Using Diagnoses to Improve Treatment Robert M. Gordon, Ph.D. ABPP J&K Seminar 2013. 1. How does diagnoses (DSM, ICD, PDM) affect treatment ? 2. How to tailor treatment to the diagnoses of personality organization and personality patterns . . My Eclectic Background.
1. How does diagnoses (DSM, ICD, PDM) affect treatment?
2. How to tailor treatment to the diagnoses of personality organization and personality patterns.
Studies with PTSD support the idea that the ventromedial prefrontal cortex is an important component for reactivating past emotional associations and events, mediating pathogenesis of PTSD.
Patients with borderline personality disorder had significantly lower density of grey matter (the brain's working tissue) in the anterior cingulate cortex, an area (yellow right) that regulates the brain's fear hub (amygdala-yellow left).
MRI scan data shows the difference between patients and controls.
Patients with borderline personality disorder had significantly higher density of grey matter in the brain's fear hub, the amygdala (red areas). MRI scan data shows where patients and controls differed.
Emotions and attachment drives in mammals are similar and evolved for functional reasons. They may be affected by thoughts, but they are not created by them.
Damasio, et al., 2002
Panksepp, J. (2003).
Science, Oct 10th.
Herman & Panksepp, 1979
Attachment Security in Infancy and Early Adulthood: A Twenty-Year Longitudinal Study.Walters, E. Merrick., S.; Treboux, D.; Crowell, J. and Albersheim, L. (2000), Child Development.
Experimental Test of Unconscious Transference
Kernberg’s Differentiation of Personality Organization That Preceded the PDM
Identity +integrated - diffused -
Defensive +higher -primitive -
Reality + + -
No integrated concept of self
No integrated concept of significant others
– Projective identification
– Omnipotent control
Variable Reality Testing
Healthy Defense Mechanisms
Isolation of Affect
Idealization / Devaluation
Omnipotence and Omnipotent control
Splitting of self-image or image of others
Personality Disorders P Axis
P103. Psychopathic (Antisocial) Personality Disorder P103.1 Passive/Parasitic: “con artist” P103.2 Aggressive: explosive, predatory, often violent
P104. Narcissistic Personality Disorders P104.1 Arrogant/Entitled: devalues, vain, commanding P104.2 Depressed/Depleted: idealizing, envious, easily hurt
The Doberman threw himself out the second-story window after he realized the family had indeed named him “Binky.”
P105. Sadistic and Sadomasochistic Personality Disorders P105.1 Intermediate Manifestation: Sadomasochistic Personality Disorders:alternate between attacking and feeling insulted
P106. Masochistic (Self-Defeating) Personality Disorders P106.1 Moral Masochistic: self-esteem depends on suffering P106.2 Relational Masochistic: suffer for sake of relationship
“Penny for your thoughts, Arnold!”
P107. Depressive Personality Disorders P107.1 Introjective: self-critical, self-worth P107.2 Anaclitic: concern with attachment issues
Depressive Personality Disorder
Lodge owner Harold Shuffle saw only the negative side of things.
“My brother, Tilford, had trouble with hemorrhoids and he never did anything like this!”
“You’re gonna spoil that dog, Annie!”
“It’s almost like they do it on purpose, isn’t it, Fred?!”
P112. Obsessive-Compulsive Personality Disorders P112.1 Obsessive: Self-esteem depends on thinking,ruminative P112.2 Compulsive: Self-esteem depends on doing, meticulous
Once again Elliot Zambini’s tidiness ruins the act.
P113. Hysterical (Histrionic) Personality Disorders P113.1 Inhibited: reserved, naiveté, somatization P113.2 Demonstrative or Flamboyant: seductive, dramatic
Implications for TreatmentDepressive Personality Disorder(Most Common type in Clinical Situations)P107.1 Introjective: self-critical, preoccupied with self-worth, guilt P107.2 Anaclitic: concerned with attachment issues, relatedness, trust, inadequacy (May combine with dependent or narcissistic personality disorder)
focus more on using insight into past traumas that need to be worked through.
You will find that your greater empathy will be felt by your patient, and this can greatly improve any treatment.