Ethics and the Difficult Person: What the New PDM Can Teach Us All Presenter: Robert M. Gordon, Ph.D.

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Ethics and the Difficult Person What the New PDM
Can Teach Us AllPresenter Robert M. Gordon,
Ph.D.

• Learn to recognize clients who can be a risk
  management problem and/or create ethical
  dilemmas.
• Learn how the adult Axis P of the PDM can help
  with a deeper understanding of difficult clients.
  
• Learn the Borderline is a level of personality
  organization that can be at the basis of any
  personality disorder.
• Reference Gordon, R.M., (2007d) PDM Valuable in
  Identifying High-Risk Patients. The National
  Psychologist, 16, 6, November/December, page 4.
  Can be found at www.mmpi-info.com

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Job consultant's against the grope in 10M suit
BY BARBARA ROSS?DAILY NEWS STAFF WRITERMonday,
July 9th 2007, 400 AM

•  
• A former model who claims that a prominent job
  consultant grabbed her bottom during a 2002 job
  interview will finally get her day in Manhattan
  Supreme Court this week as a jury starts to hear
  evidence in her 10 million lawsuit.
• Let me begin by discussing two frivolous suits
  against psychologists. These are both examples of
  revenge by people at the borderline level of
  personality organization.

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Case of sex the shrinkJob hopeful says doc
wanted her to strip - and that ain't allBY JOSE
MARTINEZ ?DAILY NEWS STAFF WRITERWednesday, July
11th 2007

• An ex-model suing a Manhattan psychologist for
  allegedly groping her ?testified yesterday the
  shrink went from professional to pervert in a
  ?very hands-on job interview.
• It took 5 years for this case to go to trial.
  During that time the psychologist was humiliated
  by the press and lost his job.

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Spacy site haunts NYC shrink's accuser

• NEW YORK, July 12 (UPI) -- The New York Post
  said psychologist Robert Gordon testified "She
  holds herself out to be an indigo child from
  another planet who is made of light," Gordon told
  the Manhattan jury, adding, "this is a very
  unstable person Gordon also said examination
  records indicated a level of paranoia and bipolar
  disorder.
• She had presented herself as a therapist
  in the job interview with the psychologist. She
  claimed at the second 20 minute interview he
  groped at her and almost touched her genitals.
  She clamed to have been raped by her grandfather.
  She stated that she doesnt trust men, even her 8
  year old son. Her web site stated that she is
  from another planet and has special healing
  powers. In her deposition she stated that she
  didnt need a license,that god told her to heal.
  Her PAI had her in the psychotic range.  She lost
  in court, but the psychologist had been fired
  from the university due to the publicity. He
  spent most his savings defending himself.

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PDM valuable in identifying high-risk patients

• I have often served as an expert witness in
  malpractice cases where psychologists had missed
  the psychopathic or borderline traits in
  patients. They were naively trying to help and
  before they knew it, they were defending
  themselves in court, with their professional
  careers at risk. The DSM classifies antisocial
  and borderline personality disorders by precise
  and narrow symptoms. This is often misleading.
  Psychopathy can be a complex personality pattern
  that combines with or is obscured by other
  personality patterns, and borderline can be
  viewed as an entire level of personality
  organization that can be applied to the various
  personality disorders. For example, a patient may
  have a dependent personality disorder that is
  organized at either the neurotic or borderline
  levels of severity.  If it is at the borderline
  level (no matter how sweetly the patient
  initially seems), the patient will most likely
  use splitting (splitting reality into extremes so
  that you suddenly go from a great therapist to an
  all bad, rejecting or abandoning therapist) and
  projective identification (project his own
  manipulateness and hostility on to you and then
  treats you accordingly). The Psychodynamic
  Diagnostic Manual (PDM Task Force, 2006) makes
  these distinctions and so much more. You will
  less likely to be blind sided by a victimizing
  patient if you are familiar with the PDM
  formulation of personality.
• Gordon, R.M., (2007d) PDM Valuable in Identifying
  High-Risk Patients. The National Psychologist,
  16, 6, November/December, page 4.

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My Psychologist Abandoned Me!

• Middle age woman, with no history of psychiatric
  or psychological problems seeks out help after
  her husband commits suicide.
• Psychologist does gives Beck Depression
  Inventory, it shows depression and the
  psychologist does CBT.
• A CBT therapist will have more insight into
  patients with a psychodynamic formulation. If one
  only looks at the surface symptoms, the
  underlying personality dynamics will be missed.

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Complaint to Licensing Board and Civil Suit for
Damages

• At first the patient is sweet and appreciative.
• Calls psychologist frequently between sessions.
  Begins to stalk him and insist on an outside
  relationship with him
• At his rejection, she becomes suicidal and
  requires hospitalization
• Psychologist refers her to other psychologists
  for treatment and does a termination session with
  her.
• Later she sues for abandonment.
• This psychologist did nothing wrong, but
  practiced poor risk management. He did not manage
  her as someone with a dependent personality
  disorder at the borderline level personality
  organization.

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10.10 Terminating TherapyAvoid claims of
abandonment and know this standard!

• (a) Psychologists terminate therapy when it
  becomes reasonably clear that the client/patient
  no longer needs the service, is not likely to
  benefit, or is being harmed by continued service.
• (b) Psychologists may terminate therapy when
  threatened or otherwise endangered by the
  client/patient or another person with whom the
  client/patient has a relationship.
• (c) Except where precluded by the actions of
  clients/patients or third-party payors, prior to
  termination psychologists provide pretermination
  counseling and suggest alternative service
  providers as appropriate.

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• A diagnostic framework that attempts to
  characterize the whole person--the depth as well
  as the surface of emotional, cognitive, and
  social functioning
• The PDM could be the most important source of
  information to help you spot people who are most
  likely to create ethical dilemmas and risk
  issues.

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Developed by leading researchers and five
psychoanalytic organizations

• American Psychoanalytic Association
• International Psychoanalytical Association
• Division of Psychoanalysis (39) of the American
  Psychological Association
• American Academy of Psychoanalysis and Dynamic
  Psychiatry
• National Membership Committee on Psychoanalysis
  in Clinical Social Work

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The New York Times Book ReviewFor Therapy, a New
Guide With a Touch of Personality January 24,
2006 By BENEDICT CAREY

• The encyclopedia of mental disorders known as
  the Diagnostic and Statistical Manual is built on
  a principle that many therapists find simplistic
  that people's symptoms are the most reliable way
  to classify their mental troubles.

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The New York Times Book Review

• The most striking proposal in the new manual is
  its insistence that personality be evaluated
  first, and symptoms considered secondary.
• The first section of the book describes 14
  different personality patterns. It also restores
  others that were dropped from recent editions of
  the D.S.M., like sadistic, masochistic and
  passive-aggressive personality patterns.
• "The D.S.M. is a taxonomy of diseases or
  disorders of function. Ours is a taxonomy of
  people, the new manual declares.

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Financial Ties between DSM-IV Panel Members and
the Pharmaceutical IndustryLisa Cosgrovea,
Sheldon Krimskyb, Manisha Vijayaraghavana, Lisa
Schneidera Psychotherapy and Psychosomatics
200675154-160

• Of the 170 DSM panel members 95 (56) had one or
  more financial associations with companies in the
  pharmaceutical industry.
• One hundred percent of the members of the panels
  on 'Mood Disorders' and 'Schizophrenia and Other
  Psychotic Disorders' had financial ties to drug
  companies.

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The PDM is a superior system for case formulation
and psychotherapy

• Under HIPAA, insurance companies who accept and
  process insurance claims electronically are only
  required to accept the International
  Classification of Diseases, 9th Revision,
  Clinical Modification (ICD-9-CM). The
  International Classification of Diseases is
  published by the World Health Organization.
• Use the ICD-9-CM for reimbursement and the PDM
  for case formulations

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Basis

• The PDM is based on current neuroscience,
  treatment outcome research, and other empirical
  investigations.

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• Objective Measurements of Psychodynamic
  Functioning
• Scales of Psychological Capacities (SPC) From
  the Menninger Psychotherapy Research Project,
  PRPII, 17 scales designed to create a profile of
  personality functioning, which would reflect
  changes in underlying personality organization
  i.e. structural changes in the ego (DeWitt,
  Hartley, Rosenberg, Zilberg, Wallerstein, 1991
  Wallerstein, 1988 Zilberg, Wallerstein, DeWitt,
  Hartley Rosenberg, 1991)
• Karolinska Psychodynamic Profile (KAPP) Created
  in Sweden 17 scales of personality attributes
  (Weinryb, Rossel, Asberg, 1991)
• Operationalized Psychodynamic Diagnosis (OPD)
  Created by German researchers. (Dahlbender,
  Rudolph, OPD Task Force, p. 615)
• Structured Interview of Personality Organization
  (STIPO) Created by the Kernberg-Clarkin group
  at Cornell, covering 94 areas of inquiry,
  divided into six overall domains of personality
  functioning (Clarkin, Caligor, Stern Kernberg,
  2004 Stern, Clarkin, Caligor Kernberg, 2005)
• McGlashan Semistructured Interview (MSI)
  Similar to the STIPO, covering 32 areas of
  personality functioning (Miller, McGlashan,
  Rosen, Cadenhead, Cannon, Ventura, et al., 2004)
• Analytic Process Scales (APS) Created by
  Waldron and his group in New York, designed as a
  process measure to assess the contributions of
  the analyst, of the patient, and of the
  interactional characteristics of their
  relationship (Waldron, Scharf, Crouse, Firestein,
  Burton, Hurst, 2004 Waldron, Scharf, Hurst,
  Firestein Burton, 2004)
• Psychotherapy Process Q-Set (PPQS) A Q-sort
  providing for the description and classification
  of treatment processes and as an outcome measure
  of personality change (Jones, 2000)
• Shedler-Westen Assessment Procedure (SWAP) Also
  a Q-sort geared to assessment of overall
  personality functioning (Shedler Western, p.
  573)
• Object Relations Inventory (ORI) - Created by
  Blatt and his colleagues at Yale, organized as a
  measure of personality structure, into two
  separate scales of personality organization
  (Blatt Auerbach, 2001 Blatt, Auerbach, Levy,
  1997 Blatt, Chevron, Quinlan, Schaffer, Wein,
  1988 Blatt, Stayner, Auerbach Behrends, 1996
  Diamond, Blatt, Stayner, Kaslow, 1991)

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Conceptual and Research Foundations of a
Psychodynamically Based Classification System for
Mental Health Disorders

• Historical and Conceptual Foundations
• Psychoanalytically Based Nosology Historic
  Origins R. S. Wallerstein
• Suitability and Indications for Psychoanalytical
  Psychotherapy A. Braconnier, N. Guedeney, B.
  Hanin, F. Sauvagnat, J. M. Thurin, and D.
  Widlöcher
• A Developmental Framework for Depth Psychology
  and a Definition of Healthy Emotional Functioning
  S. I. Greenspan and S. G. Shanker
• The Contribution of Cognitive Behavioral and
  Neurophysiological Frames of Reference to a
  Psychodynamic Nosology of Mental Illness H.
  Shevrin

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Research Foundations
Psychoanalytic Therapy Research Its History,
Present Status, and Projected FutureR. S.
Wallerstein Evaluating Efficacy, Effectiveness,
and Mutative Factors in Psychodynamic
PsychotherapiesS. J. Blatt, J. S. Auerbach, D.
C. Zuroff, and G. Shahar Personality Diagnosis
with the Shedler-Westen Assessment Procedure
(SWAP) Bridging the Gulf Between Science and
PracticeJ. Shedler and D. Westen Psychic
Structure and Mental Functioning Current
Research on the Reliable Measurement and
Clinical Validity of Operationalized
Psychodynamic Diagnostics (OPD) System R.
Dahlbender, G. Rudolf, and the OPD Task Force
Overview of Empirical Support for the DSM
Symptom-Based Approach to Diagnostic
ClassificationA. Herzig and J. Licht The
Empirical Status of Empirically Supported
Psychotherapies Assumptions, Findings, and
Reporting in Controlled Clinical TrialsD.
Westen, C. Novotny, and H. Thompson-Brenner Evide
nce-Based Psychodynamic Psychotherapies P.
Fonagy A Review of Meta-Analyses of Outcome
Studies of Psychodynamic Therapy F. Leichsenring
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• Unbeknownst to most students of psychology,
  Pavlovs first experiment was to ring a bell and
  cause his dog to attack Freud's cat.

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Schools of psychology originated with
philosophical assumptions of the mind.
Psychoanalysis assumes the evolution of brain
structures that are often in conflict, and that
child rearing and temperament add to or mitigate
these conflicts. Behaviorism grew in opposition
to the idea of an unobservable mind (as a defense
against insight).
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Psychodynamic View of Consciousness
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• O.K. What part of malignant regression and
  pathogenic reintrojection as a defense against
  psychic decompensation dont you understand?
• Psychoanalytic theory is threatening to many. It
  is intellectually challenging, demands a high
  degree of psychological mindedness and
  self-reflection. It stirs up repressed material
  that people would rather avoid by shooting the
  messenger (rejecting the theory).

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• "Look, call it denial if you like, but l think
  what goes on in my personal life is none of my
  own damn business."

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Neuro-psychoanalysis

• A new discipline called neuro-psychoanalysis
  is completing Freud's project, made up of many of
  the world's most impressive neuroscientists, such
  as Nobel Prize-winner Eric Kandel, who stated,
  Much of what we do is unconscious. That is a
  revelation that largely comes from Freud.

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Most of what goes on in our brain is unconscious
and it affects our emotions, thoughts,
perceptions and motives.

• Most of what goes on in the brain is unconscious
  that affects our subjective feelings, perceptions
  and behaviors

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Split Brain Experiments

• Roger Sperry (who won the Nobel prize in 1981)
  and Michael Gazzaniga are two neuroscientists who
  studied patients who had surgery to cut the
  corpus callosum.
• Their research demonstrated that since the corpus
  callosum was cut, the two sides of the brain
  could not communicate.
• The patient would smell a rose, pick a rose from
  several objects behind a screen, but deny any
  smell of the rose. It demonstrated unconscious
  perception and motivation.

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Split Brain Studies of Unconscious Perception
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Bruyer, R. (1991). Covert face recognition in
prosopagnosia A review. Brain and Cognition,
15, 223-235.

• Individuals with prosopagnosia, who lose the
  capacity to discriminate faces, unconsciously
  show differentiated electrophysiological
  responses to familiar versus unfamiliar faces

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Emotions in mammals are all similar and evolved
for functional reasons. They may be affected by
thoughts, but they are not created by thoughts-
as in the assumption of CBT.
Damasio, et al., 2002
Panksepp, J. (2003). Science, Oct 10th.
Herman Panksepp, 1979
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Attachment and emotions are before cognitions.
They are part of implicit or unconscious
personality. The love objects are mother
surrogates. Freud, 1910 Freud in 1912 said,
To ensure a fully normal attitude in love, two
currents of feeling have to unite the tender
feelings and the sensual feelings...
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Mickelson, K. D., Kessler, R. C. Shaver, P. R.
(1997). Adult attachment in a nationally
representative sample. Journal of Personality and
Social Psychology, 73, 1092-1106.

• In a non-clinical sample of 5,000 adults a
  history of parental loss and separation was
  associated with higher ratings of insecure
  attachment and lower attachment security

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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.

• Researchers looked at relationship patterns in 50
  young adults who were studied 20 years earlier as
  infants.
• Overall, 72 of the adults received the same
  secure verses insecure attachment classification
  they had in infancy.
• Our unconscious attachment history remains with
  us and affects our intimacies. This can not be
  reached at a cognitive-behavioral level, but only
  within an empathic therapeutic relationship.

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Bartels and Zeki used a fMRI to peer into the
brains of 17 people who had been madly in love
for an average of about two years. By comparing
the brains of these people as they looked at
loved ones and then as they looked at friends,
Bartels and Zeki produced what they believe are
the first pictures of the brain in love. Bartels
compared the brains of mothers looking at their
infants to those of lovers looking at their
significant others. Except for activity in the
hypothalamus--located at the base of the
brain--that seems to be linked to sexual arousal,
the intense devotion of a mother and a lover are
indistinguishable to an fMRI machine.
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• Helen Fisher found that the area of the brain
  known as the caudate is associated with passion.
  Did you notice it in the lovers brains in the
  previous slide?

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Can Transference be Scientifically
Studied?

• Study subjects are subliminally shown aggressive
  (A) or positive (B) stimuli
• and then rate a neutral stimulus (C)
• Subjects shown panel A, subsequently rated the
  boy in panel C more negatively. They
  unconsciously transferred their feelings. (Eagle,
  M. (1959). The effects of subliminal stimuli of
  aggressive content upon conscious cognition.
  Journal of Personality, 27, 678-688)

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Adams, Wright, Lohr (1996) Homophobic men
reported low levels of sexual arousal to
depictions of homosexual intercourse, but
physiological measures indicated higher degree of
arousal than non-homophobic men. Morokoff
(1985)Women highest on indexes of sex guilt
showed more physiological arousal to erotic
pictures, however, they denied being aroused.
Reaction Formation Research- Indications of
Unconscious Defenses
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Figure 1 Mean T scores and standard
deviations of parents' MMPI-2s from 158 court
ordered child custody evaluations. T50 is an
average score and T65 is high and clinically
significant. LK-F indicates splitting defenses
and the Goldberg Index (LPaSc)-(HyPt)
indicates a borderline level of functioning and
the favoring of primitive defenses such a
projective identification. Parents who alienate
their children from the other parent project
their bad self onto the other parent and then
treat that parent accordingly.
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Delusional mother alleging child sex abuse
against the father in a custody case. There was
no evidence of abuse. She lied about me in her
Board complaint claiming I was abusive to her.
She expressed the same paranoia about me as she
did with the father. Her MMPI-2 is similar to the
Alienating Parents in the study in the previous
slide. She sees no fault in herself and projects
her pathology on to others. The investigator
never brought her claim to the board.
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Empirical Support for Psychoanalytic Theory in
the MMPI Hysteria Scale

• Dahlstrom, Welsh, and Dahlstrom (1972) stated
  that the items on the Hysteria scale seem
  mutually contradictory. They developed this scale
  on actual hysterics. It turns out to support
  Freuds theory of hysteria.
• The Hysteria scale has such seemingly unrelated
  issues such as
• somatic complaints,
• naiveté,
• denial of aggressive motives,
• unhappy home life
• and sexual conflicts.

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The functional anatomy of a hysterical
paralysis.Marshall, John C. Halligan, Peter W.
Fink, Gereon R. Wade, Derick T. Frackowiak,
Richard S. J., Cognition. 1997 Jul Vol 64(1) B1-B8

• Neuropsychologists studied the fMRI of a woman
  with conversion hysteria. When the woman tried to
  move her "paralyzed leg," her primary motor
  cortex was not activated as it should have been
  instead her right orbitofrontal and right
  anterior cingulate cortex parts of the brain that
  have been associated with action and emotion were
  activated. Authors reasoned that these emotional
  areas of the brain were responsible for
  suppressing movement in her paralyzed leg.

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Figure 1. Higher scores on hysteria as
psychoanalysis begins are related to more
concerns with sexual conflicts six to twelve
months into psychoanalysis. Rosemary Cogan and
John H. Porcerelli, presented at the American
Psychoanalytic Assoc. New York, 1.19.07
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Figure 2. Higher scores on obsessiveness as
psychoanalysis begins are related to more
concerns with hostile conflicts twelve months and
longer into psychoanalysis.
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Gordon, R.M. (2001) MMPI/MMPI-2 Changes in
Long-Term Psychoanalytic Psychotherapy. The
MMPI is very stable and does not react to low
dose treatment. It did react to high dose long
term psychoanalytic psychotherapy with patients
with personality disorders. It took years to get
to the level of structural changes- reduced
symptoms and more emotional maturity.
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Now that you have seen some examples of
psychodynamic research- back to the PDM.

• The PDM adult nosology begins with a
  classification of personality patterns and
  disorders,
• then offers a "profile of mental functioning"
  covering in more detail the patient's capacities,
  
• and finally considers symptom patterns, with
  emphasis on the patient's subjective experience.

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P Axis

• This dimension has been placed first in the PDM
  system because of the accumulating evidence that
  symptoms or problems cannot be understood,
  assessed, or treated in the absence of an
  understanding of the mental life of the person
  who has the symptoms.

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Dimension I Personality Patterns and Disorders
P Axis

• The PDM classification of personality patterns
  takes into account two areas
• the person's level of severity by personality
  organization,
• and the characteristic personality pattern or
  personality disorder.

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Kernbergs Differentiation of Personality
Organization Preceded the PDM

• Neurotic Borderline Psychotic
• Identity integrated -
  diffused -
• Integration
• Defensive higher -
  primitive -
• Operations
• Reality
  - poor
• Testing

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Borderline Personality Disorder DSM IV Criteria
is a Collection of Symptoms

• A pervasive pattern of instability of
  interpersonal relationships, self-image, and
  affects, and marked impulsivity beginning by
  early adulthood and present in a variety of
  contexts, as indicated by five (or more) of the
  following
• 1. frantic efforts to avoid real or imagined
  abandonment. Note Do not include suicidal or
  self-mutilating behavior covered in Criterion 5.
• 2. a pattern of unstable and intense
  interpersonal relationships characterized by
  alternating between extremes of idealization and
  devaluation.
• 3. identity disturbance markedly and
  persistently unstable self-image or sense of
  self.
• 4. impulsivity in at least two areas that are
  potentially self-damaging (e.g., spending, sex,
  substance abuse, reckless driving, binge eating).
  Note Do not include suicidal or self-mutilating
  behavior covered in Criterion 5.
• 5. recurrent suicidal behavior, gestures, or
  threats, or self-mutilating behavior
• 6. affective instability due to a marked
  reactivity of mood (e.g., intense episodic
  dysphoria, irritability, or anxiety usually
  lasting a few hours and only rarely more than a
  few days).
• 7. chronic feelings of emptiness
• 8. inappropriate, intense anger or difficulty
  controlling anger (e.g., frequent displays of
  temper, constant anger, recurrent physical
  fights)

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Level of Personality Organization (Severity of
Personality Disorder)Note that borderline in
the PDM is a level of severity

• Healthy Personalities (Absence of Personality
  Disorder)(favoring defenses such as suppression,
  humor, sublimation, altruism)
• Neurotic-Level Personality Disorders(favoring
  defenses such as repression, intellectualization)
• Borderline-Level Personality Disorders(favoring
  defenses such as splitting, projective
  identification, denial)

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The Determination of Personality Organization or
Severity of Personality is Based on Seven
Capacities

• To view self and others in complex, stable, and
  accurate ways (identity)
• To maintain intimate, stable, and satisfying
  relationships (object relations)
• To experience in self and perceive in others the
  full range of age-expected affects (affect
  tolerance)
• To regulate impulses and affects in ways that
  foster adaptation and satisfaction, with
  flexibility in using defenses or coping
  strategies (affect regulation)
• To function according to a consistent and mature
  moral sensibility (super-ego integration, ideal
  self-concept, ego ideal)
• To appreciate, if not necessarily to conform to,
  conventional notions of what is realistic
  (reality testing)
• To respond to stress resourcefully and to recover
  from painful events without undue difficulty (ego
  strength and resilience).

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Once the level of Personality is Determined
(neurotic or borderline), then Consider the Type
of Personality Disorder

• P101. Schizoid Personality Disorders
• P102. Paranoid Personality Disorders
  
• P103. Psychopathic (Antisocial) Personality
  Disorders  P103.1  Passive/Parasitic   P103.2 
  Aggressive
• P104. Narcissistic Personality Disorders  P104.1 
  Arrogant/Entitled  P104.2  Depressed/Depleted
• P105. Sadistic and Sadomasochistic Personality
  Disorders  P105.1  Intermediate Manifestation
  Sadomasochistic Personality Disorders
• P106. Masochistic (Self-Defeating) Personality
  Disorders  P106.1  Moral Masochistic  P106.2 
  Relational Masochistic

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• P107. Depressive Personality Disorders  P107.1 
  Introjective  P107.2  Anaclitic   P107.3 
  Converse Manifestation Hypomanic Personality
  Disorder
• P108. Somatizing Personality Disorders
• P109. Dependent Personality Disorders  P109.1 
  Passive-Aggressive Versions of Dependent
  Personality Disorders  P109.2  Converse
  Manifestation Counterdependent Personality
  Disorders
• P110. Phobic (Avoidant) Personality
  Disorders  P110.1  Converse Manifestation
  Counterphobic Personality Disorders
• P111. Anxious Personality Disorders

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• P112. Obsessive-Compulsive Personality
  Disorders  P112.1  Obsessive  P112.2 
  Compulsive
• P113. Hysterical (Histrionic) Personality
  Disorders  P113.1  Inhibited  P113.2 
  Demonstrative or Flamboyant
• P114.  Dissociative Personality Disorders
  (Dissociative Identity Disorder/Multiple
  Personality Disorder)
• P115.  Mixed/Other

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The P Axis- Personality Disorders Considers the
Following Factors

• Temperamental,
• Thematic,
• Affective,
• Cognitive, and
• Defense patterns

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For Example P102. Paranoid Personality Disorders

• Contributing constitutional-maturational
  patterns Possibly irritable/aggressive
• Central tension/preoccupation Attacking/being
  attacked by humiliating others
• Central affects Fear, rage, shame, contempt
• Characteristic pathogenic belief about self
  Hatred, aggression and dependency are dangerous
• Characteristic pathogenic belief about others
  The world is full of potential attackers and
  users
• Central ways of defending Projection, projective
  identification, denial, reaction formation

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P103. Psychopathic (Antisocial) Personality
Disorder P103.1  Passive/Parasitic
con artist P103.2  Aggressive
explosive, predatory, often violent

• Contributing constitutional-maturational
  patterns aggressiveness, high threshold for
  emotional stimulation
• Central tension/preoccupation Manipulating/being
  manipulated
• Central affects Rage, envy
• Characteristic pathogenic belief about self I
  can make anything happen
• Characteristic pathogenic belief about others
  Everyone is selfish, manipulative, dishonest
• Central ways of defending Reaching for
  omnipotent control

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P105. Sadistic and Sadomasochistic Personality
Disorders P105.1  Intermediate
Manifestation Sadomasochistic
Personality Disorders alternate between
attacking and feeling insulted

• Contributing constitutional-maturational
  patterns Unknown
• Central tension/preoccupation Suffering
  indignity/inflicting such suffering
• Central affects Hatred, contempt, pleasure
  (sadistic glee)
• Characteristic pathogenic belief about self I am
  entitled to hurt and humiliate others
• Characteristic pathogenic belief about others
  Others exist as objects for my domination
• Central ways of defending Detachment, omnipotent
  control, reversal, enactment

61
Beware of the Quiet Borderline

• According to the PDM, borderline is a level of
  personality organization. It can be lurking under
  neurotic symptoms or a seemly mild personality
  disorder. Until
• The borderline patient demands magic or love and
  if you do not provide it, you are viewed as
  rejecting or abandoning.
• The borderline patient may have a psychotic
  transference to you.
• The borderline patient may manipulate you into
  boundary violations that will get you in trouble.

62
The PDM May be Your Best Friend in Spotting
Difficult Patients

• Learn from it!
• Thank You.