Academic literature on the topic 'Countertransference; Psychodynamic Diagnostic Manual-2; personality disorders'

We thank Andrew Shaw and colleagues for their recent paper¹&nbsp;in&nbsp;<em>Bipolar Disorders</em>, highlighting that the effective treatment of patients with bipolar disorder requires a good therapeutic alliance, which is related to the clinicians' countertransference reactions and their management. The authors suggest that the integration of a psychodynamic approach into the biological paradigm in psychiatry might be helpful to increase countertransference awareness in clinicians, and potentially improving dyadic communication, resolution of alliance ruptures, and treatment adherence. They also mention that although the theoretical literature on countertransference is well developed, no good empirical studies exist that investigate the countertransferential responses experienced by mental health clinicians involved in the care of individuals during acute phases of bipolar disorder. We would, however, like to add some examples of empirical evidence for the use (and further study) of the countertransference in the clinical care of these patients. A substantial and growing body of research exists for countertransference indicating that patients with the same diagnosis tend to elicit specific and similar countertransferential responses. For example, a study²&nbsp;assessing psychiatrists and senior psychiatry residents' subjective experiences of new patients at the first clinical diagnostic interview found that clinicians experienced significantly higher levels of tension, impotence, difficulty in attunement, and disconfirmation with patients diagnosed with bipolar I disorder (<em>n</em>&nbsp;=&nbsp;59 with current episode manic or mixed and with no comorbid cluster A or B personality disorder) than with patients with unipolar depressive and anxiety. Conversely, clinicians had fewer difficulties in attunement with bipolar than with schizophrenic patients, as well as greater engagement with and less feeling of being disconfirmed by patients with bipolar than cluster B personality-disordered patients. Similarly, a recent systematic review³&nbsp;on patient personality and therapist reactions in individual psychotherapy settings also found that patients who share the same personality features or disorders tend to evoke specific and similar patterns of countertransference response in their therapists. Despite the studies included in the review excluded patients with psychotic symptoms or disorder or psychopathology that could have complicated differentiation between personality traits and psychological states, the fact that persons with bipolar disorder have high rates of coexisting psychiatric conditions, including, in more than a third of cases, personality disorders, leads us to hypothesize that countertransference responses toward bipolar patients might be coherently and predictably related also to patient's personality characteristics, at least during the euthymic and depressive phases. Furthermore, it is likely that bipolar disorders, due to its core features&mdash;such as emotional dysregulation, psychotic symptoms, recurrence of illnes episodes, high rates of self-injury, and presence of negative feelings due to prior ineffective treatments for misdiagnosis, along with the above mentioned high rates of comorbidity and personality issues&mdash;might evoke even more&nbsp;<em>complex</em>&nbsp;and&nbsp;<em>intense</em>&nbsp;countertransference reactions in clinical work, especially during episodes of mixed hypomania, mania or depression with psychotic symptoms. This would be particularly important considering that findings from a recent meta-analysis indicate that successful countertransference management is related to better psychotherapy outcomes (<em>r&nbsp;</em>=&nbsp;0.39).³ Finally, it should be mentioned that also the existence of specific and mostly adverse countertransferential reactions towards suicidal patients has increasing empirical support. For example, a pilot study⁴&nbsp;involving adults psychiatrically hospitalized for suicide risk (including 11 subjects with diagnosis of bipolar disorder type I, II, or not otherwise specified) found that clinicians' conflicting emotional combination of distress and hopefulness (i.e., low hope but low distress or high hope but high distress) to high-risk patients predicted short-term post-discharge suicide outcomes, independent of traditional risk factors such as suicidal ideation, depression, and entrapment. Another study⁵&nbsp;involving patients with various diagnoses (including 47 patients with bipolar disorder) found that the relationship between clinicians' negative countertransference response at the first psychotherapeutic or psychopharmacological session and patients' suicidal ideation one month later was mediated by the patients' perception of the therapeutic alliance. These findings are particularly important in light of the high incidence of death by suicide (10&ndash;30-fold higher than in non-psychiatric population) among persons with bipolar disorder. Overall, the existing empirical evidence concerning countertransference indicates the potential clinical value of identifying and managing such responses, and the research base, while modest, may also be larger than realized. We agree with Shaw et al. that there would be value in adding training about the concepts to the preparation for practice across settings (including emergency rooms, psychiatric wards, and outpatients facilities) where people with bipolar often get services. Implementing evidence-based assessment and treatment is essential to reduce patients' burden at an individual, societal and public health levels. Because both diagnostic and treatment processes take place inside the patient&ndash;clinician relationship, reintroducing humanistic and emotional dynamics to them (e.g., the range of affective, cognitive, and behavioral responses the members of the care dyad have toward each other) may lead to better patients' acceptance, uptake, and adherence of the treatment, mediating processes that in turn improve outcomes.

The article analyzes psychodynamic clinical models focused on clinical case formulation and treatment planning, offers practitioners empirically grounded and clinically validated alternatives to such personality maps as the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). The PDM-2 diagnostic model aims to provide a systematic description of healthy functioning and personality disorders; individual profiles of mental functioning (including patterns of relationships with other people, understanding and expressing feelings, overcoming stress and anxiety, regulating impulses, observing one's own emotions and behavior and forming moral judgments, etc.); as well as symptom patterns, including differences in each person's subjective experience of symptoms and in the subjective experiences of treating therapists.

Background: Depressive disorders in adolescence are among the most challenging clinical syndromes to diagnostically identify and treat in psychotherapy. The Psychodynamic Diagnostic Manual, Second Edition (PDM-2) proposes an integration between nomothetic knowledge and an idiographic understanding of adolescent patients suffering from depression to promote a person-centered approach. This single-case study was aimed at describing and discussing the clinical value of an accurate diagnostic assessment within the PDM-2 framework. Method: Albert, a 16-year-old adolescent with a DSM-5 diagnosis of major depressive disorder, was assessed using instruments from various perspectives: the Structured Clinical Interview for DSM-5; the Psychodynamic Chart-Adolescent of the PDM-2, and other clinician-report instruments; and the Shedler–Westen Assessment Procedure for Adolescents and Defense Mechanisms Rating Scale Q-sort, coded by external observers. Results: Albert’s assessment revealed impairments in various mental capacities, especially in regulating self-esteem. He presented a borderline personality organization at a high level and an emerging narcissistic personality syndrome. Conclusions: The case discussion showed the importance of providing clinically meaningful assessments to plan for effective treatments in youth populations. Especially, it is necessary to understand the adolescent’s unique characteristics in terms of mental and personality functioning and consider the developmental trajectories and adaptation processes that characterize this specific developmental period.

Theories of both Personality Organization (PO) and Bioenergetic Character Analysis (BA) are born from Psychoanalysis. Due to the influence of a medical model of understanding and treating mental health disorders PO and BA have been taught and developed separately. This article explains PO to the Bioenergetic audience, via the Psychodynamic Diagnostic Manual, Second Edition (PDM-2), and proposes a circumplex model for how to integrate the two theories. A psychoanalytic understanding of how people can organize their sense of self in a borderline or psychotic way is described, in contrast to a medical model of viewing borderline and psychotic experiences as discreet disorders. A concept of the self is defined and provides the basis for the integration of theories. Dynamics and traits for borderline and psychotic organization are described and contrasted so that a clinician can identify the difference between the two. A case study is presented to demonstrate how the integration of the two theories looks in practice.

This study assessed the concurrent validity of the Psychodynamic Diagnostic Manual (PDM- 2, APO, 2017) personality syndromes (P Axis) formulation by factor analyzing the countertransference expectation ratings of 412 clinicians of the PDM-2 personality syndromes. This study compared the resulting factor structures of those ratings to some of the leading taxonomies of personality disorders i.e., DSM-5&rsquo;s three personality clusters; levels of personality organization model of Kernberg (1984); internalizing, externalizing, and borderline-dysregulated personality dimensions of the Shedler-Westen Assessment Procedure-II (Westen, Shedler, Bradley, &amp; DeFife, 2012), and the DSM-5&rsquo;s alternative model (American Psychiatric Association, 2013) which uses the Personality Psychopathology Five disorder trait specifiers: negative affectivity, detachment, antagonism, disinhibition, and psychoticism. The results found good concurrent validity for the new PDM-2, P Axis with these leading diagnostic taxonomies. However, it appears that understanding the complexity of personality is not a matter of adding up personality traits as suggested by the DSM-5 Alternative Model.

Depressive disorders in adolescence pose unique challenges for assessment and treatment, particularly due to their high comorbidity with various personality disorders. Moreover, young depressed patients may elicit very intense and difficult-to-manage emotional responses in therapists (in this context, countertransference). This study aimed at empirically identifying specific personality disorders (or subtypes) among adolescents with depressive pathology and exploring distinct countertransference patterns emerging in their psychotherapy: 100 adolescents (58 with depressive disorders; 42 with other clinical conditions) were assessed by their respective clinicians (n=100) using the psychodiagnostic chart-adolescent of the Psychodynamic Diagnostic Manual (PDM) - second edition, and the therapist response questionnaire for adolescents. Results showed that depressed adolescent patients exhibited marked traits of four personality subtypes (i.e., depressive, anxious-avoidant, narcissistic, and borderline) characterized by different levels of mental functioning and personality organization. These subtypes were predictably related to specific clinicians’ emotional responses, even when controlling for the intensity of depressive symptomatology. Patients with depressive or anxious-avoidant personality subtypes evoked more positive countertransference responses, whereas patients with narcissistic or borderline subtypes elicited strong and hard-to-face emotional responses in therapists. Consistent with the next edition of the PDM, the study emphasizes the importance of comprehensive psychodynamic assessment in the developmental age, which frames depressive disorders in the context of accurate emerging personality and mental functioning profiles. This approach, which also relies heavily on the clinician’s subjective experience in therapy, provides crucial information on how to specifically tailor interventions that more effectively meet the needs of adolescents with these heterogeneous and complex clinical conditions.

What do typical practitioners think of a psychodynamic taxonomy? A sample of mental health practitioners from a wide range of educational backgrounds and theoretical orientations (N= 438) were asked to rate the utility of the Psychodynamic Diagnostic Manual&rsquo;s taxonomy with a recently seen patient. Our survey indicated that the percent rated as &ldquo;helpful &ndash; very helpful&rdquo; in understanding their patient for each diagnostic taxon were: level of personality organization 75%, personality disorders 62%, mental functioning 67%, and cultural/contextual dimension 41%. Only 30.5% rated symptoms as &ldquo;helpful-very helpful&rdquo; in understanding their patient. All differences were statistically significant. These results suggest that our earlier findings with 61, mainly psychodynamic assessment experts are likely to be generalizable to most non-psychodynamic practitioners. The results suggest that a useful taxonomy should include the psychodynamic categories: personality organization (healthy, neurotic, borderline, psychotic), personality syndromes (ex: schizoid, histrionic, narcissistic, etc.), and mental functioning (ex: capacity for intimacy, defensive level, self observing capacity, etc.) in addition to manifest symptoms. Our results are also generalizable to the forth coming PDM-2, which has the same diagnostic categories as the PDM. We recommend teaching the PDM/PDM-2 along with the ICD and DSM.

Operationalizing the Psychodynamic Diagnostic Manual: A Preliminary Study of the Psychodiagnostic Chart (PDC) 1 Abstract: The Psychodiagnostic Chart (PDC) operationalizes the Psychodynamic Diagnostic Manual (PDM) Adult section. We collected 104 PDC cases from 15 psychologists who are MMPI-2 experts. We found very good construct validity when compared to MMPI-2s, the Karolinska Psychodynamic Profile (KAPP) and the Operationalized Psychodynamic Diagnosis (OPD) Psychic Structure/Mental Functioning Scales. We found very good reliability for the 73cases with a two week test-retest of the PDC. Additionally, 61 psychologists were recruited from listservs and asked to use the PDC on a recent client; 84% rated Level of Personality Organization as &ldquo;helpful-very helpful&rdquo; in understanding their patients. There was also similar support for the Personality Patterns or Disorders, and Mental Functioning dimensions. In comparison only 31% rated the ICD or DSM symptoms as &ldquo;helpful-very helpful&rdquo; in understanding 1 Part of these findings were presented at the American Psychoanalytic Association National Meeting at New York Discussion on January 17, 2013, &ldquo;Research in Psychoanalysis: Creating the Psychodynamic Diagnostic Manual, Version 2 (PDM-2): Conceptual and Empirical Issues.&rdquo; The session was co-organized by the American Psychoanalytic Association and the Psychodynamic Psychoanalytic Research Society. The IRBs of Muhlenberg College and Chestnut Hill College determined that this project adequately protects the welfare, rights, and privacy of human subjects and voted unanimously to approve it. OPERATIONALIZING THE PDM 2 their patient. The PDC may be used for diagnoses, treatment formulations, progress reports, and outcome assessment, as well as for empirical research on the PDM.&nbsp;

The Psychodynamic Diagnostic Manual (PDM,&nbsp;2006) was developed to add a contrasting, person-centered perspective to the conceptualization and diagnosis of psychological dysfunction in traditional diagnostic systems (i.e., the International Classification of Diseases, the Diagnostic and Statistical Manual of Mental Disorders). In addition to considering symptom patterns (Axis S), the PDM&mdash;and its recently updated version, PDM-2 (Lingiardi &amp; McWilliams, 2017)&mdash;enables clinicians to describe overall level of personality organization, specific personality patterns and syndromes (Axis P), and the patient&rsquo;s mental functioning in a broad array of domains, including strengths and vulnerabilities (Axis M). This article discusses scale development, structure, format, scoring, and interpretation of the Psychodiagnostic Chart (PDC; Gordon &amp; Bornstein, 2012, 2015), an instrument for coding PDM/PDM-2 data. We evaluate the psychometric soundness of the PDC with respect to internal consistency, interrater and retest reliability, and relations to external criteria. Following a review of evidence bearing on the construct validity of the PDC and clinical utility of constructs assessed by the measure, we discuss the instrument&rsquo;s strengths and limitations, and offer suggestions for continued work in this area.

For well over a century, since the publication of Freud’s seminal “On Narcissism” in 1914, pathological narcissism was widely considered to be a disorder of the “character” or the personality. This culminated in the 1980s and 1990s with the inclusion of Narcissistic Personality Disorder (NPD) in the third, fourth and text revision editions of the Diagnostic and statistical Manual (DSM). Cold Therapy is based on two premises: (1) That narcissistic disorders are actually forms of complex post-traumatic conditions and not disorders of the personality; and (2) That narcissists are the outcomes of arrested development and attachment dysfunctions. Consequently, Cold Therapy borrows techniques from child psychology and from treatment modalities used to deal with PTSD. Cold Therapy consists of the re-traumatization of the narcissistic client in a hostile, non-holding environment which resembles the ambience of the original trauma. The adult patient successfully tackles this second round of hurt and thus resolves early childhood conflicts and achieves closure rendering his now maladaptive narcissistic defenses redundant, unnecessary, and obsolete. In the process, both transference and countertransference are encouraged in order to most closely recreate the roles of the original “perpetrator” of abuse (abuser) and his or her victim (the patient or client). Cold Therapy makes use of proprietary techniques such as erasure (suppressing the client’s speech and free expression and gaining clinical information and insights from his reactions to being so stifled). Other techniques include: grandiosity reframing, guided imagery, negative iteration, other-scoring, happiness map, mirroring, escalation, role play, assimilative confabulation, hyper vigilant referencing, and re-parenting.

This chapter gives a brief history of how personality disorders (PDs) have been viewed and treated in both individual and group psychotherapy. Cognitive-behavioral group treatments have led to the development of structured programs, some of them theoretically eclectic, that treat homogenously diagnostic groups of PDs. However, before, during, and after the development of these programs, psychodynamic and existentially oriented groups have continued to treat personality traits and disorders in unstructured, diagnostically heterogeneous groups. This chapter presents a transtheoretical “friendly” psychodynamic model of group interventions. It employs the unique properties of groups and group strategies in the treatment of maladaptive personality traits and disorders, which are illustrated using clinical vignettes. Groups offer a wider range of intervention opportunities than individual therapy. Psychodynamic process-oriented group therapy focuses upon therapist-induced, group patient examination of here-and-now interactional processes. Groups are especially useful in treating patients with PDs who have dysfunctional needs to be other-validated instead of self-validating. Groups also facilitate the capacity to be psychologically present and empathize with others. They offer opportunities to practice repairing damaged relationships, as well as to develop new, meaningful, and rewarding interpersonal relationships. The importance of using countertransference to facilitate change and avoiding its pitfalls, in here-and-now groups, is also described. To further operationalize the use of the unique properties of groups, a toolbox of specific verbal interventions and a list of strategic group therapy tips are offered. In many ways, this chapter is a “How-to Manual” for conducting process-oriented group therapy with patients who have PDs.