addition, feelings of deprivation of borderline patients may be intensified due to competition with the group to the attention of the therapist. Finally, borderline patients tend to maintain a certain distance in group psychotherapy because of their primary attachment to the individual therapist. 474-6 The narcissistic patient A certain amount of self-love is not only normal but also desirable. The point along the continuum of self-respect, where the healthy narcissism turns into pathological narcissism is not so easy to identify. Another source of confusion is the fact that certain behaviors may be pathologically narcissistic in an individual while in another are simply a manifestation of a healthy self-esteem. Imagine, for example, a boy of fifteen who stands in front of the mirror drying hair for forty-five minutes to be sure to have every hair perfectly in place. Most of us watching this would smile, and conclude that a vanity of this kind is completely normal for a young teenager. We think now a man of thirty years go by the same amount of time every morning in front of the mirror with a hairdryer. The picture is a bit 'more puzzling, since absorption upon themselves to this kind is not normal for a man of this age. A tragedy that afflicts these people is their inability to love. Interpersonal relationships healthy we can identify some fundamental traits, such as empathy and concern for the feelings of the other, a genuine interest in the ideas of others, the ability to tolerate ambivalence in long-term relationships without reaching a waiver , and the ability to recognize their contribution in interpersonal conflicts. Individuals who have interpersonal relationships characterized by these qualities can sometimes use others to gratify their own needs, but this occurs in a broader context of relations marked by sensitivity and interest in other people, and does not represent a style pervasive to relate with others. On the contrary, the individual with a narcissistic personality disorder approaches to others by treating them as objects to use and leave according to his needs, regardless of their feelings. The others are not perceived as people who have a separate existence or specific needs. The subject with narcissistic personality disorder often interrupts a report after a short period of time, usually when the other starts to put requests relating to his needs.
483-5 The descriptions of narcissistic patients submitted by the various authors can be conceptualized inscrivendole between the two poles of a continuum based on a typical style of interpersonal relationships. From a descriptive point of view, the two opposite extremes of this continuum can be defined as "unconscious narcissistic" and "narcissistic hypervigilant". The types unaware seem to have any kind of awareness of their impact on others. They talk as if writing to a wide audience, establishing rarely make eye contact and looking usually over the heads of those who are around them. Speak "in the presence" of the other, not "with" the other. They are unaware that they are boring and that therefore some will abandon the conversation to seek companionship elsewhere. Show a clear need to be the center of attention, and their speeches are full of references to their success. They are insensitive to the needs of other people, to the point of not allowing others to contribute to the conversation. Are often perceived as if "they had a transmitter but not a receiver." The type of unconscious narcissistic personality disorder generally corresponds to the clinical picture described by DSM 4. The aspects of the narcissistic type hypervigilant, on the other hand, are manifested in ways quite different. These individuals are extremely sensitive to how others react to them. Their attention is therefore constantly directed towards others, contrary to the concentration on himself unaware of the narcissist. Like the paranoid patient, listen to others carefully searching for the slightest critical reaction, and tend to feel offended continuously. These patients are shy and inhibited to the point of being small children. They avoid to shine because they are convinced that they will be rejected and humiliated. In the core of their inner world there is a deep sense of shame associated with their secret desire to perform in ways great. Psychopathology in individuals with pathological narcissism have a central role i, feelings of humiliation and painful exposure arising from the comparison with the limits of their abilities or the recognition of unmet needs, and many of these individuals develop defenses that are designed to prevent an awareness of the feelings associated with these experiences. Although both types struggle to maintain their self-esteem, how they are confronted with this problem are extremely diverse. The narcissist unconsciously try to impress others with his qualities and at the same time preserve the narcissistic wound eluding their answers. The narcissist hypervigilant tries to maintain his self-esteem by avoiding situations of vulnerability and carefully studying others to "appear" as it should. 486-8 Kohut (1971, 1977, 1984) believed that individuals narcissistically disturbed you were arrested by an evolutionary point of view at a stage where they need specific answers from the people in their environment to maintain a cohesive self. In the absence of such responses, these individuals tend to fragmentation of the self. Kohut explained this situation as the result of empathic failures of the parents. In particular, the parents had not responded to the demonstrations of exhibitionism of the child, appropriate with respect to its development phase, with validation and admiration, had not offered experiences twins, and did not provide the child a model worthy of idealization. These deficiencies are manifested in the patient's tendency to form a mirror transference, twin or idealizing. According to Kohut, along the course of our lives we need answers to such self-object by those around us. In other words, at some level we all treat others not as separate individuals, but as a source of gratification to the Self. The need of the functions comforting, validating the self-objects is never exhausted. The goal of treatment is to help the patient overcome the need for self-objects archaic and acquire the ability to use self-objects more mature and appropriate. Kernberg distinguished the narcissistic personality disorder borderline personality on the basis of the narcissist's grandiose Self, integrated but pathological. Patients with narcissistic personality disorder are identified in their idealized images of themselves in order to deny their dependence on external objects (other people) and the internal images of these objects. At the same time, they deny the unacceptable aspects of their self-images by projecting them in the other. while the borderline patients tend to have self-representations alternate, that make them appear different from day to day, patients narcissists have a level of functioning more regular and consistent based on a self pathological integrated. Kohut conceptualized the narcissistic self as a "normal" self archaic that is simply frozen in its development. In other words, saw the individual narcissist as a child in the body of an adult. Conversely, Kernberg (1974a, b) saw the self of these patients as a highly morbid and free of similarity with the normal development of the self of the child. He emphasized that the expression of exhibitionistic child is charming and tender, and has nothing to do with greed and the claims of the self pathological narcissist. Another difference in their conception of the self refers to its defensive function. Kohut considered the Self narcissist substantially not defensive (ie, a self that is simply stuck in the course of normal development). Kernberg considered instead the Self pathologically grandiose as a defense against the investment in the other, and in particular against the dependence on others. This can manifest as a pseudoautosufficienza, through which the patient denies any need of occurrence and simultaneously try to impress others and get their approval. Patients narcissists frequently argue, for example, to have no reaction on the occasion of the holiday of their therapists. If the patient is male, can present a syndrome of "Don Giovanni", so systematically seduces women he meets and then download them when the idealization against them results in devaluation. Considering only the "achievements", has no ability to empathize with their internal experience. A patient of this type generally shows little interest in what others say, unless it is flattering comments. Although these patients are much more commonly male, even female subjects may suffer from such a narcissistic pathology. 489-94 For Kohut empathy was the key point of the technique (Ornstein, 1974b, 1998). The therapist must empathize with the patient to try to reactivate a failed parental relationship Kohut Emphasis on the need to empathize with the patient, as a victim of deficiencies empathetic than others, does not imply a technique mainly supportive. He stressed that the analyst or therapist should interpret - instead of actively reward - the patient's need to be comforted (Kohut, 1984). A typical intervention should sound like this: "The fact of not being treated as we feel we deserve it can be painful." Kernberg believed that people with narcissistic personality disorder were among the most difficult patients to treat because most of their efforts aimed at derailing the therapist. Because the therapy and the therapist to be effective, these patients have to deal with intense feelings of envy toward the one who has positive qualities that they lack. The patient uses defensively depreciation and omnipotent control to hold off the therapist. According to Kernberg because treatment can continue these defensive maneuvers need to be addressed continuously. In stark contrast to the parents of missing empathy, some parents of patients narcissists tend to be blatantly lenient, and seem to encourage the grandeur through a pattern of excessive reflection. Exhibit their children with admiration and approval, making them feel really special and gifted. When these children grow up, they will repeatedly shocked by the fact that others do not always react as their parents. In other cases, mother-son incest or its variants can cause a framework narcissistic type hypervigilant (Gabbard, Twemlow, 1994).
495- 501 in the treatment of patients narcissists predictable countertransference problems arise, Some are of such magnitude and severity irrevocably undermine the therapeutic situation. The therapist involved in the idealizing transference of a narcissistic patient may be pleased to enjoy a warmth and a love so intense as to get him to collude with the patient's desire to exclude the hate and anger therapy. Frequent evolution in the treatment of patients narcissists is that they initially idealizzeranno their current therapist while devalue all those who have previously encountered. Instead of considering this process as a defensive maneuver, therapists who wish to be idealized can simply accept it as an expression of the fact that they possess qualities that these colleagues did not. Narcissistic issues are not solely within the purview of narcissistic personality disorder, but are present in all patients and in all therapists. Therapists who can not recognize and accept their narcissistic needs, and then use them to make treatment more effective, and can instead disconoscerli esteriorizzarli. These defenses contribute to the creation of a mistaken view of the patient, which is considered as the only member of the dyad patient-therapist who shows signs of narcissism. Another issue that arises regularly countertransference in the treatment of narcissistic patients is boredom, usually linked to the impression that the patient ignores the presence of the therapist is aware of it or not. The therapist may have to endure for long periods of time the feeling of being used by the patient as a sounding board. This pattern is particularly common with patients unaware, who speak as if they were in front of a large audience, without considering the therapist as a separate person with their own thoughts and feelings. These patients generate a strong hatred countertransference, which can induce comments vindictive or wrong decisions regarding the management of the patient, in an attempt to make the pair. Although as therapists we are able to contain a certain amount of ill-treatment, we all have a limit that only we can determine. When this line is crossed, the therapist may find themselves unwillingly in the need to deal firmly with the contempt of the patient stressing that this barrier is destroying the ability of the patient to receive effective treatment. 501-4 The dynamic psychotherapy group for narcissistic personality disorders can be very difficult if it is the only treatment (Azima, 1983; Horner, 1975; Wong, 1979, 1980; Yalom, 1985). Patients unaware narcissists can enjoy the idea of having an audience in group psychotherapy, but they can also resent the fact that others absorb the time and attention of the therapist. The narcissistic patient hypervigilant may instead feel hurt even before the proposal of a group therapy. This tip is seen as a rejection or as a sign that the therapist does not feel interest in him. The majority of patients will consider narcissistic group psychotherapy as a situation in which their uniqueness and their uniqueness will be neglected. When they become part of a group psychotherapy, patients often narcissists monopolize discussions or assume the role of "physician assistant" making comments on other people's problems but denying their (Wong, 1979). Despite the problems inherent in the group setting for patients narcissists, this therapeutic approach clearly has some advantages. In one group, patients narcissists must accept the fact that others have needs and that they can not expect to be constantly in the spotlight. They can also benefit from the feedback that the group members provide about the impact of their character traits over others. group psychotherapy can serve to dilute intensely negative transference. This principle is certainly applicable to narcissistic patients, and other members of the group are often helpful in pointing out the distortions inherent in devaluation or idealization of the therapist. In the same way, also countertransference reactions that are so problematic in the treatment of narcissistic patients may be diluted in the therapy group (Wong, 1979). However, it is desirable to have only a narcissistic patient at a time in a diverse group, considered the overwhelming impact that these patients may have on others. 504-5 Patients young narcissists often complain of the quality of their intimate relationships. They may have had repeated infatuations that were short and unsatisfactory. After the initial excitement wears the report, the idealization of the partner gives way to the devaluation or boredom, and they end up setting out in search of new partners can meet their needs for admiration, affirmation, unconditional love and harmony. This way of squeezing the other order to turn behind then emptied with the passage of time can be tiring. Beyond appearance, often there is the fear of being shamed and humiliated by the partner (to use the terms of the psychology of the self, the fear of a fragmentation of the Self). A narcissistic husband can, for example, to accuse his wife of groped deliberately humiliate rather than admit to having problems due to being overly vulnerable, dependent and particularly in need of answers from self-object, such as mirroring, by the wife. This same husband can get to the end in a state of chronic narcissistic rage, so keeps to his wife a resentment and bitterness incurable because it feels treated in the manner it deems to be due. Many patients narcissists do not age well. Their grandiose fantasies of eternal youth and beauty are torn apart by the vicissitudes of aging. To test their youth and vigor they can search frantically extramarital relationships with partners whose age is half of their Much of the pleasure of the average age and old age is related to indirect satisfactions derived from the successes of younger people, often their children (Kernberg, 1974b). These feelings can lead for the first time in therapy when patients have already passed the age of forty. Faced with the feeling of having lost something and with the feeling that their life is a race wrong, they may eventually decide to undertake therapy. Often find themselves alone, without any relation to support them and with the agonizing feeling of being unloved. Patients narcissists are a great challenge for therapists. Kernberg (1974b) stated that therapeutic efforts are justified in any case, since, even if crowned with only partial success, can help to alleviate the sufferings of the second half of life. If due to therapy patients narcissists reach a certain degree of empathy, they can at least partly replace them with admiration and envy begin to accept others as separate individuals with their own needs, then you may be able to prevent the their life ends in bitter solitude. 506-8 The three personality disorders classified in Group C of the DSM-IV (American Psychiatric Association, 1994) - obsessive-compulsive, avoidant and dependent-are grouped together because people who suffer from these disorders generally have in common as a prominent feature anxiety or fear. The distinction between disorder (or neurosis) obsessive-compulsive disorder and obsessive-compulsive personality disorder is based on the difference between symptoms and character traits lasting. As described in Chapter 9, the patient who suffers from obsessive-compulsive disorder is plagued by recurring thoughts from unpleasant content and is pushed to implement comportamentirituali. These symptomatic manifestations are ego-dystonic, meaning that the patient recognizes them as usual problems and want to get rid of it. On the contrary, the features that constitute the diagnosis of obsessive-compulsive personality disorder according to DSM-IV are patterns of behavior lasting and ego-syntonic. These traits rarely cause discomfort to patients and can also be considered as highly adaptive. In fact, studies of physicians, for example, suggest that certain features of obsessive-compulsive contribute significantly to their professional success (d Gabbar 1985 Krakowski, 1982; Vaillant et al., 1972). The rigorous devotion to work typical of the subject obsessive-compulsive lets achieve a significant success not only in medicine, but also in other professions where the attention to detail is essential. However, the success in the scope of employment is often achieved at a high price; family members and partners often find it difficult to live with these individuals, and often push them to ask for a psychiatric consultation. Although the distinctions between the obsessive-compulsive disorder and personality disorder ossessivocompulsivo outlined in DSM-4 are clear and useful, the degree of overlap between these two diagnostic entities exists some controversy. Symptoms of obsessive-compulsive disorder have also been seen as transient events in the course of a psychoanalytic treatment of patients with obsessive-compulsive personality disorder (Munich, 1986). However, empirical studies indicate that a wide range of personality disorders can occur in patients with OCD. Other research has found that the obsessive-compulsive personality disorder is significantly more common among patients with obsessive-compulsive disorder than those with panic disorder or a major depressive disorder (Diaferia et al., 1997), and that the obsessive symptoms are more frequently associated with traits of obsessive-compulsive personality traits rather than with other personality disorders (Rosen, Tallis, 1995). Despite the uncertainty with respect to the possible correlation between the two conditions, the obsessive-compulsive personality disorder and obsessive-compulsive disorder are usually presented separately because the therapeutic implications for the two disorders are very different. 569-71 Individuals with obsessive-compulsive personality disorder suffer from a significant lack of self-confidence. As children their experience has often been that of not being sufficiently valued or loved by their parents. In some cases, this perception may be related to an actual distance or coldness of parental figures. while in others such children may simply have required reassurance and affection in excess of the norm for a feeling of parental approval. The psychodynamic treatment of these patients reveals a strong but unfulfilled longing of dependency and a reserve of anger towards their parents, guilty of not being emotionally available. Since the obsessive-compulsive patients are both anger that addiction consciously unacceptable, defend themselves from these feelings with defenses as reaction formation and isolation of affect. In an attempt to deny any form of addiction, many individuals obsessive-compulsive face great efforts to demonstrate their complete autonomy and their "inflexible individualism". Similarly, strive to gain complete control over every form of anger, and may also appear compliant and obsequious to avoid giving the impression of harbor feelings of anger. Intimate relationships pose a significant problem to the patient obsessive-compulsive disorder. The intimacy raises the possibility of being overwhelmed by intense desires to be loved, with the concomitant potential for frustration connected to these desires, which can give rise to feelings of hatred, resentment and revenge. The feelings generated by the relations of intimacy are threatening because they can "lose control", one of the individual's fundamental fears obsessive-compulsive disorder. The closest people frequently complain that the obsessive-compulsive exercising excessive control. These reports often experience deadlocks or impasse, as obsessive-compulsive people refuse to admit that someone else might have a better way of doing things. This need to control others originates from the fundamental feeling that external sources of affection are ephemeral and can disappear at any moment. Somewhere in every OCD is a child who does not feel loved. The low self-esteem related to this childish feeling of not being valued induce these individuals to believe that others would prefer not to have to deal with them. A fear of losing the other can also help the high level of aggression and intense destructive desires that are lurking in the unconscious obsessive-compulsive disorder. These patients often fear that their destructiveness can alienate others or cause controaggressione, a projection of their own anger. Despite their efforts to be respectful, thoughtful and condescending, the fear of being able to remove the other is often justified. The obsessive-compulsive behavior tends to irritate and exasperate those who come in contact. The person who manifests that behavior can however be perceived very differently depending on the ratio of power that characterizes the relationship (Josephs, 1992). To subordinates individuals with obsessive-compulsive personality appear as dominant, hypercritical and parent, while their superiors may seem persuasive and falsely obsequious. Paradoxically, the real true love and approval that these individuals are looking for then put at risk by their own behavior, and they constantly feel unappreciated despite seek desperately to get the much desired approval of others. Obsessive-compulsive people are also characterized by a search for perfection. Seem to have the secret conviction that if they are able to reach a state of transcendent perfection, then it will finally receive approval from parents and estimates that have not had in childhood. These children often grow up with the idea of not having tried and committed enough, and adults feel chronically of "not doing enough". The parent who seems constantly dissatisfied is internalized as a superego that expects more and more from the patient. Many individuals become obsessive-compulsive workaholics because they are unconsciously driven by the belief that love and approval can be obtained only through the heroic efforts aimed at achieving extraordinary levels in the professional sphere. The irony in this pursuit of perfection, however, is that people obsessive-compulsive rarely seem satisfied with their achievements. obsessive-compulsive individuals seek to be perfectly rational and logical in everything they do. They fear any situation emotionally uncontrolled, and their mechanical tendency to be totally devoid of emotions can push those around them to move away. Moreover, their thinking is logical only within certain restricted areas, and their thought patterns can be described as rigid and dogmatic (Shapiro, 1965). From a dynamic point of view, these features can be interpreted as compensatory compared to the lack of confidence in himself and the ambivalence that afflict the subject obsessive-compulsive disorder. In contrast to the cognitive style of the hysterical patient, the patient's ossessivocompulsivo implies an extreme attention to detail Those obsessive-compulsive invest a tremendous amount of energy to maintain their rigid cognitive styles and attentional: absolutely nothing of what they do is effortless . Going on vacation, or just relax, activities that are generally not exert any attraction for the true obsessive-compulsive disorder. Although many of these individuals are professionally established, few realize that their style character impairs their ability to achieve success in the job. The obsessive-compulsive subjects can ruminate endlessly about small decisions, exacerbating those around them. Often lost in details losing sight of their main objective. Their indecision can be dynamically linked to deep feelings of self-doubt. They may feel that the risk of making a mistake is so great as to preclude a final decision in one direction or another. Similarly, the fear that the end result of a project can not be perfect can contribute to their indecision. Many subjects obsessive-compulsive are extraordinarily adept verbally but face considerable psychological difficulties in writing because of this fear. These patients are always driven by internal supervisors who order about what they "should" or "should" do. From a dynamic point of view, have little independence from the injunctions of their superego. Behave as they do because they have to, with no regard to how their behavior affects others. The superego hypertrophic patient's obsessive-compulsive disorder is rigid in its demands for perfection. When these demands are not met for a long period of time, can emerge a depression. This nexus between psychodynamic character ossessivocompulsivo and depression has been observed by clinicians for many years. The subject obsessive-compulsive may be at high risk of depression toward middle age, when the idealistic dreams of youth have been broken by the reality of fleeting time. At this stage of their life cycle such patients can become suicidal and have required hospitalization, despite a long history of operating reasonably well in the employment context. Patients with obsessive-compulsive personality disorder frequently have the feeling of not being appreciated and consequently feel hurt and angry. The lack of approval leads them to torture and to doubt themselves. This uncertainty must be kept hidden to superiors, because individuals with obsessive compulsive personality fear humiliation and shame associated with the fact that others recognize that their poor self-confidence. Are often convinced that others will see them as weak and whiny. Next to this aspect of the sense of private self exists the firm conviction of their own moral superiority compared to those who occupy a subordinate position. 571-5 In contrast to the refractory nature of obsessive-compulsive personality disorder, obsessive-compulsive disorder often improves greatly with psychoanalysis or psychotherapy emphasis on individual expression. these improvements are wide-ranging, and cover both the symptoms of personality disorder is anxiety, depression, interpersonal problems and functioning in general. For patients with obsessive-compulsive personality disorder may also be effective psychotherapy group dynamic. In individual psychotherapy and in that group therapeutic problems that may arise are nevertheless similar, and require similar approaches. To try to manage the feeling of being threatened, the individual obsessive-compulsive may devalue all the insight of the therapist defining them as "nothing new." Patients may initially be reluctant to admit that the therapist is saying something which they are not aware (Salzman, 1980). This resistance can be understood as one of the typical defensive operations that occur in the psychotherapeutic process. These defenses include isolation of affect, intellectualization, undoing, reaction formation and movement. The isolation of affect can present as a lack of awareness than any feeling experienced towards the therapist, in particular as regards anger and sense of dependence. The patient can talk at length about facts relating to past and present situations without showing any apparent emotional reaction to these events. The obsessive-compulsive respond to the threat posed by an intense affection through their obsessive tortuosity, which acts as a smokescreen to mask their true feelings, or more precisely from cloud anesthetic that induces sleep in the other. While the patient wanders away more and more original by the argument, the therapist may lose the thread that binds the patient's associations and begin to "turn off the connections" with the person in front of him. During a psychotherapy scheme tortuous discourse typical of the subject ossessivocompulsivo led delete frequently thoughts or wishes he were just verbalized. In addition, a iperinclusività thought causes the patient to tell secondary events that lead the discourse and further away from the main theme of the session. Many obsessive-compulsive patients will attempt to become "perfect patient". Can groped to reproduce exactly what they think the therapist will listen, with the unconscious fantasy of being able to finally get the love and esteem that feel they have had children. Because they are certain that any expression of anger will cause disapproval, can not consciously try any feelings of anger while unconsciously express completely monopolizing the session. Other obsessive-compulsive patients manifest instead recreating their resistance in the transference relationship with the therapist the power struggle with parents. An effective strategy in the psychotherapeutic treatment of patients with obsessive-compulsive character structure is to overcome the smoky defense of words to try to go directly to the feelings, the therapeutic process is often hampered by the fact finding by the patient, which in this so try to avoid feelings When the patient constantly ruminates on seemingly irrelevant details, the therapist can stop these ruminations and return the patient to the central theme or topic with which he had started the session. Group psychotherapy is often very effective in addressing these problems, because the patient can accept similar feedback from other members of the group without being evoked the power struggles that accompany the therapist's interventions. these patients should accept their humanity, and the fact that their attempts to ignore the feelings of anger, hatred, pleasure, addiction and so on are doomed to fail. Must be integrated as part of self-experience of the individual rather than being repressed, denied, removed or unacknowledged as belonging to someone else. The therapist may periodically use interventions comparison on unrealistic expectations that these patients often feed on about themselves. When the obsessive-compulsive patients can finally try and express anger undisguised towards the therapist, they learn that it is far less destructive than they thought. The therapist is a figure consistent and stable, this week after week and clearly not damaged by their expressions of anger. At the same time, patients find that their anger is not necessarily turns them into monsters destructive. Patients with obsessive-compulsive personality disorder tend to be plagued by "criminal thoughts". In their unconscious there is little difference between a thought and angry to punch someone in the nose. Patients with obsessive-compulsive personality disorder tend to be plagued by "criminal thoughts". In their unconscious there is little difference between a thought and angry to punch someone in the nose. Try to change the superego of the patient during a dynamic therapy or psychoanalysis means at least partially help him understand that the impulses, feelings or aggressive thoughts are simply not equivalent to shares. The patient eventually learns that thoughts and feelings are not subject to the same moral principles of disruptive behaviors. Moreover, the acceptance of one's inner life also reduces anxiety. For the patient, obsessive-compulsive sexual feelings are often just as unacceptable feelings of anger or addiction. Avoiding to take a judgmental therapist allows the patient to finally understand that these prohibitions are internal, not external. Interventions that recognize the fear of these patients compared to the possibility that others may discover their sadistic impulses, their desires of submission and their pervasive insecurity can help create a welcoming environment in which the darker aspects of the psyche can be explored. 576-83 This controversial disorder has been proposed to characterize a group of individuals with social withdrawal distinguished from schizoid patients. avoiding the patient, unlike the schizoid patient, want the close interpersonal relationships but it was also scared. These individuals avoid relationships and social occasions because they fear the humiliation connected with the failure and the pain associated with rejection. Their desire for relationships may not be immediately obvious because of the way they present timid and shy. The avoidant personality disorder is then characterized as a neurosis of character in contrast to the schizoid personality disorder that reflects a more primitive organization that some authors consider within the spectrum borderline. The disorder rarely constitutes the main or the only diagnosis in clinical practice (Gunderson, 1988). More often it is a diagnosis that is put together with that of another personality disorder or a diagnosis on the axis 583-4 1. The psychotherapeutic and psychoanalytic treatment of patients with these concerns, however, often identifies shame as an affective experience central. Shame and self expression are intimately connected. In general what patients fear is avoiding any situation where they are forced to reveal aspects of themselves that make them vulnerable. While the fault involves the fear of being punished for violating some internal rules, the shame is more closely related to an evaluation of the self as somehow inadequate, not corresponding to an internal standard. Individuals with this disorder may feel that social situations must be avoided because they make sure that their inadequacies are exposed for all to see. They may be ashamed of many different aspects of the self; for example, can perceive themselves as weak, unable to compete, physically or mentally inadequate, messy, disgusting, unable to control bodily functions or exhibitionists (Wurmser, 1981). The term shame derives etymologically from the verb "hide" (Nathanson, 1987), and the patient often avoidant retires from interpersonal relationships and social situations because of the desire to "hide" the affection very unpleasant shame. Shame can not be reductively connected to a moment in the evolution of the child's life, but it seems to arise from many different developmental experiences in various ages. Attachment theory can contribute significantly to our understanding of patients avoidant. Individuals with an avoidant attachment style usually by children have felt rejected by parents or those who had to take care of them, and therefore in adulthood are afraid to develop loving relationships (Connors, 1997). They often feel that their developmental needs were excessive or inappropriate, and suffer from lack of adequate responses from the self-object (Miliora, 1998). 585-6 These individuals are not able to make decisions for themselves, are unusually subdued, they always need reassurance and are not able to function satisfactorily if someone else does not take care of them. The diagnosis of dependent personality disorder, such as avoidant personality disorder, is seldom set as main diagnosis or exclusive. Various studies have demonstrated the existence of high rates of comorbidity for patients who suffer from this disorder. Among the conditions of the axis 1 frequently associated with dependent personality disorder include major depression, bipolar disorder, some anxiety disorders and eating disorders. Borderline patients react with anger and abandonment manipulation, while those employees become submissive and adhesives (Hirschfeld et al., 1991). Moreover, the intensity and instability that characterize the relations of the borderline patient are not found in the reports of individuals with dependent personality disorder. 589-90 An empirical study (Head et al., 1991) found that families of individuals with dependent personality disorder were characterized by a reduced expression and a high control, contrary to the families in a clinical group of control and in a normal control group.
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Re: Psychopatology Gabbasrd

Post  counselor on Sun Nov 30, 2014 11:08 am

Another study early family environment (Baker et al., 1996) found that families of patients with a dependent personality disorder were offering little independence and a high control. An insecure attachment is a characteristic sign of dependent personality disorder, and studies of individuals with this disorder (West et al., 1994) found in these patients an attachment patterns entangled. Many patients have grown up with parents who in one way or another have indicated that independence was full of danger. May have been subtly pressured to remain attached to their parents, who seemed to reject them in response to all their attempts to achieve greater autonomy. The main motivation of patients with dependent personality disorder is to obtain and maintain relationships reassuring and supportive. To achieve this objective may engage in active and assertive behaviors that are quite adaptive. the dependent patient seeking people who take care of him because of deeper anxieties. The cling to other pieces of employees often mask aggression. The person who is the object of attachment of pcs employee may perceive the demands of the latter as hostile and tormenting. 591-2 The psychotherapy of patients with dependent personality disorder presents a therapeutic dilemma from the beginning: that these patients overcome their addiction problems, they must first develop a dependence on the therapist. Often this problem is processed in a specific form of resistance, for which the patient sees the dependence on the therapist as a goal in itself instead of considering it as a means to achieve a goal. After some time these patients may forget the nature of suffering that brought them to therapy, and their only purpose becomes the maintenance of their attachment to the therapist. Fearing the end of therapy, can repeatedly remind the therapist how they feel scared to be sure that it continues. If the therapist highlights some improvement, the patient can paradoxically worsen, because the thought of improvement is identified with the end of therapy. A rule of thumb in dealing dependent patients is to remember that what they say they want probably is not what they need. They will try to ensure that the therapist tell them what to do, allowing their addiction continues, and collude with them avoid making decisions or to assert their desires. The therapist must feel serene in frustrate these trends and instead promote the independence of thought and action of the patient. Must be able to transmit that anxiety produced by that frustration is tolerable and even productive, as it can lead to associations on the origins of addiction and fears associated with it. Another common trend is the transference idealization of the therapist (Perry, 1995). The patient can begin to consider the therapist as "the one who knows everything", and therefore wish to transfer to him all responsibility for important decisions. Often patients have the fantasy that the solution to all their problems is becoming just like the therapist. This desire to circumvent the difficult task of finding a genuine sense of self separate from the therapist needs to be interpreted and compared as the therapy progresses. The patient may even try to hinder the achievement of therapeutic goals to prove that he can not think or function independently of the therapist.
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