18 - 523_Dynamic_Psychopathology

01 - 1. Defence mechanisms

1. Defence mechanisms

02 - How is a defence mechanism formed

How is a defence mechanism formed?

03 - Mature defences

Mature defences:

© SPMM Course

  1. Defence mechanisms

Defence mechanisms are not descriptions; they are explanations for certain human behaviour and experiences. Hence they are a part of explanatory psychopathology. These defences operate both in normal individuals and under pathological conditions. Anna Freud organised Freudian defences; Klein and later contributors added some more defence mechanisms. Vaillant (1977) classified them and categorised them to mature, immature and neurotic defences. Kleinian defences are sometimes called as psychotic defences. Using a narrow repertoire of defences repeatedly and repeated use of immature or neurotic defences may be associated with disease states or traits. How is a defence mechanism formed?

Mature defences: SASHA is a mnemonic for the mature defences. Altruism: Using constructive and gratifying service to others to receive a vicarious satisfaction. This does not involve giving up one’s pleasures. Altruism is distinguished from altruistic surrender, in which surrender of direct gratification of instinctual needs takes place to satisfy the needs of others to the detriment of the self.

Wish or Impulse Wish or Impulse Prohibitions (moral, social or legal) Prohibitions (moral, social or legal) Signal Anxiety Signal Anxiety Defence operation Defence operation Symptoms formed Symptoms formed

© SPMM Course ALTRUISM Conflict Result Process ‘Defeat’ in a situation Unconditional offer of help Replaces aggression and competition by support: Achieve vicarious satisfaction

Humour: Here comedy is used to express feelings and thoughts overtly without personal discomfort and without producing an unpleasant effect on others. It allows the person to tolerate and yet focus on troublesome aspects. HUMOUR Conflict Result Process Failure, loss or destruction of belongings Highlighting amusing aspects of threat signals or outcome Anxiety converted to comedy or irony

Anticipation: Here one plans realistically for future inner discomfort and expects worse to occur with mental preparation. Note that anticipation without specific target or goal is nothing but freefloating anxiety and this is not helpful; Anticipation mechanism is goal-directed and implies careful planning for potential difficulties. ANTICIPATION Conflict Result Process Sudden threat event Predicting probabilities and planning countermeasures Matching events and coping resources to achieve a sense of control

Sublimation: Achieving impulse gratification but only after altering a socially objectionable impulse to a socially acceptable one. Sublimation allows instincts to be channelled, rather than blocked. SUBLIMATION Conflict Result Process Unacceptable impulses Socially acceptable behaviour Rechanneling impulses into acceptable expressions

Suppression: Consciously or semiconsciously postponing attention to a conscious impulse or conflict. Issues may be deliberately cut off, but they are not avoided. Discomfort is acknowledged but minimized. ALTRUISM Conflict Result Process

04 - Neurotic defences

Neurotic defences:

© SPMM Course Painful event or sexual impulse Postponement of painful problems and feelings Intentional blocking of recall (this is NOT unconscious forgetting – contrast from repression)

Neurotic defences: Neurotic defences act at the level of mental inhibition. As a result the patient is deprived of some degree of freedom in decision-making, but retains insight. Displacement: The process by which interest and/or emotion is shifted from one object onto another less-threatening, often less-retaliating one. For example one who is told off by her consultant during clinical supervision may displace the anger felt onto her spouse or dog (though the reaction may be extremely different from these two objects!) DISPLACEMENT Conflict Result Process Fear/threat by an object; love or hate for an object Expression of love/hate/anger or fear against an unprovoking stimulus (clinically: phobias) Transfer of feelings from one object to a substitute

Dissociation: Temporarily but drastically modifying one's sense of personal identity to avoid emotional distress. Fugue states and hysterical conversion reactions are common manifestations of dissociation. Dissociation may also be found in counter-phobic behaviour; here a person with fear of heights takes up parachute diving and experiences dissociation during the act. DISSOCIATION Conflict Result Process Promiscuous, hostile or irresponsible behaviour (clinically: Multiple personalities, fugue, amnesia) Temporary alteration of identity including consciousness, memory and perception.

Isolation: Splitting or separating an idea from the affect that accompanies it normally but is now repressed. Noted in OCD. ISOLATION Conflict Result Process Painful emotions or memories Talking about emotional events without feeling (clinically: obsessions) Separate content from affect, remove affect completely

Rationalisation: Offering rational explanations in an attempt to justify attitudes, beliefs, or behaviour that may otherwise be unacceptable. Such underlying motives are usually instinctually

© SPMM Course determined. It often involves finding excuses that will justify unacceptable behaviours when selfesteem is threatened, often seen in teenagers and those who abuse alcohol and drugs. RATIONALISATION Conflict Result Process Low self-esteem along with socially unacceptable behaviours

Self-serving explanations and justification of behaviours False but socially acceptable explanations are offered for unacceptable behaviours

Reaction formation: This involves transforming an unacceptable impulse into its exact opposite. Reaction formation is characteristic of obsessional neurosis, but it may occur in other forms of neuroses as well. If this mechanism is frequently used at any early stage of ego development, it can become a permanent character trait, as in an obsessional personality. REACTION FORMATION Conflict Result Process Feelings of hostility and disinterest Devotion, self-sacrificing behaviour, cleanliness, correctness Substituting wishes/feelings that are exactly opposite to true feelings

Repression: This refers to expelling or withholding from consciousness an idea or feeling. Primary repression refers to the curbing of ideas and feelings before they have attained consciousness: secondary repression excludes from awareness what was once experienced at a conscious level. Note that this differs from suppression – suppression is mere postponement not the loss of thoughts from conscious perception. Repression is the primary defence. Other defences reinforce it. REPRESSION Conflict Result Process Threatening feelings / memories/ fears Gaps in memory; often unnoticed Banning thoughts and feelings from recall; subject unaware (not conscious)

Intellectualisation: This refers to excessively using intellectual processes to avoid affective expression or experience. Here the needless emphasis is focused on the inanimate to avoid intimacy with people; attention is paid to external reality to avoid the expression of inner feelings, and irrelevant details are emphasised to avoid perceiving the whole. Intellectualization is closely allied to rationalization but unlike rationalisation, intellectualisation is not an attempt to substantiate one’s instinctual impulses.

© SPMM Course INTELLECTUALISATION Conflict Result Process Disturbing feelings and thoughts (‘dissonance’) Abstract thinking, doubting, indecisiveness, generalizations Removing personal and emotional components of an event and focusing only on factual aspects

Intellectualisation Rationalisation No instinctual impulses/drives involved Instinctual impulses/urges involved Avoid experience of unpleasant affect Might experience the affect, but attempts to reduce the impact Deals with inanimate objects i.e. emphasize details and facts instead of feelings Provides ‘excuses’: e.g. alcohol, teenage conduct

Identification with the aggressor: Observed where the victim of aggression begins to assume the qualities of the proponent of aggression. IDENTIFICATION WITH THE AGGRESOR Conflict Result Process Sexual threat or life / limb threatening violence Perpetrates violent acts Identify with aggressor, may reduce direct resistance and aid in survival during acute trauma

Undoing: This is seen in OCD and is associated with magical thinking and rituals. A student might think that if he taps his table three times before the start of his exam, he will surely succeed! UNDOING Conflict Result Process Sadistic wishes, unacceptable impulses Superstitions (compulsive behaviour clinically) Symbolic negating of an impulse

05 - Narcissistic defences

Narcissistic defences:

© SPMM Course Repression Dissociation Information is stored in the unconscious in archaeological way – at various depths.

Information is stored in a horizontal fashion; all units are equally accessible to retrieval.

Motivated forgetting underlies repression Amnestic barriers maintain dissociation Information is scattered across time e.g. Dynamic conflicts. Information is discrete and delimited in time Information is transformed and disguised Untransformed storage Uncovering requires repeated trials with later interpretation

Direct retrieval e.g., hypnosis Interpretation and working through transference is needed in therapy Integration of memories and working through traumatic events is required in therapy

Narcissistic defences: Projection and denial are often called narcissistic defences though some authors may dispute this and regard them as immature defences. Projection: This refers to perceiving and reacting to unacceptable inner impulses as though they originated outside the self. For example, the person who attributes hostility to others may be unconsciously projecting their own hostility. Thus, internal threats become externalised and then are easier to handle. PROJECTION Conflict Result Process Hostility, unacceptable wishes Ideas of reference, prejudice, suspiciousness, injustice Attributing one’s own feelings to be coming from others

Denial: It is the explicit refusal to acknowledge a threatening reality. It may persist despite constant explanation of the facts. It is not same as conscious avoidance of painful topics or thoughts. DENIAL Conflict Result Process Painful reality Stubborn and angry negation of reality that is visible to onlookers Refusal to acknowledge the awareness of reality; disavow problems at unconscious level

06 - Kleinian defences

Kleinian defences:

© SPMM Course Kleinian defences: (SIPDOG – splitting, introjection, projective identification, denial, omnipotence, grandiosity) Splitting: It is seen most often in those with borderline personality. Here qualities of an object or person are split into black and white i.e. either good or bad with no grey area in between. SPLITTING Conflict Result Process Overwhelming experience of negative qualities of oneself or positive qualities of others Idealization alternating with devaluation (denigration) Stripping off either all positive or all negative qualities of others

Idealisation and denigration: These two are often accompanied by splitting in those with borderline traits. Here an object is either glorified, and supremacy is ascribed (idealised, omnipotence ascribed) or considered very negatively and cursed! (Denigration). Psychiatrists are treating such patients often experience phases of both idealisation and denigration. Projective identification: It is a Kleinian defence. Here an aspect of self is projected onto someone else. The projector influences the recipient to identify with what has been projected and projector herself now believes that the aspect originated from the reactor. This may result in the recipient behaving in a manner similar to the projector. Now the projector identifies his feelings as reactions to the recipient’s aggression (identification of the origin, but wrongly attributed to the other person). (Please read psychoanalytic psychology for further explanation). It may be seen in psychotic paranoid states. PROJECTIVE IDENTIFICATION Conflict Result Process Hostility, hate and anger Ideas of reference, prejudice, suspiciousness, injustice Converting own hostile impulses to justifiable reactions to the hostility expressed by others

Ogden’s model divides projective identification into three steps.  Step 1 is the projection of a part of oneself onto an external object. Step 1a is the blurring of self and object representations (may or may not be seen).  Step 2 is an interpersonal interaction in which the projector actively pressures the recipient to think, feel, and act in accordance with the projection.  Step 3 is the reinternalization of the projection after the recipient has psychologically processed it Note that step 3 is absent while step 2 is not necessary to define ‘projection’. Projective identification has manifold aims: – It may be directed toward the ideal object to avoid separation, or it may be directed toward the bad object to gain control of the source of danger.

07 - Immature defences

Immature defences:

© SPMM Course – Various parts of the self may be projected, with various aims: bad parts of the self may be projected in order to get rid of them as well as to attack and destroy the object, good parts may be projected to avoid separation or to keep them safe from bad things inside or to improve the external object through a kind of primitive projective reparation. Introjection: This involves internalizing the qualities of an object. It is seen in normal development too. INTROJECTION Conflict Result Process Need for gratification Accusing others of causing distress Internalising the qualities observed in an external ‘object’ e.g. mother, friend, etc

Omnipotence: Original Freudian description pertains to the belief that one can transform or influence the external world through one's thoughts alone. Seen in OCD (e.g. a woman with depressive obsessions says ‘I keep getting thoughts that something might happen to my baby: I am distressed because I think something will actually happen due to these thoughts’). OMNIPOTENCE Conflict Result Process Helplessness Obsessions, narcissistic features Attaching great value (‘power’) to thoughts and believing they can influence external objects

Grandiosity: Klein’s description pertains to manic defence, closely associated with narcissism. See the box below for Kleinian definition GRANDIOSITY Conflict Result Process Inferiority feelings, guilt Self-glorification, presumption and entitlement Converting inferiority to superiority feelings

Immature defences: These are mostly normal in early phases of development and do not essentially convey abnormality. Acting out: This refers to the expression of an unconscious wish or impulse through action to avoid being conscious of an accompanying affect. The unconscious fantasy is lived out impulsively in behaviour, thereby gratifying the impulse instead of prohibiting it. ACTING OUT Conflict Result Process

© SPMM Course Sexual and aggressive impulses Violence, stealing, rape, lies Non-reflective and uncontrolled wish-fulfillment

Passive aggression: Expressing aggression towards authorities indirectly through passive obstructive activities. For example to ‘defeat’ one’s boss, one may involve in procrastination, and take sick leave that affects the boss more than oneself. PASSIVE AGGRESSION Conflict Result Process Resentment, hostility, low selfesteem Procrastination, loss of followthrough Expression through inactivity

Somatisation: Converting psychological states and tension to bodily symptoms. SOMATISATION Conflict Result Process Threat or unidentified fear Bodily Complaints Converting mental tension to physical symptoms

Regression: Moving back into childish or earlier developmental phase to avoid confronting a conflict. Regression is also considered an essential concomitant of the creative process. REGRESSION Conflict Result Process Threat or humility Childish, immature behaviour Moving back to earlier developmental stages (seen during normal development too)

Somatosensory Amplification: The tendency to experience bodily sensations as unusually intense or distressing, and this is thought to underpin somatisation and the somatoform disorders. SOMATOSENSORY AMPLIFCATION Conflict Result Process Threat or fear unidentified Bodily complaints, fear of catastrophic illness Oversensitivity to innocuous bodily features

08 - Defences and disorders

Defences and disorders

© SPMM Course Defences and disorders Disorder Defenses commonly used Alcoholism Denial, rationalization Anorexia Denial, rationalization Borderline Splitting, idealization, denigration, projection, dissociation, acting out Depression Regression Dissocial personality Acting out Fugue or amnesia Dissociation Hysteria Repression, conversion OCD Isolation of affect, undoing, reaction formation, magical thinking Paranoid delusions Projection Phobia Displacement, avoidance Schizoid personality Fantasy, avoidance Somatoform disorders Somatisation Narcissistic personality Projection, splitting

09 - 2. Dynamic models of the mind

2. Dynamic models of the mind:

10 - Topographical theory

Topographical theory

11 - Problems with topographic theory

Problems with topographic theory:

© SPMM Course 2. Dynamic models of the mind:

Topographical theory This was elaborated in The Interpretation of Dreams in 1900. Here, the mind is divided into three regions: the conscious system, the preconscious system, and the unconscious system. The functions of these regions are based on one of the two principles. The Pleasure Principle is the innate tendency to avoid pain and seek pleasure. The reality principle is a learned function, which requires delay or postponement of wish fulfillment according to environmental reality. The conscious system  Receives and process information from the outside world.  Its contents are communicated via speech and behaviour.  Attention cathexis refers to the investment of psychic energy on a particular idea or feeling to process it consciously.  Operates secondary process thinking mainly. The unconscious system:  Contains the contents of censored or repressed wishes, etc.  Characterized by primary-process thinking,  Governed by the pleasure principle.  Shift of cathexis happens very often and quickly  Evident via parapraxes (Freudian slips) and dreams. The preconscious system:  As and when needed service  Interfaces with both unconscious and conscious - contents of unconscious become conscious by ‘squeezing’ through the preconscious  Maintains the ‘repressive barrier’ to censor unacceptable wishes and desires (not the repressed contents). Problems with topographic theory: When someone employs defense mechanisms such as displacement, repression etc., he or she are not aware of the process of this defense. Hence, these cannot be represented by preconscious as Freud thought – as preconscious is available to conscious as and when needed. An unconscious need for punishment was frequently noted among Freud’s patients – topographical theory fails to explain this.

12 - Instinctdrive theory

Instinct/drive theory

13 - Hierarchy of anxiety

Hierarchy of anxiety

14 - Analytical Psychology (Jungian Model)

Analytical Psychology (Jungian Model)

© SPMM Course Instinct/drive theory This theory has derived most of its terms from biology. Drive and instinct are often used interchangeably. An instinct has four principal characteristics: source, impetus, aim, and object.  Source – part of body where instinct originates from  Impetus - intensity/force of the instinct.  Aim - action directed towards the discharge of energy/tension  Object - the target for action. Dual instinct theory holds that sexual energy and aggressive energy are the dual instincts. Libido is the force by which the sexual instinct is represented in the mind. It can also be considered as a part of Eros. Aggression is an instinct with destruction as aim and originates in skeletal muscles. It can also be considered as part of Thanatos (see below) Eros and Thanatos are life and death instincts respectively. According to Freud, the dominant force in biology is Thanatos. Hierarchy of anxiety  Signal anxiety – unconscious perception of external or internal threat leads to resource mobilization and aversion of threat. This forms the basis of defence mechanisms discussed earlier.  Disintegration / annihilation anxiety - concerns about fusion with an external object.  Stranger anxiety – around 7-9 months age  Separation anxiety – when mother is recognized as independent object  Fear of object loss / loss of love – especially in girls at phallic stage  Castration anxiety  Superego anxiety – mature form of anxiety – id vs. ego conflicts. Analytical Psychology (Jungian Model)  Jung founded analytic psychology. His construct of psychic apparatus is shown in the figure.  Collective unconscious (CU) – all mankind’s collective symbolic past. (Something like a DNA in psychoanalytical terms!). This must be differentiated from the personal unconscious (PU), which is same as Freudian unconscious, a collection of repressed

© SPMM Course individual memories.  Archetypes – part of CU. Includes representational images with universal symbolic meaning (e.g. Hero, Old Wise Man, Tree, etc.)  Complexes – part of PU and are stimulated by interpersonal interactions. Feeling toned ideas are developing as a result of the interactions of complexes with archetypes.  Persona – mask covering one’s personality – presented to outside world  Anima – unconscious feminine aspect of a man  Animus - unconscious masculine aspect of a woman  Shadow – an archetype - a personification of unacceptable aspects of oneself symbolized as a dark internal alien.  Individuation – ultimate goal of life where an individual develops a sense of self- identity  Introduced terms extraversion and introversion

15 - 3. Dynamic interpretation of dreams

3. Dynamic interpretation of dreams

© SPMM Course 3. Dynamic interpretation of dreams

Freud was initially trained as a neurologist. Joseph Breuer & Freud together treated Bertha Pappenheim, (Anna O.), after which hypnosis became a psychoanalytic technique. Freud later used the cathartic method of abreaction - the process of recovering and verbalizing suppressed feelings that cause the symptoms. However, Freud encountered patients who could not recall significant memories – he called this resistance. He later proposed resistance to being caused actively by largely unconscious forces involved in repression - which leads to symptom production. This made him abandon abreaction/catharsis and pursue free association – where patients are allowed to ‘speak their mind’ without censor.

Patients often reported their dreams during free association - Freud noted that dream content was related closely to repressed memories and unconscious. Freud declared dreams were the ‘royal road to the unconscious’. According to his wish fulfillment theory, dreams are attempts to fulfill unconscious wishes in a surrogate manner.

The content of dreams may include nocturnal sensory stimuli (e.g. thirst, hunger, etc.), the daytime residue (thoughts and ideas from waking life), and repressed impulses.

Freud distinguished two types/layers of dream content - manifest content refers to what is recalled by the dreamer; latent content refers to unconscious thoughts and wishes that threaten to awaken the dreamer. The unconscious mental operation by which latent content is transformed into manifest content is called the dream work.  Condensation - several unconscious impulses are combined into a single image in the manifest dream content. e.g., One’s father and the horrible teacher may be unified and occur as a single dreadful monster in a child’s dream.  Irradiation or diffusion – this is the converse of condensation where multiple images in dreams represent one unconscious impulse  Displacement refers to the transfer of energy from an original object to a symbolic representation of the object. It is not the mere formation of alternate substitute but includes transfer of affective energy on that substitute – cathexis.  Symbolic representation - highly charged objects or abstract concepts could be represented by using innocent images that were in some way connected with the original object. e.g., a dream of intense dancing may represent one’s desire to attract a colleague sexually.  The mechanisms of condensation, displacement, and symbolic representation characterize the primary process thinking that defies logic, lacks a sense of time and space, can accept

© SPMM Course Notes produced using excerpts from  Casey, P. & Kelly, B. (Ed) Fish’s Clinical Psychopathology. 3rd ed. RCPsych publications.  Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th Edition. Lippincott Williams & Wilkins 2007  Vaillant GE. Adaptation to Life. Boston: Little, Brown; 1977  http://www.eric.vcu.edu/home/resources/pipc/Other/Personality/Table_Defenses.pdf  Semrad E: The operation of ego defenses in object loss. In The Loss of Loved Ones, DM Moriarity, editor. Charles C Thomas, Springfield, IL, 1967; the presence of contradictory items simultaneously, and often incoherent. (This primary process thinking is the modus operandi for Id – refer below).  A more mature aspect of the ego helps to organize primitive aspects of dreams more coherently; this is called secondary revision. The process by which secondary revision occurs is called secondary process – this is logical, with intact time and space boundaries and is mature.  According to Freud, anxiety dreams reflect a failure in the protective function of the dream-work mechanisms.  Punishment dreams defy wish fulfillment theory – Freud explained that these dreams existed as a compromise between conscience and repressed wish. The wish for punishment is supposed to exist as an unconscious wish.

DISCLAIMER: This material is developed from various revision notes assembled while preparing for MRCPsych exams. The content is periodically updated with excerpts from various published sources including peer-reviewed journals, websites, patient information leaflets and books. These sources are cited and acknowledged wherever possible; due to the structure of this material, acknowledgements have not been possible for every passage/fact that is common knowledge in psychiatry. We do not check the accuracy of drug related information using external sources; no part of these notes should be used as prescribing information.