PSYCHIATRY II
Psychopathology
Psychopathology refers to problematic patterns
of thought, feeling, and behavior
Disrupted functioning at home, work,
and in the persons social life
Patterns that cause distress in the
person or in others
Psychopathology literally means
sickness of the mind
Psychopathology varies between and within cultures
Understanding Psychopathology
What is abnormal?
The definition of ABNORMAL used in
DSM-IV-TR (Diagnostic and Statistical Manual of
Mental Disorders, 4th edition)
Abnormal describes behavioral,
emotional, or cognitive dysfunctions that are
unexpected in their cultural context and
associated with personal distress or substantial
impairment in functioning.
Psychoanalysis
Freud
Office-based psychiatry
Drive theory
Structural model of the mind (ego, id,
superego)
Unconscious
Psychoanalysis in practice
Free association
Transference
Resistance
Psychoanalytic Theory of Personality
Sigmund Freud
Components of Personality
Defense mechanisms
Psychosexual stages
Sigmund Freud
(1856-1939)
Jewish background, though avowed
atheist
Lived in Vienna until Nazi occupation in
1938
Had medical background- wanted to do
neurophysiological research
Private practice with specialty in
neurology
Private practice in nervous and brain
disorders
Early 1900s published many works--
Interpretation of Dreams (1900)
The Psychopathology of Everyday
Life (1901)
1905 concept of sexual drive being
most powerful personality
component
1906 Psychoanalytic Society formed
Many works burned in Nazi occupation
(starting 1933)
Left Austria, fled to England 1938
Died of jaw cancer 1939
Freud's Path
How did a medically trained neurologist come
to describe this particular theory of the mind?
State of art of psychological care in the 19th
century
Freudian problems in Victorian context
Basic Principles
Pleasure Principle: constant drive to reduce
tension thru expression of instinctual urges
Mind is a dynamic (changing/active) process
based on the Pleasure Principle
Libidinal (sexual, aggressive) instincts drive
people
In children libido isnt purely sexual,
its pleasure thru sensations (oral, anal
gratification, etc.)
Behaviors result from conflicts:
Between instinctual libidinal drives
(aggression, sex) and efforts to repress
them from consciousness)
More Basic Principles
The Cathartic Method
Primary vs. Secondary Gain
Transference and Countertransference
Ego-Syntonic vs. Ego-Dystonic
Cathartic Method
Therapy benefits thru release of pent-up
tensions, catharsis
Some inherent value in the talking cure-
being able to unload, or get stuff off your
mind
Primary vs. Secondary Gain
Primary Gain
symptoms serve a purpose: they function to
decrease intra-psychic conflict and distress by
keeping such unpleasantries from conscious
awareness
Example:
Comfort of being taken care of thru assumption
of the sick role
Conversion Disorder- psychological conflict is
converted into physical symptom that allows
for more acceptable expression of an
unacceptable wish
Secondary Gain
Actual or external advantages that patients
gain from their symptoms, or from being ill:
Relief from duties, responsibilities
(work)
Prescription drugs (ex. Opiates)
Manipulation in relationships
Deferring of legal proceedings, exams
Food, shelter, money (financial gain)
Transference
Displacement (false attribution) of feelings,
attitudes, behavioral expectations and
attributes from important childhood
relationships to current ones
Traditionally refers to what the patient projects
onto the therapist, but applies to other
situations as well- ex. relationships in general
Aka emotional baggage
Occurs unconsciously (persons unaware
theyre doing it)
Countertransference
Feelings toward another are based on your own
past relationships/ experiences.
Traditionally refers to the therapist projecting
their own feelings (issues, emotional
baggage) onto their patient
Ego-syntonic vs. dystonic
Neurotic symptoms are distressing to the
person, or ego-dystonic
Vs.
Character pathology, which is ego-syntonic;
patient doesnt perceive as a problem; only
problematic in dealings with others/ external
world
Two Freudian Schemata
The importance of theories of the mind-a
framework in which to understand presenting
problems.
Topographic theory
Structural theory
Topographical Model
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Freuds first model of psychopathology
Division of the mind into three different layers
of consciousness:
Unconscious
Preconscious
Conscious
Conscious (cs)-the part of the mind that
interacts with the external world, and which
can reflect on itself.
Pre-conscious (pcs)-the part of the mind in
which thoughts, feelings and ideas are being
prepared for outward expression. Can be
brought to attention.
Unconscious (ucs) governed by the pleasure
principle. The cauldron of wishes, desires and
fears that make up the bulk of our mind.
3 Levels of Awareness
1. Conscious
Current contents of your mind that you actively
think of
What we call working memory
Easily accessed all the time
Unconscious
Contains repressed thoughts and feelings
Unconscious shows itself in:
Dreams
Hypnosis
Parapraxes (Freudian slips)
Driven by Primary Process Thinking
Primary Process Thinking
Not cause-effect; illogical; fantasy
Only concern is immediate gratification (drive
satisfaction)
Does not take reality into account
Seen in dreams, during hypnosis, some forms
of psychosis, young children, psychoanalytic
psychotherapy
Freudian Slips (Parapraxes)
A slip of the tongue
Errors of speech or hearing that reveal ones
true but unconscious feelings
2. Preconscious
Contents of the mind you are not currently
aware of
Thoughts, memories, knowledge, wishes,
feelings
Available for easy access when needed (cues)
3. Unconscious
Contents kept out of conscious awareness
Not accessible at all
Processes that actively keep these thoughts
from awareness
Freudian Components of Personality
Id
Resides completely at the unconscious level
Acts under the pleasure principle
immediate gratification, not willing to
compromise
Generates all of the personalitys
energy
The home of our sexual and aggressive urges.
Fully unconscious, although the unconscious is
not fully id.
the dark inaccessible part of our
personality...We approach the id with
analogies: we call it chaos, a cauldron full of
seething excitation.
Home of instinctual Drives
I want it and I want it NOW
Completely unconscious
Present at birth
Operates on the Pleasure Principle and
employs Primary Process Thinking
To Review:
Pleasure Principle: constant drive to reduce
tension thru expression of instinctual urges
Primary Process Thinking: Not cause-effect;
illogical; fantasy; only concern is immediate
gratification (drive satisfaction)
Superego
The moralist and idealistic part of the
personality
Resides in preconscious
Operates on ideal principle
Begins forming at 4-5 yrs of age
initially formed form environment and
others (society, family etc)
Internalized conventions and morals
Essentially your conscience
Internalized morals/values- sense of right and
wrong
Suppresses instinctual drives of ID (thru guilt
and shame) and serves as the moral
conscience
Largely unconscious, but has conscious
component
Develops with socialization, and thru
identification with same-sex parent (via
introjection) at the resolution of the Oedipal
Conflict
Introjection: absorbing rules for behavior from
role models
Ego
Resides in all levels of
awareness
Operates under reality
principle
Attempts negotiation between Id
and Superego to satisfy both
realistically
Created by the ID to help it
interface with external reality
Mediates between the ID,
Superego, and reality
Partly conscious
Uses Secondary Process
Thinking:
Logical, rational
How does the ego develop?
Ego development occurs as result of:
meeting basic needs
identification with others
learning
mastery of developmental tasks
effective problem-solving
successful coping
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The ego develops capacities to function in the 1. Mature
world, known as ego functions Altruism
Enable people to function in coherent, Unselfishly assisting others to avoid
organized manner negative personal feelings
Anticipation
List of ego functions: Thinking ahead and planning
Reality testing appropriately
Judgment Humor
Sense of reality of the world & the self Sublimation
Modulating & controlling drives, affects, & Healthiest defense mechanism
impulses Compromise
Object or interpersonal relations Takes socially unacceptable impulses
Thought processes and turns them into something positive
Adaptive regression in the service of the & acceptable
ego Suppression
Defensive functioning
Autonomous functioning 2. Immature
Mastery-competence Acting Out
Somatization
Conflicts of Personality Components Regression
Conflicts between the Id, Superego and Ego
Blocking
arise in unconscious mind
Introjection
Cant be reached bc in unconscious
Hypochondriasis
Come out in various ways
Slips of tongue (Freudian slip)
Dreams 3. Narcissistic
Jokes Denial
Anxiety Distortion
Projection

4. Neurotic
Defense Mechanisms Dissociation
Reaction Formation
Ego Defense Mechanisms Repression
Result from interactions between the ID, Ego, Displacement
and Superego Isolation of Affect
Thus, theyre compromises: Intellectualization
Attempts to express an impulse (to Rationalization
satisfy the ID) in a socially acceptable
or disguised way (so that the Superego Repression
can deal with it) Internal impulses and memories too
Less mature defenses protect the person from threatening so bared from entering awareness
anxiety and negative feelings, but at price Denial
Some defense mechanisms explain aspects of Refusal to accept external realities because
psychopathology: too threatening to enter awareness
Ex. Identification with aggressor: can explain Displacement
tendency of some abused kids to grow into Shifting attention from one target that is no
abusers longer available to a more acceptable or
How defenses operate: safer substitute
Defense mechanisms operate out of conscious Redirection of unacceptable feelings, impulses
awareness, while coping mechanisms are from their source onto a less threatening
conscious person or object
Defenses protect individuals from intolerable or Ex. Mad at your teacher, so you go home and kick the
unacceptable impulses dog
Effective defenses enable optimal functioning Projection
without undue anxiety, while maladaptive Attribute unacceptable thoughts or impulses
defenses distort reality & impair overall ego onto others (project these inappropriate
functioning thoughts etc onto others)
Primary Repression Falsely attributing ones own unacceptable
Conflict arises when the IDs drives threaten to impulses or feelings onto others
overwhelm the controls of the Ego and Can manifest as paranoia
Superego Rationalization
Ego pushes ID impulses deeper into the Explaining an unacceptable behavior in a way
unconscious via repression that overlooks present shortcomings or failures
Material pushed into unconscious does not sit Giving seemingly reasonable explanations for
quietly- causes symptoms unacceptable or irrational feelings
Anna Freudian Ego Defenses Reaction Formation
Repression Converting unacceptable and dangerous
Reaction formation impulses into something positive to reduce
Projection anxiety
Isolation Transforming an unacceptable impulse into a
Undoing diametrically opposed thought, feeling,
Regression attitude, or behavior; denying unacceptable
Introjection (internalization) feelings and adopting opposite attitudes
Turning against the self Ex. Person who loves pornography leads a
Reversal movement to outlaw its sale in the
Sublimation neighborhood
Displacement
Classification of Defenses Regression
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Reverting to behavior that is characteristic to Focus: weaning- becoming less
an earlier stage of development when dependent
confronted with stress or anxiety Not resolved? aggression or
Return to earlier level of functioning (childlike dependency later in life-- fixation with
behaviors) during stressful situations oral activities (smoking, drinking, nail
Ex. Kids regress after trauma biting etc.
Anal (18-35 months)
Somatization Fixation on bowel and bladder
Unconscious transformation of unacceptable elimination
impulses or feelings into physical symptoms Focus: search for control
Magical Thinking Not resolved? anal retentive (rigid and
A thought is given great power, deemed to obsessive personality) or anal expulsive (messy
have more of a connection to events than is and disorganized personality
realistic Phallic (3-6 years)
Ex. Thinking about a disaster can bring Focus: genital area and difference btwn
it about males and females
Can manifest as obsessions Electra Complex or Oedipus Complex
Oedipus Complex (boys)
Psychosexual Development Unconscious sexual desires towards
Children pass thru a series of age-dependent mother, father is competition
stages during development Simultaneously fears the dad-
Each stage has a designated pleasure zone castration anxiety
and primary activity Electra Complex (girls)
Each stage requires resolution of a particular Unconscious sexual desires towards
conflict/task father and mother is completion
Stages of development in which conflict over Penis envy
Ids impulses plays out Resolution?
Ego must control these impulses Kid identifies with same sex parent
If not resolved, psychological issues can
emerge later in life Latency (6 yrs to puberty)
Sexual interest is repressed
Psychosexual Stages Kids play with same sex others-- until
Failure to successfully navigate a stages puberty
particular conflict/ task is known as Fixation Genital (puberty and beyond)
Leaving some energy in a stage Sexual urges awaken
Specific problems result from Fixation, If developed properly develop these
depending on which stage is involved urges towards opposite sex members
Fixation may result from environmental with fixation on the genitals
disruption
Key Contributions of Freud
Psychic Determinism/ Dynamic Model
Topographical Model of the Mind
Freud's stages are based on clinical observations Unconscious, Preconscious, Conscious
of his patients Stages of Psychosexual Development
The Stages are: Structural Model of the Mind
Oral Defense Mechanisms
Anal Transference and Countertransference
Phallic Eriksonian Ego Psychology
Latency The work of Erikson not only grew out of a
Genital critique of Freud's psychsexual stages, it also
Freudian Psychosexual Stages integrated observations from post-Freudian ego
psychology.
Oral stage (First year of life)
Focus on primary Epigenetic Stages Ages
gratification through oral means Virtue
Anal stage (2-3 yrs)
Focus on primary Basic trust vs. mistrust (0-18 mo) HOPE
gratification through holding on & Autonomy vs. shame & doub (18-3 yr) WILL
letting go, corresponds with toilet Initiative vs. guilty (3-6 yr)SENSE OF
training PURPOSE
Phallic (Oedipal) stage (3-5 yrs) Industry vs. inferiorit (6-11 yr)COMPETENCE
Focus on primary Identity vs. confusion (11-18 yr)PERSONALITY
gratification through genitals; IDENTITY
awareness of erotic feelings for Intimacy vs. isolation (young adulthood)LOVE
parents; emergence of triangular Generativity vs. stagnation (middle
relationships dulthood)CARE
Latency stage (5 or 6 through puberty) Integrity vs. despair (old age)WISDOM
Focus on repression of
erotic feelings What is a crisis?
Genital stage (puberty through An upset in psychological equilibrium triggered
adulthood) by:
Focus on primary outside harm or threat from the
gratification though meeting adult environment
sexual needs internal developmental or biological
changes
Psychosexual Stages interpersonal challenges, conflicts, or
Oral Stage (0-18 months) losses
Pleasure centering around the mouth Symptoms may include anxiety, guilt, shame,
(sucking, biting etc) sadness, envy, disgust, fear
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Traumatic stressactual or threatened
severe injury or death of oneself or significant
others
Psychopathology, according to classical theory
Unresolved conflicts of the mind between id,
ego, & superego or between ego & external
environment:
May cause fixation at developmental
stages
May cause weak ego functioning ,
leading to difficulties with adaptation
May cause inadequate defensive
functioning leading to symptoms
Symptoms of unresolved conflict (e.g., anxiety,
depression, compulsions, or sociopathy) are:
Efforts to overcome or work through
conflicts
Efforts to compensate for conflicts
Transferencea key to treatments
Transference defined as:
The feelings & wishes from past
experiences
placed onto another in the present
The central component of the talking
cure
A means for viewing clients
unresolved conflicts
by the interaction with the clinician
Countertransference defined as:
The clinicians feelings about the client
in treatment
Through understanding transference,
clients may develop insight & self-
understanding, leading to change
EGO-MODIFYING TREATMENT
Focus: past & present; conscious,
unconscious, & preconscious
Nature of change: insight & conflict
resolution
Curative process: make unconscious
conscious through interpretation
Use of relationship: use & understand
positive & negative transference
EGO-SUPPORTIVE TREATMENT
Focus: current behavior, conscious
thoughts/feelings; limit past focus
Nature of change: ego mastery, increased
understanding, better person-in-environment
fit
Curative process: strengthen ego, shore up
defenses, promote adaptation
Use of relationship: real relationship,
positive transference, corrective relationship
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