Posted by: faithful | April 29, 2011

emory psychiatry lectures

The Mental Status Exam

The mental status exam is the heart of the psychiatric evaluation.   Technically part of the neurological exam, the mental status exam has both objective and subjective components.  A properly performed mental status exam allows you to describe the important aspects of observed and reported cognitive and emotional functioning and helps guide further examination and study.

The setting of the mental status exam is critical.  Insure that you and the patient are comfortable.  Asking a frightened, paranoid patient if they would like a blanket or something to eat can do wonders in terms of building rapport.  Make sure that the patient has as much privacy as the situation allows, minimize distractions, such as television or hallway conversations, and prepare yourself to focus entirely on what the patient is telling you.  This may be very difficult when on call with many other responsibilities and limited time, but a rushed mental status exam will ironically cost you more time and effort as you attempt to get the information you need.

Remember also that a mental status exam is more than simply a means of gathering information.  It is also therapeutic.  Your first contact with the patient, the mental status exam sets the stage for your future relationship.  Being empathic, warm, yet neutral can often be very soothing even to a patient who is very agitated, depressed, frightened, or angry.  You may be rushed and distracted by other things, but your patient will often remember your first encounter even years later.

Elements of the mental status exam:

As with any other portion of the physical exam, having a systematic approach insures that you will be comprehensive and efficient, by forcing you to focus on several different areas in turn.

Appearance:  How is the patient dressed?  What about the patient’s grooming, hygiene, and body language?  Often the first things you notice about a patient are significant.

Orientation:  There are four general elements to orientation:  person; place; time; and situation.  Orientation to person is simply the ability to identify one’s name and is the last element of orientation to be lost, usually only in very severe dementia or in psychotic states.  It’s a good idea to preface your inquiry with a general comment about the fact you ask every patient these questions (otherwise patients will often take offense at your asking them their name or where they are).  Orientation to place is the ability to name where they are, or at least what building, city, or state they are in.   Time includes the date (allow a day or two error for inpatients who are frequently somewhat disoriented), day of week, year, and season.   Situation is the ability to describe their global circumstances, for example:  “I came to the emergency room with chest pain and the doctors are evaluating me to see if I had a heart attack.  You must be some clown they called in from psychiatry.”

Registration/Recall:   Registration is the ability to repeat back a piece of information immediately after hearing it.  It is a good idea to memorize three objects yourself before examining a patient and to use those three objects consistently.   I use dog, ball, and truck.  A more rigorous exam might use a combination of adjectives and nouns, for example, brown dog, red ball, and green truck, or a combination of tangible and intangible items, for example, loud noise or high ideals.  Recall is the ability to repeat back the information after a space of 3-5 minutes.  It is important to inform the patient that you will ask the information again in a few minutes (then remember yourself to ask!).  Give them a few seconds to commit the information to memory.

Behavior and Motor Activity:  do they make eye contact as you enter the room, do they cross their arms and stare sullenly at the floor, or are they flirtatious or intrusive?  Psychiatrists often speak of psychomotor agitation (e.g., pacing, hand-wringing, excessive fidgeting) or retardation (paucity of spontaneous movements, general bradykinesia).  The latter is classic for melancholic depression, but medical conditions such as hypothyroidism or parkinsonism must be considered.  Other things to look for are bizarre, repetitive motions known as stereotypies seen in some forms of schizophrenia.  Also, look for perioral, periorbital, or tongue twitching which may indicate past exposure to neuroleptics (antipsychotic medications).

Speech:  The most important elements of speech are rate, fluency, and content.   The rate of speech can be increased in conditions such as mania or stimulant intoxication or decreased in conditions such as depression or sedative intoxication.  The fluency is of more interest to the neurologist in sorting out aphasias, but can also be helpful to the psychiatrist in determining if a patient is responding to internal stimuli.  Thought blocking, in which the patient stops in mid-sentence and fails to pick up the thread of conversation without prompting, is a sign of severe psychosis.  The content of speech is perhaps the most important and the most subjective part of the exam.  The underlying assumption of the mental status exam, an assumption not always valid, is that speech is a reflection of thought.  A patient whose every word exudes hopelessness, despair, and the pointlessness of everything must be distinguished from a patient who ruminates over bowel functioning, somatic concerns, or sexuality.  Step back every now and then and pay attention to the overall theme of what the patient is saying.  See thought process, below, for more aspects of speech to pay attention to.

Thought Content:  thought content includes assessment for the presence of a number of important psychiatric signs or symptoms, including:

Hallucinations:  these come in several flavors.  Auditory hallucinations can be voices (very common in  schizophrenia) or recurrent sounds (such as of helicopters, artillery common in combat veterans suffering posttraumatic stress disorder).  Visual hallucinations often imply an organic etiology (such as delirium, withdrawal, or some central nervous system lesion), but can be seen in schizophrenia and other psychiatric states.  Visual hallucinations of deceased love ones are common in grieving.  Other types of hallucinations include tactile, olfactory, or gustatory.

Delusions:  fixed, false, idiosyncratic beliefs.  Common delusions are grandiose and persecutory.  They may take a religious or historical theme.  You cannot talk a patient out of a true delusion (by definition).  The best way to assess a delusion is to take an objective, logical stance.   Without sounding judgmental or confrontational, try to get the patient to elaborate on his belief system, citing evidence for and against the delusional conclusion.  For example, if someone believes hit men are trying to kill him and he states that he owes $10,000 in gambling debts to a man named Rocko who promised to break his legs, then this may be based in reality (you aren’t paranoid if everyone IS out to get you).  However, if he says he knows someone is trying to kill him because the television commentator mentioned it would rain tomorrow.  (This is also an example of looseness of association and a possible idea of reference).

Ideas of reference:  special messages from the television, radio, or other objects all qualify as ideas of reference.  For example, a patient who believes he is really the president of the United States may tell you she gets messages from the local newscasters telling her to be on the alert for the coming coup that will restore her to office.  Patients who experience ideas of reference may place extreme significance on benign or random events (e.g., a helicopter passing overhead, a certain commercial, or even a song on the radio).

Suicidal ideation:  no mental status exam is complete without an assessment for dangerousness, specifically suicidal or homicidal ideation.  Both have three parts:  ideation; intent; and plan.  Ideation covers a range from occasional fleeting thoughts, such as, “I’d be better off dead,” to a recurrent, intrusive obsession with suicide or murder.  This is a judgment call, but always take any suicidal statements, however vague, very seriously.  Remember that patients can and do commit suicide in the hospital, so never assume that being in an institutional setting is a guarantee of safety.  Explore how strong the thoughts are.  Patients who are chronically suicidal can sometimes rate the strength of their suicidal ideation on a scale from 1 to 10.   Intent refers to whether the patient is simply thinking about or even wishing her own death or has an intent to actively do something to bring it about.  This is also a judgment call; you aren’t responsible for reading the patient’s mind, but you are responsible for asking and documenting the patient’s response.   Having a suicidal or homicidal plan is an indication of seriousness and should make you consider hospitalization for safety.  A patient with suicidal ideation, intent, and plan should be hospitalized and put on suicide precautions.  Assess the lethality and reality of the plan.   A patient who threatens to overdose on Prozac and ends up taking 10 pills in a gesture is less worrisome than a patient who is found with a loaded gun to her head, although both should be taken very seriously.   The only element unique to homicidal ideation is target:  you have a medicolegal obligation to report and protect any intended victim of assault or homicide.  If a patient tells you he is thinking of killing his wife, he cannot leave the emergency room until he either reassures you that he has no intent or plan or until you have called her and made every reasonable step (including commitment or incarceration) to prevent him from harming her.

Thought Process:  This is an assessment of how a patient’s thoughts flow and is heavily dependent upon and related to an assessment of their speech.   First, assess the connectedness of each of the patient’s ideas.  Do they flow logically one from the other?  If so, the patient’s thought processes would be described as cogent.  Do they flow logically, but stray from the flow of conversation to the point that the patient takes you on a “wild goose chase.”  If so, is the patient experiencing flight of ideas, a hallmark of mania?  Or is the patient circumstantial and overinclusive, a sign of organicity or obsessive-compulsiveness?  Does the patient never return to the original flow of conversation, in which case you would describe the thought process as tangential?   If the ideas are not logically connected, or jump several times, invite the patient to help you understand his logical system.  For example, you might say,  “I don’t quite follow what you just said.  Could you help me see the connection between your income tax return and the proliferation of nuclear weapons?”   These concepts are difficult to understand, so examples follow:

Flight of ideas:  “My name?  Why it’s Bob, as in Bob Dole.  Did you know Dole is from Kansas?  Kansas – what a state!  Did you know Kansas produces more wheat than most countries in the world?  Wheat is important.  In fact, without wheat, there would be no Wheaties.   Wheaties makes me regular.  I hate being constipated, don’t you?  I think constipaton is the root of most of the evils in the world.  I’ll bet you Hitler was constipated.  That’s because he was a vegetarian.  What other questions do you have?” Circumstantial:  “My name?  I thought you’d never ask.  You doctors are always asking so many useless questions, you forget the most important ones.  I had a doctor once back in 1982 – or was in 1983? – I think he was a family practitioner, or maybe he was an internist.  No, definitely an internist.   Anyway, he treated me for thirteen years without ever once addressing me by name.  I think he didn’t know my name.  Maybe I was just Patient Number 7155 or something.  But now that you asked, my name is Bob.”

Overinclusive:  “You want me to describe my pain?  Well, it’s sort of a dull pain on the left side of my chest, except when it’s sharp, in which case it drifts over the right side of my chest and I’ve noticed I tend to be more flatulent with the sharp pain.   I sometimes get sharp pain and sometimes dull.   Sometimes it’s neither sharp nor dull, but a little of each, sort of at the same time.”

Loose associations:  “My name?  Well, I’d tell you my name except for the weather, which is humid.  Hot weather really bothers me, makes me want to paint my car blue.   I got fired last week.  Chocolate is my favorite flavor of pudding.  Centrally planned economies will always fail because no one can regulate the temperature in that room you’re going to admit me too.”

Mood and Affect:  Mood is what the patient reports to you.  Affect is what you observe.   Mood should be described as dysphoric (sad), euphoric, or euthymic (normal range).  You can also use qualifiers such as labile, angry, irritable, or anxious.  Affect, on the other hand, includes facial expression, tone of voice, body language and other objective manifestations of mood.   Affect is typically described as constricted (sad), bright, or normal range.  You should also note whether the affect is congruent with the underlying reported mood (for example, a patient who laughs while talking about how much they miss their dead mother could be said to have an inappropriate or mood incongruent affect).

Cognition:  Several objective tests exist to test cognition, from pencil and paper IQ tests to the mini-mental status exam, but the latter is probably the best for bed-side testing purposes.  If you are rushed and wish to perform a quick and dirty test, ask the patient to manipulate coins (“If I have four quarters, two dimes, and a nickel, how much money do I have?  If I take away a dime and a nickel, how much is left?”), perform serial 7s (“Take 99, subtract 7, then subtract 7 from that, etc.”), spell the word “WORLD” forward and backward, or to interpret proverbs (“What do people mean when they say a bird in the hand is worth two in the bush?  Don’t count your chickens before they hatch?”).  For proverb interpretation, note whether the explanation is concrete – merely a restatement of the proverb in different words – or whether the patient is capable of abstraction, moving from the specific to the general.  Vocabulary, diction, and word usage are also very good indicators of global cognitive functioning, although you must adjust somewhat for educational background.

Insight and Judgment:  Insight is a patient’s awareness of themselves and their condition.  Judgment as used on the mental status exam refers most commonly to an assessment of the patient’s ability to avoid behavior that might be harmful to themselves or others.

Diagnostic and Statistical Manual, Fourth Edition (DSM-IV)

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM-IV) is the latest attempt to classify complex phenomena such as various presentations of mental illness into a set of specific disorders that share common characteristics.  The objective of the Diagnostic and Statistical Manual system is to improve reliability and validity among diagnosticians and observers, improve diagnosis, treatment, and research.

Reliability, remember, is the extent to which different observers agree on a particular diagnosis.   (If they are all wrong, but consistently wrong, they would still have high reliability, just low validity.)  Reliability can be thought of as how closely a series of shots taken with a rifle fall on a target;  even if they are far from the bullseye, if they are close together then reliability will be high.  Reliability can also be viewed as reproducability.

Validity, on the other hand, is how close the diagnosis of a given instrument falls to some gold standard, or how “correct” it is.  Using the rifle range analogy, validity is how close the shot lands to the bullseye.  Scattered shots centered around the bullseye might have high validity, but low reliability.  Obviously, with subjective phenomena such as mental illnesses, a gold standard is generally lacking.  Agreement between professionals using a clinical interview and some predefined criteria is as close to a gold standard as we can come using today’s technology.  Platelet studies, MRI, and PET scans offer some “hard” evidence for some psychiatric disorders, but none is practical as a screening tool.

Psychiatric researchers must focus on common characteristics, lontitudinal course, reported subjective symptom and observed signs of various illness and empirical evidence to various interventions to determine the validity of an illness or a classification system.   Before the Diagnostic and Statistical Manual, clinicians used idiosyncratic terms defined in either theoretical or abstract ways.  For example, one’s clinician’s depressive neurosis might be another clinician’s dysthymia.  This made standaradized research of psychiatric disorders almost impossible.  In addition, recently third party payers have become very interested in linking reimbursement to diagnosis; for example, therapy for personality disorders might not be fully reimbursed, whereas treatment of an Axis I disorder (see below) such as major depression would be.  This obviously puts pressure on clinicians to give some diagnoses more than others, thereby diluting the validity of the diagnostic system.

The Diagnostic and Statistical Manual attempts to be atheoretical and descriptive.  It attempts to rely as much as possible on observed behavior and reported symptoms and does not attempt to explain etiology.  A tremendous effort has been made to incorporate the most recent research findings into the Diagnostic and Statistical Manual, now in its fourth edition (and frequently referred to as DSM-IV).  The DSM-IV is the most widely used diagnostic manual in the United States and one of the most widely used in the world.      Note that the Diagnostic and Statistical Manual does not address treatment or outcome.

The Five Axis Classification System

The Diagnostic and Statistical Manual uses a Five Axis system to help guide the evaluation of the psychiatric patient.

Axis I includes major psychiatric diagnoses, such as major depression, bipolar disorder (manic depression), schizophrenia, alcohol dependence, or posttraumatic stress disorder.  Traditionally, Axis I disorders are considered by insurance companies and third party payers, to be the most serious psychiatric disorders, even though a severe Axis II disorder can be just as disabling.

Axis II is where developmental disorders are coded; these include personality disorders and mental retardation.  The Axis I- Axis II dichotomy is somewhat controversial, particularly since an emerging body of evidence indicates a strong biological underpinning to temperament and personality.

Axis III is where any medical disorders such as hypertension or diabetes are coded.

Axis IV provides a six point rating scale for psychosocial stressors that contribute to the presentation of the current disorder.  The coding ranges from none to catastrophic:

None: no identifiable stressors.

Mild:  starting graduate school, having a child leave home.

Moderate:  marriage, marital separation, loss of job.

Severe:  divorce, birth of first child, extreme poverty.

Extreme:  death of  a spouse, serious physical illness, or victim of rape, serious illness in self or child, ongoing sexual or physical abuse.

Catastrophic:  suicide of spouse, concentration camp victim, natural disaster.

Note that some judgment must be used here, but there is a tendency to overrate psychosocial stressors.  Most psychiatric patients probably fall in the moderate to severe range of psychosocial stressors.

Axis V:  Global Assessment of Functioning (GAF):  this is a scale ranging from 0 to 90, 90 being the highest functioning:

GAF: 90:  no symptoms or dysfunction. 80: transient symptoms. 70: mild, e.g., depressive mood or insomnia, mild difficulty in social or occupational functioning. 60: moderate symptoms, e.g., flat affect, circumstantial speech, panic attacks, moderate difficulty in social or occupational functioning. 50:  serious symptoms, e.g., suicidal ideation, frequent shoplifting, obsessive rituals. 40:  some impairment in reality testing or serious difficulty in multiple areas. 30:  behavior influenced by severe psychiatric symptoms, e.g., delusions, suicidal ideation, or auditory or visual hallucinations. 20:  some danger of hurting self or others. 10:  persistent danger to self or others, or complete inability to attend to personal hygiene.

Note also that every diagnosis in the DSM-IV has a numerical code associated with it and may have several modifiers.  For example, alcohol intoxication is 303.00; alcohol dependence is 303.90; and alcohol abuse 305.00.  (There is no need to memorize these numbers; they are simply given as examples.)

V Codes:  These codes represent issues or problems that do not represent major psychiatric disorders, but may contribute to the presentation.  For example, academic problems could be coded as v62.30, malingering v65.20,  marital problems v61.10, uncomplicated bereavement v62.82.

Psychoanalysis and Psychodynamic Psychotherapy

History and Background 

Sigmund Freud, a Viennese neurologist, could perhaps be considered the first psychiatrist.  He became very interested in mental anguish or conflict expressed as physical illness, such as paralysis or an unwanted tic.  He attempted to develop a unifying theory of human behavior and emotion and modeled his theory on the work being done on thermodynamics in his day.  Freud theorized that unresolved, unconscious conflicts, possibly arising from early childhood trauma, become manifest in the adult patient through maladaptive, “fixated” defenses against painful memoy of the trauma.

Anna Freud made one of the more enduring contributions through her elucidation of mechanisms of ego defense, an area her father frequently alluded to but did not as clearly and categorically define.   Unfortunately, much of the subsequent history of psychoanalysis was marred by bitter fighting between the master and his former pupils, such as Jung and Adler, who both broke away from Freud with his emphasis on infantile sexuality, so no coherent single body of psychoanalytic literature emerged.  Rather, warring camps of neo-Freudians, such as Karen Horney, battled with the orthodox defenders of psychoanalyst’s founder.  It is unclear if Freud intended his theories to be viewed as a foundation to be built upon or a fortress to be defended, but he had been criticized for turning any counterarguments ad hominum (he wrote Jung before their split that his first inclination was to treat anyone who resisted his ideas as patients, that is displaying unconscious resistance).  The circularity of this line of  thinking (i.e., that any legitimate scientific skepticism must represent some unresolved unconscious conflict on the part of the critic (Johnson, 1992)) has been one of the main obstacles to universal acceptance of psychoanlytic principles or to its critical acceptance.

Freud’s Topographic Theory

The Topographic Theory was Freud’s first attempt to divide the mind into structural regions, separated by function:

The Unconscious

The Unconscious is the repository of repressed ideas and affects (emotions).  Usually these ideas are unaccessible to consciousness.  In fact, consciousness may make an effort to exclude them via repression.   Three states in which these ideas bubble up to consciousness is when asleep (through dreams), in jokes, and when overwhelmed (neurotic symptom formation). In the land of the unconscious, the primary process rules.  The primary process is a type of mental activity that knows no logical constriants or boundaries, concepts of time, and permits contradictions.  Immediate gratification is its motto.  To see the primary process at work, observe children in a candy store and their complete inability to delay gratification.      The unconscious is also where instincts and unfulfilled wishes are stored.

The Preconscious

The Preconscious can be viewed as the link between conscious and unconscious processes.  It acts as a screen, filter, or censor.   Secondary process is the rule here.  Secondary process thinking recognizes the reality principle, that there are constraints, that logic must be followed, that contradictory truths cannot coexist.   The secondary process attempts to regulate or delay discharge of instinctive energy, and to prevent unpleasantness.

The Conscious

Freud viewed the conscious as the instrument of attention.  Only a minority of mental energy occurs here (most is unconscious).  We are only immediately aware of our conscious and preconscious; the rest of the mind is beyond awareness, but can percolate up to consciousness for example through dreams or jokes.

Freud’s Structural Theory:  the Id, the Ego, and the Superego.

Freud divided the mind into three provinces, not necessarily anatomical, but theoretical:  the Id, the Ego, and the Superego.  (These unfortunately latinate terms are klunky translations of the much more simplistic and direct German ones, which translate more literally into the “It”, the “I”, and the “Above Me” or “Higher I”. )      The main difference exists between the id and the ego.      Id:  locus of primary, primitive drives.  Your id is what steers you toward that car on the showroom you know you can’t afford or your eyes toward that person across the room even if you’re there with your significant other.  The id operates under the pleasure principle, meaning it has no regard for reality, constraints, or consequences.  A wild sexual fantasy or dream is pure id.      Ego: balances the drives of the id against the reality of the world.  More organized than the id, the ego attempts to avoid displeasure and pain.  Patients with good control of their impulses and ability to tolerate difficult emotional challenges are said to have good “ego strength.”  This is where Freud felt the real action was:  viewing it in somewhat neurological terms, he described it as critically involved in self-preservation of the organism through memory, awareness of stimuli, and making changes in the external environment to gain advantage.  The ego also can delay or discharge various impulses of the id, leading to release or tension.      Superego:  locus of the internalized moral values, prohibitions, and ideals of the person.  The superego is what compels men to climb out of foxholes under fire to pull a wounded comrade back to safety.  It also is what probably drove you to attend medical school or become a physician.  It is the repository of your ego ideal, your idealized self, the self you want yourself ideally to be.  The superego is also where your conscience lives and is responsible for the experience of guilt.

The Oedipus Complex

Central to Freud’s theory was the idea of an Oedipus complex.  Based on the Greek tragedy Oedipus Rex, in which a boy banished as an infant by his father, the king, comes back and murders his father – unaware of his identity – at a crossroads, then marries his mother – also unaware until too late of her identity, the Oedipus complex posits that 3-5 year-old boys go through a crisis in which they seek to seduce their mother while fearing retaliatory castration by their father.  Successful resolution of this conflict involves acceptance that mother is unattainable and belongs to father, but that one day a mate might be found who will be a substitute for the relinquished mother.      The Oedipus complex is perhaps one of the most controversial and widely criticized aspects of psychodynamic theory.   The female equivalent is more fuzzy and feminists and others have objected to the phallocentrism of his ideas (why, for example, should a girl suffer penis envy; why shouldn’t a man suffer breast envy?)      Further criticism of psychoanalysis developed during the mid-twentieth century, when it was observed that a number of cultures had no recognizable Oedipal complex.

This called into question the Eurocentricity of Freudian ideas.   Freud’s goal in formulating his theories of what drives people to do the things they do was to create an all-encompasising theory of human behavior and emotion, something akin to the universal laws of thermodynamics and physics that were being developed and popularized during his lifetime.  (Indeed, many of his earlier models viewed the psychic apparatus in hydraulic or mechanical terms; “psychical energy” was “absorbed” or “discharged”.)

Many Freudian concepts continue to be useful, however. For example, the idea of personality disorders representing a collection of maladaptive defenses (maladaptive in that they no longer serve the survival function they might have had in a traumatic childhood) is one shared by many researchers in the field, regardless of theoretical orientation.  Psychoanalytic concepts such as denial, rationalization, and acting out, although at times applied pejoratively and indiscriminately to any difficult patient, shed some light on what were otherwise incomprehensible, bizarre behaviors, and offered guidance in intervention.   In addition, thinkers who advanced the work of Freud to the interpersonal realm, such as Harry Stack Sullivan and Karen Horney, or to the concept of object constancy, such as Melanie Klein and Heinz Kohut, have enriched our view of  human suffering.  Kohut also stressed the importance of attempting to understand and empathize with the patient’s inner world.   Empathy, however, does not preclude the therapist from confronting the patient when the patient is engaging in destructive or counter-therapeutic behavior.  Much of the research done on psychodynamic psychotherapy is naturalistic and suffers from a lack of randomization, control groups.  Some argument might be made for brief psychodynamic psychotherapy, consisting of 10-12 sessions over a 6-12 month period, originally thought to be inappropriate for severely personality disordered patients, but now viewed as helpful, especially if therapy focuses on current problems, is solution-oriented, and limited in its scope (the patient is not encouraged to develop strong transference feelings).  Brief psychodynamic psychotherapy can also be given intermittently over a long-term basis (Silver, 1985).      The objective of any psychodynamically oriented psychotherapy is to make the unconscious conscious, allowing previously repressed conflicts, wishes, fantasies, and drives, to be dealt with and in some way mastered.  The underlying assumption is that insight will lead to some meaningful change:  for example, a person who becomes aware of how much angry men remind him of his father and leave him paralyzed with fear may become more functional in the presence of angry men.

Psychodynamic Defenses

Sigmund Freud first coined the idea of defense mechanisms in 1894, but it was his daughter, Anna Freud, who perhaps best articulated the concept in her 1936 book, The Ego and The Mechanisms of Defense.  She claimed that everyone, normal as well as neurotic, uses a set of defense mechanisms to varying degrees.  Each theorist posited that most mental processes occur unconsciously – that is beyond our conscious awareness – and that when various drives, wishes, or fantasies become too painful, we must use unconscious processes to ward off what would otherwise be overwhelming psychic anguish.  However, this unconscious resistance has a cost; Sigmund Freud used the analogy of soldiers having to be split from the main body of an army to guard against the unwanted affect or emotion.  The more soldiers diverted, the less are available for the conflicts of everyday life.   Perhaps the best way to conceptualize defense mechanisms is as a mental abstraction that helps us understand a set of behaviors that otherwise would be incomprehensible.  Defense mechanisms in and of themselves are neither good nor bad; it is only in how appropriately they are used and how adaptive they are that determines if they are problematic.   Defenses are viewed as a means of dealing with anxiety or resolving conflict.

Acting Out:  behavior that symbolically expresses what one is either unwilling or unable to more consciously express.  For example, if someone has unconscious resistance to learning about human behavior, he might simply not show up for class or be late.  The person may seem to have a valid excuse in each instance, but the overall pattern is that the person is disproportionately late for human behavior lectures.

Denial:  seeing but refusing to acknowledge what one sees.  All of us engage in denial on a daily basis.  For example, when we get into our cars each day, we do so in at least partial denial of the reality that we may be killed or maimed.  Without this denial, we might not be able to function in a dangerous and random world.  However, this can lead to problems if we deny that we are in any way vulnerable, and don’t wear seatbelts or drive recklessly.  In a relationship, denial can be destructive if one partner is either unwilling or unable to acknowledge the contributions to the problems in a relationship he or she might be making.  Note that denial, as is true for any of the defense mechanisms, is unconscious, so the person is unaware of the process as it occurs.  This is why it can be so exasperating to try to confront someone with something over which they’re in denial.

Intellectualization:  the control of affect and impulses by thinking about things instead of experiencing them emotionally.  A person who is a victim of a tornado, for example, may read everything about tornadoes and meteorology he can in an attempt to gain some mastery over the traumatic experience.  Although this may be a normal response, it may interfere with the patient’s mourning, acceptance, and ability to deal with attendant affect.

Passive Aggressive Behavior:  this includes behaviors that although prima facie are passive are in actuality aggressive.  The classic example is the secretary who never directly confronts you, but by various acts of omission – failure to return calls, perform duties in a timely manner, or pass along important messages – engages in behavior whose impact is to hurt a supervisor.   It is considered an immature defense and can obviously be very destructive;  the secretary in this case is avoiding the anxiety associated with direct confrontation with the supervisor but ends up creating far more tension and damage over the long-term albeit in an indirect way.

Projection:  perceiving and reacting to unacceptable inner impulses as though they were coming from outside the self.  For example, one might feel a tremendous hostility toward a group of people, such as Jews, Moslems, or Christians, but experience the hostility as arising from that group, leading to prejudice.  Freud was primarily concerned with intrapsychici defense mechanisms, but clearly these defenses can be seen at the societal or cultural level.

Regression:  returning to a more primitive stage of functioning to avoid the anxieties associated with a more advanced stage.  This is very common among patients admitted to a hospital, who although functioning independently as outpatients become very needy and appear less mature when hospitalized.

Somatization:  conversion of anxiety into somatic symptoms, such as abdominal pain or diarrhea.  It is often very difficult to determine if the patient is suffering from a bona fide medical illness or is simply experiencing mental pain in somatic form, but it is the clinician’s task to sort this out.   Many illnesses are worsened by mental tension or conflict, so the old mind-body dualism is a false dichotomy.   Somatization becomes problematic when the patient becomes so focused on their bowels that they are unable to articulate and deal with their anxiety, depression, or other mental difficulties.  In extreme form, somatization can lead to multiple unnecessary diagnostic and therapeutic interventions, such as exploratory laparotomies or cardiac catheterizations so it is extremely important to identify this defense when it is occurring.  However, it is also important to remember that somatic patients get myocardial infarctions or appendicitis also, which makes the clinician’s role a very difficult one.

Rationalization:  in contrast to intellectualization, the fallacious justification of various attitudes, beliefs, or behaviors.  For example, a person who goes through 6 chaotic relationships in a row because of his rigid personality style may tell himself he’s better off without those relationships.  (An intellectualizer, on the other hand, might read every self-help book available about what makes relationships succeed or fail, memorizing statistics on divorce and marriage and filling his head with facts while avoiding any painful emotions.)  Societal and cultural rationalizations include the concept of Manifest Destiny that rationalized the dominance of North America by Europeans or the concept of Lebensraum that Hitler used to rationalize his dominance of Europe.  True rationalization (as a defense mechanism) is unconscious and should be contrasted with the sociopath’s calculated, conscious dishonesty (although someone with antisocial personality disorder may also engage in unconcsious rationalization (“I really needed a new car and the person I was stealing it from was probably rich enough to go out and buy another.”)

Reaction formation:  management of unacceptable impulses by creating its polar opposite.  For example, a person who loves alcohol and drinking to intoxication may join a temperance movement, condemning any and all alcohol.  A man who has secret impulses to fondle young boys may become active in a religion with harsh sexual prohibitions and mandates.

Repression:  expelling from conscious awareness any feelings or ideas that are considered unacceptable.  Psychoanalytic theory holds that repression is usually accompanied by symbolic behavior, showing that repression is not entirely successful.  For example, the person who tells you repeatedly that he is not angry that you forgot to join him for dinner might let slip his displeasure in other ways, such as slips of the tongue (“Where should I beat you – I mean, meet you?”).

Sublimation:  the expression of prohibited or secret impulses or feelings through societally accepted means.  For example, the person filled with homicidal urges may become a movie director of violent movies that are critically acclaimed instead of acting directly on the homicidal impulses and killing someone.  Someone with sadistic impulses may become a surgeon, cutting open flesh and breaking bones in a societally acceptable way.

Suppression: the conscious or semi-conscious postponing of dealing directly with painful affect.  This is to be contrasted with repression, which is an unconscious process.  For example, when Scarlett O’Hare in Gone With the Wind says she will think about that tomorrow, she is engaging in suppression, since she is consciously aware of the delay.  One of the ways of viewing psychoanalysis is that it encourages a patient to substitue more mature or adaptive defenses for more primitive or maladaptive ones.

Key Concepts and Terms:

    Personality Style = deeply ingrained, pervasive pattern of inner experience and interpersonal behavior that is relatively stable from adolescence through adulthood = “who we are.”    

   Personality Traits = characteristics of behaving, interacting, and reacting that define our personality style.  E.g. vulnerability to criticism, entitlement, and difficulty with empathy.

   Personality Disorder = collection of personality traits that is markedly deviant from the individual’s culture and that leads to conflict or chaos in multiple life areas, such as regulation of mood and impulses, ability to self-soothe, be in an intimate relationship, hold a job, tolerate criticism or rejection, or defer gratification.

Personality Disorders:

Cluster A (Avoidant):

    Paranoid: chronic pattern of suspicion and distrust of others WITHOUT JUSTIFICATION; interprets mistakes as malevolent; quick to anger; reluctant to confide in others because of fear information will be used to harm; doubts fidelity of significant other.  Must differentiate from schizophrenia and psychotic disorders; hint: paranoid personality disorder has no hallucinations or frank delusions.      Schizoid:  SOCIAL WITHDRAWAL and paucity of interpersonal relationships because of NO  DESIRE for this contact (v. anxiety disorders or avoidant personality disorder, in which social contact is desired, but FEARED).   NOT psychotic or bizarre; make excellent night watchmen and librarians.  HAS NOTHING TO DO WITH SCHIZOPHRENIA.     Schizotypal:  ODD and BIZARRE with strange beliefs (e.g. ideas of reference, paranoid ideation, overelaborate or stereotyped speech), lack of close friends because of strangeness or paranoia.  Maybe associated with schizophrenia.

Cluster B (Boisterous):

     Antisocial:  pervasive pattern of disregard for rights of others, beginning before age 16; classical behaviors:  firestarting, animal torture, criminality (stealing, assaulting); LACK OF REMORSE (no conscience) is a critical feature; usually “smooth operators,” pleasant and manipulative.  Rule out substance abuse, narcissistic p.d., major psychiatric disorder.  Estimated prevalence:  1-3% of men, 1% of women.      Borderline:  remember RABID:  Relationships are stormy; Affect is unstable and they have trouble self-soothing; Boundaries (interpersonal) are poorly defined and maintained; severe Identity disturbance (a chronic inner emptiness is the core of their problem); and they engage in self-Destructive behaviors (suicidal gestures more than attempts, as well as SELF-MUTILATION (wrist-cutting, burning is classic)).      Histrionic:  remember Scarlett O’Hara; craves attention, is inappropriately sexually seductive or provocative, has shallow and shifting emotions, uses physical appearance to draw attention to self, very impressionistic speech, theatrical and dramatic, considers relationships to be more intimate than they are.  Sometimes difficult to distinguish from borderline.      Narcissistic:  critical features are LACK OF EMPATHY for the suffering of others, SENSE OF ENTITLEMENT to things they haven’t earned, and extreme SENSITIVITY TO CRITICISM (as well as its flipside:  being overly dependent on external validation such as grades, money, public acclaim to feel whole).  Like the borderline, narcissists have profound inner emptiness.  Unlike the antisocial, narcissists usually have tremendous inner pain (the antisocial is usually cool, pleasant, and collected [unless caught!]).

Cluster C (Clinging):

     Avoidant:  avoids any relationship unless acceptance is guaranteed; feels inadequate or inept especially socially;  fears public ridicule or criticism (but unlike the narcissist would react with self-reproach, not rage).    Usually shy, quiet, and self-deprecating.  Need to differentiate from anxiety disorders (which have a high response rate to antidepressant medications).      Dependent:  fears being alone, will do anything to maintain a relationship that gives some support, even if unpleasant; cannot make everyday decisions without excessive advice from others; exaggerated fears of being unable to care for self.  Very similar to the borderline’s fear of abandonment (without the other disruptive features).      Obsessive-compulsive personality disorder:  rigid, obsessed with rules and regulations, often missing the “big picture”, may spend more time planning than doing; often judgmental, unpleasant people.  Can become paranoid under pressure.  Unlike OBSESSIVE-COMPULSIVE DISORDER, obsessive-compulsive PERSONALITY disorder has NO frank obsessions or compulsions (e.g. handwashing) and the behavior is EGO SYNTONIC (does not appear ridiculous or disturbing to the patient, as it does in O.C.D.).

DSM-IV Criteria for Narcissistic Personality Disorder

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)

(2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

(3) believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)

(4) requires excessive admiration

(5) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations

(6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends

(7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others

(8) is often envious of others or believes that others are envious of him or her

(9) shows arrogant, haughty behaviors or attitudes

– American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.

Optional Reading:

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), pp. 629 – 634:  gives a good overview and discussion of personality disorders in general; pp. 645-650:  good description of antisocial personality disorder; pp. 650-654:  borderline personality disorder; 658-661: narcissistic personality disorder (see below for sample criteria); 669-673:  obsessive compulsive personality disorder.

Personality Disorders and Culture: Clinical and Conceptual Interactions by Renato D. Alarcon, Edward F. Foulks, Mark Vakkur. June 1998, John Wiley & Sons, pp. 60-68:  “Personalities and Personality Disorders in World Politics”  explores Lenin, Hitler, and Stalin from a personality disorder perspective, highlighting the interplay between cultural and individual pathology.

Psychotherapy

Introduction

Psychodynamic versus Behavioral Psychotherapy

Indications for Psychotherapy

Cognitive Behavioral Therapy

:

Dialectical Behavioral Therapy

Introduction

– treatment of pychological distress through verbal and behavioral techniques; – known as “the talking cure“; – many different schools of psychotherapy, sometimes at war with each other; – listening, empathy, interpretation, and action may all be involved. – to discuss “psychotherapy” as an entity is about as difficult as discussing “medication”; there are perhaps as many types of psychotherapy as there are classes of medications, each of which may be indicated for a different population group..

At the core of any psychotherapy is an EMPATHIC RELATIONSHIP, the THERAPEUTIC ALLIANCE.  This is a unique type of relationship in which the therapist maintains a certain neutrality and objectivity while helping the patient explore and perhaps gain mastery or understanding over a problem or set of problems.

At the risk of oversimplification, psychotherapy can be divided into two broad schools:

PSYCHODYNAMIC PSYCHOTHERAPY:

– Relies on NATURALISTICmode of inquiry (see below).

– Observer is CRITICAL to the process and is entirely dependent on the ability of the observer to describe, articulate, and generalize from a particular case or set of cases.

– Skeptical of MEDICAL MODEL.

Most psychodynamic theorists eschew the idea of illness and health, per se, but instead believe that all of us fall somewhere on a spectrum (in other words, all of us are a little bit depressed, a little anxious, even a little psychotic and it is only the degree to which we are these things that defines whether we are patients or providers (or both)).

“Symptom” is only a hint of the real problem, of which the patient (and therapist) is initially unaware.  Like the tip of the iceberg, the patient’s presenting complaint (anxiety, depression, unhappiness) is simply the visible portion of a hidden, underlying conflict or problem that the therapist and patient can only discover with time.

“Blank screen” often used by therapist

–  minimal intervention.  The therapist may say very little, but instead listen, occasionally reformulating or interpreting what is reported by the patient.  The underlying belief is that the patient, through a process of free association, will stumble upon what is important given enough time.

– Process more important than content.   The symbolic meaning to a behavior or pattern of behavior is often viewed as more significant than the behavior itself.  For example, if a patient is repeatedly late to appointments, each time giving a different excuse, following the discussion of a particularly painful event in the patient’s life, the therapist might explore with the patient whether the tardiness represents unconscious anxiety and acting out toward the therapist.

Symptom reduction seen as superficial, not a goal in itself. Since symptoms are seen as the manifestation of a deeper underlying problem, unless that problem itself is addressed, psychodynamic therapists feel that symptom reduction will not be helpful or may even get in the way of probing the underlying problem, much as giving a febrile patient aspirin may lower the body temperature but do nothing to fight the underlying infection, and may even mask a worsening of the illness.

All behavior seen as symbolic:  “nothing happens by accident.”  Refer again to the example of being late.  Freud posited that there is no such thing as an innocent slip of the tongue, but that these represent unconscious thoughts, impulses, and feelings bubbling to the surface.

COGNITIVE-BEHAVIORAL PSYCHOTHERAPY (

see below)

– Relies on EMPIRICAL mode of inquiry.

– Tends to be more QUANTITATIVE than QUALITATIVE.

– Endorses the MEDICAL MODEL.

Symptom reduction seen as an end in itself, the goal of therapy.  Insight or understanding is seen as either secondary or irrelevant.

Behavior taken at face value; speculation about underlying meanings or unconscious motives is discouraged.

Focuses on things that can be measured and observed (behaviors, reported mood) and avoids theoretical abstractions and speculations (e.g., avoids speculative but colorful descriptions  such as “The patient’s libidinal urges seem in conflict with her punitive superego, most likely a product of a harsh, controlling mother whose own libidinal urges were similarly prevented from discharge perhaps by strong repression and reaction formation.” instead sticking to what can be observed:  “The patient reports feeling very guilty about masturbation and becomes anxious and constricted in affect when discussing this.  She thinks this may have something to do with her mother, whom the patient describes as a `strict, religious woman.'”).

Types of Psychotherapy:

    Most therapy can be grouped into three broad categories:

Psychoanalysis          Insight-Oriented          Supportive

Psychoanalysis:

– based on the work of Freud and later theorists; – objective is to make the unconscious conscious via free association; – “blank screen” often used by the analyst, who says very little, often remains out of sight of the patient (who is supine), and thereby encourages a transference. – one must receive before giving; analysts must undergo analysis themselves. – 3-5 sessions per week over a period of 3-5 years; cost is roughly $20,000-$30,000 per year.

Insight-Oriented Psychotherapy

– any type of therapy that attempts to give patients a better understanding of themselves and their inner conflicts and drives; – referred to as “introspective psychotherapy” in Stoudemire’s text; – anxiety may increase or worsen early in the therapy; – usually weekly over a period of years.

Supportive Psychotherapy:

– objective:  immediate symptom relief or crisis management without necessarily probing deeper, underlying causes of symptoms; – means:  problem-solving, social skills training, supportive group therapy. – financial burden is minimal. – weekly-monthly over months or until problem is solved.

Indications for Psychotherapy :

     This is actually a very controversial area and is based on the theoretical background of the therapist, the financial assets of the patient, and the philosophy (and financial resources) of the third party payer.  Several principles are in conflict:

AUTONOMY v. JUSTICE:  The principle of autonomy holds that as much as possible, a patient should be allowed to have as much input into and control over decisions regarding treatment.  According to this principle, a patient who requests psychotherapy should be able to receive it.  However, the principle of justice dictates that one should attempt to allocate limited financial and medical resources (including the therapist’s time) to the most patients, hopefully triaging to those who are most in need.  These two conflict, especially if there is more demand for a therapist’s time than there is a supply of therapist hours.  In the world of managed care, this has become particularly thorny, since many managed care plans limit reimbursement for therapy.

SPECTRUM v. MEDICAL MODEL:  In the spectrum model, we’re all a little neurotic or whatever, so could theoretically all benefit from therapy, some more than others.  In the medical model, however, one likes to first make a diagnosis (answering the question, is this patient sick?) and the clinician and patient may disagree over this.  For example, if a patient with a cold demands that you give him antibiotics, you as a clinician must first make an assessment to see if the patient has a condition for which antibiotic treatment would be appropriate, such as a bacterial sinusitis.  If not, you cannot ethically prescribe the medication.  If one uses the medical model to view psychotherapy as one of many possible interventions, then the clinician is obligated to diagnose appropriately and match the patient to treatment.

THIRD PARTY REIMBURSEMENT?  This is a very thorny issue.  In the past, psychotherapy was often reimbursed at a 50% rate, no questions asked, for at least a certain number of sessions per year.  Today, managed care companies have become much more intrusive, requiring extensive documentation about indications for therapy, goals of therapy, and expected outcome and length of therapy.  When granted, reimbursement is often very limited and finite.  There are now three potential decision-makers:  the patient; the clinician; and the third party payer.  Of course, for affluent patients or those with access to a therapist in the public sector, the decision to treat is independent of the decision to reimburse, but for many patients, failure to reimburse, at least partially, means the patient could not afford therapy.

Does Psychotherapy Work?

        The answer to this question depends on how it is posed and what you measure:

Spectrum Model:  This model avoids terms such as “normal” or “illness,” instead viewing all of us as lying somewhere on a spectrum between different extremes (e.g., anxious, depressed, angry, extroverted, neurotic).  This model also assumes that one can understand the extremes of mental phenomena (such as psychosis) by improving self-awareness.  Many adherents of the spectrum model use terms such as client and provider instead of patient and doctor or therapist.     According to adherents of this model, subjective reporting by patients of relief or increased understanding is enough to prove the efficacy of an intervention.  If a patient states he is improved, then the therapy is a success.  There might be little or no attempt to account for possible sources of bias, such as survivorship (those who continued therapy might be self-selected, higher functioning patients better able to tolerate the process, for example), spontaneous remission, or comparison with other interventions (there are often no control groups).

Medical model:  This model focuses on categorizing illnesses, defining them by clusters of signs and symptoms, and makes a demarcation between healthy and pathological.  It tends to emphasize diagnosis, treatment, outcome, and uses the same terminology when viewing mental phenomena as it uses when approaching physical illness.  Adherents of this model would argue that a schizophrenic is markedly different from a non-schizophrenic, for example, that some chemical, biological, or other abnormality distinguishes his brain from those who do not suffer from the illness.  Medical model proponents tend to use terms such as patient and therapist.     To prove efficacy, they believe symptom relief must usually be operationalized in some way (clinician evaluation with a quantitative scoring system, patient self-report using a standardized instrument) and “success” or “failure” must be predefined categorically (e.g., a 50% reduction in depressive symptoms from baseline).  Adherents of the medical model may subject psychotherapy to the same scrutiny given a new medication:  is the therapy as effective as some other intervention or none at all (control group).  Does it alter the natural course of the disease?

Naturalistic v. Empirical Approach

 Some understanding of these two different ways of approaching and studying reality is necessary to understanding some of the tensions in the field of psychotherapy, as well as some of the difficulty inherent in getting adherents of one mode or the other to communicate with each other in a meaningful way.

Naturalistic

Mode of Inquiry:

QualitativeCases emphasized over studies – Observer is critical:  cogency of ideas, how eloquently they are expressed, how they relate to consensus views in the field/discipline determines “truth” – Spectrum model favored – no formal effort to control for bias (control groups, replication, blinding, etc.)

Empirical

Approach:

Quantitative:  attempts to operationalize, categorize, dichotomize variables, e.g., “depression” “response” – population-based, usually with controls – speculation by observer discouraged: “show me the data”minimizing bias is a priority – derived from

MEDICAL MODEL (diagnosis, treatment, response) – proof lies in statistical tests of difference between treatment and control group – Relatively new approach in psychotherapy; first controlled trial showing efficacy of therapy over placebo was in 1972.

Does psychotherapy work?

Naturalistic response:

– impossible to answer conclusively but many patients report subjective relief; – benefits may be intangible and difficult to measure, e.g., improved self-awareness, improved insight into repeating patterns of behavior

Empirical Response:

Many trials have demonstrated efficacy of several types of therapy: – CBT in depression and anxiety – exposure therapy in phobias – interpersonal therapy in depression Important negative results: – Boston Collaborative Study:  failure of psychoanalysis in treatment of schizophrenia

Cognitive-Behavioral Therapy (CBT):

    Cognitive-behavioral therapy is perhaps the first psychotherapy that was successfully shown to be at least as effective as medication (imipramine) (and more effective than placebo) in treating moderate depression.  It has since been shown to be effective in treating a wide array of mood disorders, including anxiety and depression, and has been used successfully in other mental disorders.     The basis of cognitive-behavioral therapy is that at the assumption that at the heart of any mood disorder is a distortion in cognition (referred to as an automatic negative thought) such as “I’m a failure; nothing I try works out.” which leads to a distortion in affect (mood).  The idea, simplistic as it sounds, has been shown to be effective:  disrupt the negative distortions with realistic interpretations (“Although I have failed at some things, I have also had successes, and on balance have had more successes than failures.”) based on an empirical weighting of the evidence for and against the negative thought.  As you can imagine, the realistic interpretation has a less negative or painful affect associated with it and over time, the cycle of distortion in cognition and mood can be prevented.     Note that CBT is not simply “positive thinking” a la Stewart Smiley (“I’m good enough, I’m smart enough, and gosh darn it, people like me.”)  Instead, the emphasis is on REALISM – seeing the world as it really is.  CBT posits that depressed patients have distortions of their view of themselves (“I’m no good.”), their relationships (“Everyone hates me.”), and the future (“There’s no hope things will ever get better.”).    Each of these thoughts is a distortion, but each has an element of truth.  (We all have faults, there are probably some people who hate us, and there is a chance things may at times be worse in the future than they are today.)  However, in depressed states, the person is unable to balance this negative view against positive conflicting evidence.     Note that CBT’s goal is symptom reduction through disruption of distorted cognitions – less distortion of affect.  The chief complaint taken at face value and the therapist and patient form a therapeutic alliance and through a very active collaborative empiricism between therapist and patient, try to reduce depressed or anxious affect.  This will often include homework assignments, keeping a log, and a much more structured type of therapy than is true in many dynamically oriented approaches.  Many patients will resist this type of therapy because it requires a lot of activity on their part and may strike them initially as too simplistic.  Also, the therapy is usually short-term, often only several weeks in length, although it can go longer if necessary.     According to Aaron Beck and early cognitive-behavioral therapists, the unconscious, underlying “meaning” of symptoms is seen as irrelevant or at best unnecessary for successful outcome.

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