personalities, psychological defenses, and …...personality disorders. •explore borderline...

Personalities, Psychological Defenses,

and Mentalizing in Primary Care

Craigan Usher, MD

Associate Professor of Psychiatry

Oregon Health & Science University

13 March 2020

Usher - Personalities, Psychological Defenses, & Mentalizing 0

Everybody is vulnerable at every stage of their lives; everybody is subject to illness, accident, personal tragedy, political and economic reality. This doesn’t mean that people aren’t also resilient and resourceful. Bearing other people’s vulnerability—which means sharing in it imaginatively and practically without

needing to get rid of it, to yank people out of it—entails being able to bear one’s own.

-Adam Phillips and Barbara Taylor, On Kindness


Disclosure: Conflicts of Interest

• I have no biomedical/financial conflicts of interest


Learning Objectives

By the end of this presentation, participants should be able to:

1) List five psychological mechanisms of defense

2) List three categories of personality disorders as defined by the DSM5

3) Define the term mentalizing and develop examples from their own practice of mentalizing and non-mentalizing stances


To get there, we’re going to…• Reflect upon the original theories out of which the notion

of psychological defense mechanisms arose.

• List the defenses and watch movie vignettes: • Rudimentary (Psychotic)

• Intermediate (Immature)

• Advanced (Neurotic)

• Mature (“Optimal or Healthy”)

• Offer some case examples of defense mechanisms.

• Outline the DSM5 Constructs of Cluster A, B, & C Personality Disorders.

• Explore Borderline Personality Disorder in greater detail.

Freud Alert!


Freud’s “discovery” or elucidation of the Unconsciousis the primary notion which distinguishes psychoanalysis from other approaches to human psychology. Like Darwin, Freud saw himself as a revolutionary, eager to bring to light the ways in which, with close inquiry, one discovers that “The ego is not master in its own house.”

A Difficulty in the Path of Psycho-Analysis, vol. 17, Complete Works, Standard Edition, eds. James Strachey and Anna Freud (1955).

Defenses: Part 1


http://www.youtube.com/watch?v=sj2JFI4BsRQ&feature=related

Freuds world, like that of Plato, is one in which illusions abound.


Two essentials to Freud’s notion of the unconscious.

Ideas are repressed.

Kept away from consciousness through continuous energy.

Thus in psychoanalysis, one discovers an unconscious idea or emotion and in learning why this is/was so intolerable, finds the energy bound up in keeping it unconscious becoming free, no longer causing pain.

Alison Bechdel’s Are You My Mother?


The Structural Model: Id, Supergo, Ego


PDX Hipster or Fin de siècleNeurologist?

Remember, Freud was fundamentally interested in neurology, with his theories and labels placeholders for

the advanced he anticipated…

Superego

EgoId


The Topological Model

Repression can be seen as all of the defenses the mind employs to keep Unconscious material from bubbling to the surface. repression can also be seen as an individual defense, a forgetting of something for defensive purposes.


To Protect the Organism

“The reason why the repressed is so intolerable is that it threatens to overwhelm the ego’s fragile manoeuvres in the real world through the urgency of its fantastic demands; this creates anxiety in the ego and makes repression necessary.”

Frosh S. Key Concepts in Psychoanalysis New York: NYU Press. 2003. 21


Ego Psychologists

• Anna Freud (1895-1982)

• Heinz Hartmann (1894-1970)

• George Vailliant(1934-


https://www.youtube.com/watch?v=v80Nd8w1uts

George Vaillant

Defenses: Part 2 – Individual Mechanisms


Neurotic Symptoms in Practice

If a drive, urge, idea, emotion breaks through there it is often expressed in a neurotic symptom. Repression then acts to make us assume that “well of course, that’s just part of life.”

Example: discomfort with one’s psychotic symptoms + feeling the Other thinks you ought to start a certain medicine->drooling and EPS->anticholinergic->urinary retention->alpha blocker->…


Primitive / Rudimentary Defenses

• Denial• Holding the absolute belief that something is true, despite

overwhelming evidence to the contrary.

• Distortion• Grossly reshaping external reality to suit one’s inner needs.


Immature Defenses

• Passive Aggression• Failure, procrastination, illness

which affects other more than one’s self and other means of“passively” sabotaging others

• Acting Out• Giving into an impulse outside the

direct relationship.• Dissociation

• Temporarily “checking out,” altering one’s behavior and awareness to flee untoward thoughts, feelings or experiences.

• Projection• Attributing one’s own feelings to

another.


Projection

You are going on vacation and inform your patient.

• Patient: “So you want to get away from me, do you?”

• Physician: “What leads you to believe that?”

• Patient: “Oh, I just know. I know how you people

operate.”


More Immature Defenses Devaluation Thinking someone is contemptible, when they are not, to preserve one’s sense of self.

Idealization Often involves projecting one’s own desired positive qualities onto another person.

Splitting Again, in a manner than often involves projection, dividing others into being “all bad”

or “all good.”


“Love” is not always an open door… to adequate judgment of trustworthiness and long-term relationship sustainability.

Neurotic Defenses

Intellectualization Avoiding intimacy through a focus on external reality (not

thoughts, feelings, inner experiences).

Isolation of Affect “No, no, I’m fine.” Separating discussion of topics/events

from the feelings the awaken.

Rationalization Like intellectualization, emphasizing the logic behind one’s

actions.


https://www.theguardian.com/business/2015/sep/21/entrepreneur-defends-raise-price-daraprim-drug

More Neurotic Defenses

• Displacement• Shifting the focus of one’s desire,

hatred or others feelings onto another.

• Repression• Involuntary holding out of conscious

awareness, something that could be available to one’s self.

• Reaction Formation• Transforming an unacceptable impulse

into it’s opposite.


Mature Defenses

Altruism Constructive service to others to

alleviate pain.

Anticipation Carefully, thoughtfully planning for

an upcoming problem and imagining how one can best manage a transition/dilemma.

Ascetism Gratification through renunciation.

For example, planning to live within one’s means. This one has an implicitly moral quality.


Mature Defenses Humor Using comedy to alleviate discomfort,

with an acknowledgement in the joking that this is helping manage one’s painful affects or anxieties.

Sublimation Channeling one’s hurts or destructive

impulses into something more constructive.

Suppression Consciously setting aside a thought to

later examine it. “Bookmarking” a feeling.


Clinical Example #1A 30-year-old man who has been in psychotherapy for three years for severe panic and generalized anxiety is completing law school. He tells his therapist he feels he’s ready to “graduate” from therapy as well and that, along with moving out of the house he has shared with close roommates (who are moving away), he would also like to “maybe check in in a few weeks but I don’t really think I need to schedule anything…”. The next week he “falls apart” and is furious at the front desk staff (whom he calls “cruel” and “worthless”) that his demands for an appointment were not met immediately and shouts that his psychotherapist would “never abandon” him like this.

Defenses: Part 2 – Clinical Examples


Clinical Example #2A 28-year-old man with Wilson’s disease is s/p liver transplant, but due to poor adherence is now in liver failure. He was not deemed a suitable candidate for re-transplant by one university, but has developed a behavior/adherence contract with another transplant team.

The week before his: “case is up for review” with the possibility of getting on their transplant list, the patient tells his parents: “I don’t want to go through that (another transplant) again. I’m done. I’m through.” He also gets two new tattoos and smokes cigarettes outside the clinic so that his doctor can see this/smell this..


Clinical Example #3

A 16-year-old being treated for ADHD and Tourette Disorder comes in for a psychotherapy session, casually noting that he attended his first high school dance with a girl who had “basically told me I needed to ask her.” He sighs and then says, “it was all right…I thought maybe there was some magic there, but I guess not. Oh well.”

Long pause. “I guess she’s big into weed.”


Clinical Example #4A 12-year-old suffering from depression and anxiety who has been wary of medication treatment sits down to talk seriously about her psychological pain and the possibility of starting an SRI.

She begins talking about a: “funny section in The Oregonian that used to be called ‘The Edge’ but is now firmly planted in the middle of the page. Anyhow, you know how they have those pharmaceutical ads with all the terrible side-effects that you’d never want. Well, ‘The Edge’ talked about all of these ‘rules’…”

This takes the two on a 20 minute conversational tangent.


Clinical Example #5

Medical Student: “Unfortunately the test results confirm that…”.

Disappointed Patient 1: “Well. Huh. You know, I love your outfit today. You look terrific.”

Disappointed Patient 2: “You don’t know what you’re talking about, get Dr. Jones in here right now. She knows what how to read the results. You don’t know anything!”

Disappointed Patient 3: “No. I don’t have any questions right now. I think I just need to process this for a bit.”


Personality Disorders: Pervasive Patterns / Clustering of Common Maladaptive Defenses

Mood DisorderEpisodic

Personality DisorderChronic

Individual Less Healthy Defenses

Healthy Defenses


Personality Disorders

• Personality Disorders involve:• Cluster A – Paranoid PD, Schizoid PD, Schizotypal PD

• Cluster B – Antisocial PD, Borderline PD, Histrionic PD, Narcissistic PD

• Cluster C – Avoidant PD, Dependent PD, Obsessive-Compulsive PD


Paranoid Personality Disorder

A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts as indicated by four of the following:

1. Suspects, without sufficient basis, that other exploiting, harming, or deceiving him/her.

2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.

3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him/her.

4. Read hidden demeaning or threatening meanings into benign remarks or events.

5. Persistently bears grudges.

6. Perceives attacks on his/her character or reputation that are not apparent to others and is quick to anger/counterattack.

7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.


Cluster A: Paranoid Personality Disorder

• The Caine Mutiny (1954)

• Falling Down (1994)


Cluster A: Schizoid Personality Disorder

• A pervasive pattern of detachment from social relationships and restricted range of expression of emotions in interpersonal settings with at least four of the following:

1. Neither desires nor enjoys close relationships, including being part of the family.

2. Almost always chooses solitary activities.

3. Has little, if any, interest in having sexual experiences with another person.

4. Takes pleasure in few, if any, activities.

5. Lacks close friends or confidants other than first-degree relatives.

6. Appears indifferent to the praise or criticism of others.

7. Shows emotional coldness, detachment, or flattened affect.


Cluster A: Schizoid Personality Disorder

• The Remains of the Day (1993)


Cluster A: Schizotypal Personality Disorder

A pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduced capacity for close relationships as well as cognitive or perceptual distortions and eccentricities with five or more of the following:

1. Ideas of reference.

2. Odd beliefs or magical thinking (telepathy, superstitions, fantasies)

3. Unusual perceptual experiences, including bodily illusions.

4. Odd thinking and speech.

5. Suspiciousness and paranoid ideation.

6. Inappropriate or constricted affect.

7. Odd, eccentric, peculiar behavior.

8. Lack of close friends or confidants outside first-degree relatives.

9. Excessive social anxiety.


Cluster A: Schizotypal Personality Disorder

• Taxi Driver (1976)


I love XX does not love me.

I hate X…Hate what X is doing to me.

=

X would never do this to me…it must be something/someone else standing in our

way.

Classic Notion of Paranoia

Y (Government, Agency, Public Figure/Celebrity) is keeping us apart and

is watching my every move.


De Clérambault Syndrome

• Erotomanic Delusion

• Assassination attempt on Ronald Reagan

• Explored in Ian McEwan’s Enduring Love


Cluster B

Usher - Personalities, Psychological Defenses, & Mentalizing

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Cluster B: Antisocial Personality Disorder

• A pervasive pattern of disregard for and violation of the rights of others, occuring since age 15 (must be 18 or older for dx) as indicated by three or more of the following:

• 1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.

• 2. Deceitfulness, as indicated by repeated lying, use of aliases, or connign others for personal profit or pleasure.

• 3. Impulsivity or failure to plan ahead.• 4. Irritability and aggressiveness as indicated by repeated physical

fights or assaults.• 5. Reckless disregard for the safety of self or others.• 6. Consistent irresponsibility as idicated by failure to be consistent

with work or financial obligations.• 7. Lack of remorse, as indicated by being indifferent to or

rationalizing having hurt, mistreated or stolen from another.


Cluster B: Antisocial Personality Disorder

Anton Chighurh in No Country for Old Men (2007)


Cluster B: Borderline Personality DisorderA pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity indicated by five or more of the following: 1. Frantic efforts to avoid real or imagined abandonment.2. Unstable and intense interpersonal relationships characterized by

alternating between extremes of idealization and devaluation.3. Identity disturbance: markedly and persistently unstable self-image or

sense of self.4. Impulsivity in at least two areas that are potentially self-damaging

(spending, sex, sub abuse, binge eating)5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating

behavior.6. Affective instability (intense, labile moods).7. Chronic feelings of emptiness.8. Inappropriate, intense, anger or difficulty controlling anger.9. Transient, stress-related paranoid ideation or severe dissociative

symptoms.


Cluster B: Borderline Personality Disorder

• Oliver Trask on The OC


Borderline Personality Disorder

• Onset in adolescence, early adulthood

• 3:1 Female:Male Ratio

• Point prevalence around 1.4%, lifetime 5.6%

• Concern in hospital: self-harm, suicidality, stress, splitting (idealizing/devaluing)

• 10yr longitudinal study in patients (18-45yo) showed 85% remission rate

• Primary Treatments: Dialectical Behavioral Therapy (DBT) also Mentalization-based Treatment (MBT)

• Pharmacotherapy for other disorders indicated, of limited use for primary symptoms.


Narcissistic Personality Disorder

• A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy featuring five or more of the following:

1. Has grandiose sense of self-importance.2. Is preoccupied with fantasies of unlimited success, power,

brilliance, beauty, or ideal love.3. Believes that he or she is “special” and can only associate with

high status individuals/organizations.4. Requires excessive admiration.5. Has a sense of entitlement.6. Is interpersonally exploitative.7. Lacks empathy.8. Is often envious of others or believes they are envious of him/her.9. Shows arrogant, haughty behaviors or attitudes.


Narcissistic PD: Mad Men’s Pete Campbell


Cluster B: Histrionic Personality Disorder

• A pervasive pattern of excessive emotionality and attention featuring five or more of the following:

1. Uncomfortable in situations in which he or she is not the center of attention.

2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behaviors.

3. Displays rapidly shifting and shallow expressions of emotions.

4. Consistently uses physical appearance to draw attention to self.

5. Has a style of speech that is excessively impressionistic and lacking in detail.

6. Show self-dramatization, theatricality, and exaggerated expression of emotion.

7. Is suggestible.

8. Consider relationships more intimate than they actually are.


Histrionic PD: Scarlett O’Hara


Cluster C: Avoidant PD

• A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation featuring four or more of the following:

1. Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection.

2. Is unwilling to get involved with people unless certain of being liked.

3. Shows restraint within intimate relationships—fearing shae or ridicule.

4. Is preoccupied with being criticized or rejected in social situations.5. Is inhibited in new interpersonal situations because of feelings of

inadequacy.6. Views self as socially inept, personally unappealing, or inferior to

others.7. Is unusually reluctant to take personal risks.


Early Roots of Avoidant PD


Cluster C: Dependent Personality Disorder

A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior, fears of separation featuring at least five of the following:

(1) difficulty making everyday decisions without an excessive amount of advice and reassurance from others(2) needs others to assume responsibility for most major areas of his or her life(3) difficulty expressing disagreement with others because of fear of loss of support or approval.(4) difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy)(5) going to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant(6) feeling uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself(7) urgently seeks another relationship as a source of care and support when a close relationship ends(8) unrealistically preoccupied with fears of being left to take care of himself or herself


Dependent Personality Disorder Traits

Harleen Frances Quinzel, MD the psychiatrist who falls under the spell of the Joker, becoming completely dependent on him to make decisions


Cluster C: Obsessive-Compulsive PDA pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:(1) is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost(2) shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met)(3) is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity)(4) is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)(5) is unable to discard worn-out or worthless objects even when they have no sentimental value(6) is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things(7) adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes(8) shows rigidity and stubbornness


OCPD: Orderliness & Perfectionism

Differs from OCD:

• OCD = Insight, Ego-Dystonic Obsessions and/or Compulsions

• OCPD = Lack of Insight, Ego-Syntonic Obsessions

Chas Tenenbaum had, since elementary school taken most of his meals in his room standing up at his desk with a cup of coffee "to save time.”


https://www.youtube.com/watch?v=5QcP-XeD9bo

Personality Disorders Sabotage Mentalizing

Closely related to the term empathy, mentalizing refers to the process of thinking:

1 about others’ thoughts, feelings, motivations, and experiences (acknowledging that others have a mind) and;2 reflecting on one’s own thoughts and feelings (when people attempt to stand outside themselves to describe their self).


Rossouw TI, Fonagy P. Mentalization-based treatment for self-harm in adolescents: a randomized controlled trial. Journal of the American Academy of child & adolescent psychiatry. 2012 Dec 1;51(12):1304-13.

Mentalizing, Attachment & Personality Disorders

• We discover our Self/Mind in the mind of the Other.

• Mind-mindedness on the part of our primary attachment figures helps us enjoy “balanced” mentalizing—a sense of security to be inquisitive about self/other. To seek to find information about ourselves (our minds) and about the world through the eyes of another.


Early Trauma: Neglect, Abuse, & PDs


Mirroring and Contingency

Attachment a necessary component of early security and may have lifelong influences on personality functioning / one’s capacity for affect regulation.

Fonagy P. Attachment and borderline personality disorder. J Am Psychoanal Assoc. 2000;48(4):1129-46

Sharp C, Venta A, et al. First empirical evaluation of the link between attachment, social cognition and borderline features in adolescents. Compr Psychiatry 2015 pii: S0010-440X(15)00121-2.

Kim S, Fonagy P, et al. Mothers who are securely attached in pregnancy show more attuned infant mirroring 7 months postpartum. Infant Behav Dev 2014. 37(4):491-504


Gathering the Bits and Pieces

There is a “very common experience of the patient who proceeds to give every detail of the week-end and feels contented at the end if everything has been said, though the analyst feels no analytic work has been done. Sometimes we must interpret this as the patient’s need to be known in all his bits and pieces by one person, the analyst. To be known means to feel integrated at least in the person of the analyst. This is the ordinary stuff of infant life, and an infant who has had no one person (mirror) to gather his bits together starts with a handicap…”.--Donald Woods (DW) Winnicott

Winnicott D.W. (1945) “Primitive Emotional Development” in D.W. Winnicott: Collected Papers. New York: Basic Books.


Mentalizing Therapeutic Techniques

1) Educate: explaining what mentalizing is and asking the patient when they find themselves the most reflective and when this goes out the window.

2) Identify, highlight, and celebrate examples of skillful mentalizing.

3) Share and provoke curiosity (LEAN IN)

4) Identify preferred non-mentalizing narratives (“Just”)

5) Notice and offer suggestions hidden feeling states (“You said ‘bored’ and of course that’s true, and I was also wondering…”)

6) Make use of your own mentalizing

7) Pause and search, use mentalistic language:

“What’s on your mind?”

“What are you thinking?”

“What’s in your thought bubble right now?”

“How is it that you ended up…?” (opposed to WHY)


Mentalizing Tips for Primary Care1) Meet people where they are at: affectively/body

posture/seat height/eye level. 2) Look for things that you enjoy about your patients; make

psychological contact.3) Reflect and don’t take “yes” for an answer.

• “So you were sad”“Yes.”

• “Please say more about that…”• “I was just sad.”• “I can’t help but wonder why. How is it that you’ve

grown sad?”


Van Baaren RB, Holland RW, et al. Mimicry for Money: behavioral consequences of imitation. Journal of

Experimental Social Psychology, 29, 393-398. 2003.

Van Baaren RB, Holland RW, Kawakami K, & van Knippenberg A. (2004) Mimicry and prosocial behavior.

Psychological Science 15, 71-74

The main points of this lecture are/were:

• Psychological mechanisms of defense help keep ideas and affects within a tolerable range of emotional arousal to the individual employing them.

• People tend to develop a more mature array of defenses over their lives.

• Individuals who, across multiple settings and with many people demonstrate an enduring pattern of cognitive, affective, interpersonal, and/or impulse control functioning that is disruptive and isolating in work, school, and personal relationships often meet criteria for a personality disorder (PD).

• There are three broad categories of PDs:• Cluster A – Paranoid PD, Schizoid PD, Schizotypal PD• Cluster B – Antisocial PD, Borderline PD, Histrionic PD, Narcissistic PD• Cluster C – Avoidant PD, Dependent PD, Obsessive-Compulsive PD

• Poor mentalizing sabotages intra-psychic and interpersonal relationships; promoting mentalizing can prove helpful.


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Fun Take-Home Activity: an earnest plea


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