The document discusses the interplay between biological and psychological factors in the manifestation of psychopathology, emphasizing the importance of early attachment experiences in shaping internal psychological models and later relationships. It outlines two primary types of psychopathology: neurotic pathology related to conflicting mental representations and personality disorders associated with failures in mentalization. The content also differentiates between various personality disorders, illustrating how attachment styles and internalization processes impact psychological health and relationship dynamics.

1. 1
From psychoanalytical point of view
and related to DSM IV Axis II

2. 22
Psychopathology 1Psychopathology 1
Biology and PsychologyBiology and Psychology
 Behavior is the result of the mutualBehavior is the result of the mutual
relation between “nature” andrelation between “nature” and
“nurture”.The result of a complicated“nurture”.The result of a complicated
interaction between “genes” andinteraction between “genes” and
“environment”→ integration Mind and“environment”→ integration Mind and
Brain.Brain.

3. 33
Psychopathology 2Psychopathology 2
 Consequences for looking atConsequences for looking at
pathologypathology
1.1. No causal relation between risc factors and theNo causal relation between risc factors and the
development of pathology; the amount of riscdevelopment of pathology; the amount of risc
factors is in a way predictable.factors is in a way predictable.
2.2. The quality of the early attachmentThe quality of the early attachment
relationships is important for the possiblerelationships is important for the possible
development of pathologydevelopment of pathology

4. 4
Psychopathology 3Psychopathology 3
 The process of internalising early experiencesThe process of internalising early experiences
and the creation of an internal psychologicaland the creation of an internal psychological
model of the interpersonal world →model of the interpersonal world →
mentalization/ creation of a mind or mentalmentalization/ creation of a mind or mental
representations.representations.
 Internal representations of the earlierInternal representations of the earlier
experiences with the primairy care givers willexperiences with the primairy care givers will
influence later relationships and theinfluence later relationships and the
development of psychopathology later ondevelopment of psychopathology later on

5. 5
Psychopathology 4Psychopathology 4
There are 2 types ofThere are 2 types of
psychopathologypsychopathology
1.1. Related to conflicting mental representations:Related to conflicting mental representations:
neurotic pathologyneurotic pathology
2.2. Related to the failing of the mentalizingRelated to the failing of the mentalizing
process itself: personality disorders this is theprocess itself: personality disorders this is the
area of the borderline personality organizationarea of the borderline personality organization

6. 6
Difference between BPD and BPO 1Difference between BPD and BPO 1
 Borderline Personality DisorderBorderline Personality Disorder
1.1. A descriptive diagnosis. Manifest andA descriptive diagnosis. Manifest and
observable behaviorobservable behavior
2.2. An enduring pattern of internal experiencesAn enduring pattern of internal experiences
that manifest themselves in a broad area ofthat manifest themselves in a broad area of
personal and social situations.personal and social situations.
3.3. DSM IVDSM IV

7. 77
Difference between BPD and BPO 2Difference between BPD and BPO 2
 Borderline PersonalityBorderline Personality
OrganizationOrganization
 Structural Diagnosis/ KernbergStructural Diagnosis/ Kernberg
 Underlying structure which is not directlyUnderlying structure which is not directly
observable.→observable.→
Dyade/Schema/I.W.M./I.I.M.Dyade/Schema/I.W.M./I.I.M.
 Includes the whole area of personalityIncludes the whole area of personality
disordersdisorders

8. 8
Two types of pathologyTwo types of pathology
Mental process disordersMental process disorders
 Inability to represent inside what is outsideInability to represent inside what is outside
 The dependency from the external world isThe dependency from the external world is
therethere
 Anxieties are interpersonal instead of intraAnxieties are interpersonal instead of intra
personalpersonal

9. 99
Two types of pathologyTwo types of pathology
Mental Process disordersMental Process disorders
 No psychological Self but the body is the selfNo psychological Self but the body is the self
 No Somatization as a defense but SomaNo Somatization as a defense but Soma
 Alexithymia: medically unexplained physicalAlexithymia: medically unexplained physical
symptoms/ conversionssymptoms/ conversions
 They live in a frightened world instead of a worldThey live in a frightened world instead of a world
they are experiencing as frighteningthey are experiencing as frightening

10. 10
Mental Process DisordersMental Process Disorders
1.1. Anxiety neurosisAnxiety neurosis
2.2. External Regulated / MotivatedExternal Regulated / Motivated
3.3. Developmental pathologyDevelopmental pathology
4.4. Building structuresBuilding structures
5.5. The area of the personality disorders Axis 2The area of the personality disorders Axis 2
cluster A and Bcluster A and B
6.6. Axis 1 Somatization, Somatoform disorder,Axis 1 Somatization, Somatoform disorder,
Panic disorder Dissociative disorder andPanic disorder Dissociative disorder and
PTSD.PTSD.

11. 11
Conflicting Mental RepresentationsConflicting Mental Representations ..
1.1. PsychoneurosisPsychoneurosis
2.2. Intrapsychic ConflictsIntrapsychic Conflicts
3.3. Conflicting pathologyConflicting pathology
4.4. RestructuringRestructuring
5.5. Internal Regulated / MotivatedInternal Regulated / Motivated
6.6. Neurotic pathology and Axis 2 cluster CNeurotic pathology and Axis 2 cluster C

12.  Mental process / mental representations
 Paranoid/Schizoid versus Depressive Pos.
 Primary love versus Basic Fault
 Primary versus Secondary Process
 Pre Oedipal versus Oedipal
 Neurotic versus Structural
 Neurotic versus Personality dis.
12

13. 13
M.KleinM.Klein
Par. Schizoid PositionPar. Schizoid Position
 Annihilation anxietyAnnihilation anxiety
 Identity undermining defensesIdentity undermining defenses
 No adequate self/object differentiationNo adequate self/object differentiation
 No adequate object constancyNo adequate object constancy
 Archaic Object RelationsArchaic Object Relations
 Ambivalences are not bearableAmbivalences are not bearable
 ““doing” instead of “containing”/”feeling”doing” instead of “containing”/”feeling”

14. 14
M.KleinM.Klein
Par.Schizoid PositionPar.Schizoid Position
 Interventions related to the inner experiencingInterventions related to the inner experiencing
are raising the anxiety and by that stimulatingare raising the anxiety and by that stimulating
“acting out”“acting out”
 Interventions should relate inner and outerInterventions should relate inner and outer
sources of stresssources of stress → facilitating mentalization→ facilitating mentalization
 Therapist as external Obs.Ego → beingTherapist as external Obs.Ego → being
introjected / mirroringintrojected / mirroring

15. 15
M.KleinM.Klein
Depressive positionDepressive position
 Anxieties related to inner ambivalencesAnxieties related to inner ambivalences
 Defenses in favour of identityDefenses in favour of identity
 Adequate S/O differentiationAdequate S/O differentiation
 Adequate Object constancyAdequate Object constancy
 Realistic Object RelationsRealistic Object Relations
 Containing instead of doingContaining instead of doing

16. 16
AttachmentAttachment
A safe attachment style supposesA safe attachment style supposes
 Adequate sensitivityAdequate sensitivity : being aware that: being aware that
there is something going on in the otherthere is something going on in the other
personperson
 Adequate responsivityAdequate responsivity : reacting to the: reacting to the
other in such a way that it is clear what isother in such a way that it is clear what is
from me and what from the otherfrom me and what from the other

17. Failing sensitivity: Externalizing pathology
 They minimize their need for relatedness. As a strategy
against the pain of the separation and the feeling not
been seen.
 Predisposition for Externalizing pathology because
there is no attention for the self, and the solution of
negative inner representations is not there → faling
sensitivity
(Dozier 1999)
17

18. Failing responsivity: Internalizing pathology
 They maximalizing their need for relatedness and they
are continually occupied with the emotional pain and
the not being available of the attachment figures.
 Predisposition for Internalizing pathology: attention
will be fixated to the availability of the caring other and
negative representations stay painfully alive → failing
responsivity
18

19. 19
 S. Blatt: Two Basic Drives
1. Relatedness
2. Autonomy
(Blatt 1998)
 Anaclytical pathology
 Preoccupied/Ambivalent
 Faling responsivity/not marked
mirroring
 I can not be on my own
 Introjective pathology
 Avoiding
 Failing sensitivity
 I do it myself

20. 2020
Anaclytical PathologyAnaclytical Pathology
Internalizing PathologyInternalizing Pathology
 Borderline Personality DisorderBorderline Personality Disorder
 Histrionic Personality DisorderHistrionic Personality Disorder
 Dependant Personality DisorderDependant Personality Disorder

21. 2121
Introjective PathologyIntrojective Pathology
Externalizing pathologyExternalizing pathology
 Schizoid/Schizotypical Personality Dis.Schizoid/Schizotypical Personality Dis.
 Narcissistic Personality DisorderNarcissistic Personality Disorder
 Antisocial Personality DisorderAntisocial Personality Disorder
 Avoidant Personality DisorderAvoidant Personality Disorder
 Somatization,Somatoform dis. DID, PTSDSomatization,Somatoform dis. DID, PTSD

22. 22
InternalisationInternalisation
incorporationincorporation
introjectionintrojection
identificationidentification

23. 23
IntrojectionIntrojection
object permanencyobject permanency
object constancyobject constancy
internal objectinternal object
independent of external objectsindependent of external objects

24. 24
ObjectconstancyObjectconstancy
Internal representationsInternal representations
Containing ambivalenciesContaining ambivalencies
Related to someone who isRelated to someone who is
notnot
actual thereactual there
MourningMourning
AutonomousAutonomous

25. 25
IdentityIdentity - 1 -- 1 -
Object constancyObject constancy
Autonomous objectAutonomous object
Internal representationsInternal representations
Time perspectiveTime perspective
Feeling instead of doingFeeling instead of doing

26. 26
Identity - 2 -Identity - 2 -
FragmentationFragmentation - cohesive- cohesive
Acting outActing out - containing- containing
Momentaneous - timeMomentaneous - time
perspectiveperspective
panicpanic - signal anxiety- signal anxiety
Splitting - repressionSplitting - repression

27.  Structural Diagnosis/ Kernberg
 Underlying structure which is not directly
observable.
 Object Relational Dyade; Schema
 Internal Working Model. Intersubjective.
Interpretive Mechanism.
 Includes the whole area of personality
disorders
27

28. 28
Structural PersonalityStructural Personality
OrganizationOrganization
KernbergKernberg (1984)(1984)
NeuroticNeurotic BorderlineBorderline PsychoticPsychotic
IdentityIdentity integratedintegrated diffuusdiffuus fragmentatedfragmentated
DefenseDefense maturemature archaicarchaic archaicarchaic
RealityReality
TestingTesting
in tactin tact in tact in a wayin tact in a way absentabsent

29. 29
Ego identityEgo identity
 S/O DifferentiationS/O Differentiation
 Mature ObjectMature Object
RelationsRelations
 Mature DefensesMature Defenses
 Reactive AgressionReactive Agression
 internal structureinternal structure
 autonomousautonomous

30. 30
Identity diffusionIdentity diffusion
 FusionFusion
 Primitive ObjectPrimitive Object
RelationsRelations
 Archaic DefenseArchaic Defense
 Primitive AgressionPrimitive Agression
 external regulatedexternal regulated
 dependentdependent

31. 3131
Weak internal structure versus StrongWeak internal structure versus Strong
internal structureinternal structure
 Archaic defensesArchaic defenses
 PanicPanic
 Regression of the egoRegression of the ego
 No ambivalenciesNo ambivalencies
 DeficitsDeficits
 Acting outActing out
 StructuringStructuring
““Borderline”Borderline”
 Mature defensesMature defenses
 Neurotic anxieties (signal)Neurotic anxieties (signal)
 regression in favour of theregression in favour of the
egoego
 AmbivalentAmbivalent
 ConflictConflict
 ContainingContaining
 RerstructuringRerstructuring
““Neurotic”Neurotic”

32.  Nonspecific manifestations of ego weakness
 Specific manifestations of ego weakness →
splitting
 Shift towards primary process thinking
 Pathalogical internalized object relations
32

33. 33

34. 34

35. 35

36. DSM IV: Axis 2
 Cluster A Eccentric: paranoid schizoid;
and schizotypical
 Cluster B Dramatic: borderline;
narcissistic; anti-social and histrionic
 Cluster C Anxiety: avoident; obsessive
compulsive and dependent
36

37. Apart from DSM IV
 Depressive P.D.
 Somatization P.D.
 Dissociative P.D.
37

38.  Cluster A
38

39.  A pervasive pattern of detachment from social
relationships
 Introjective/externalizing pathology
39

40.  Restricted range of expression of emotions in
interpersonal relationships
 No desire or missing or enjoying close
relationships
 Indifferent to praise or criticism
 Like being alone
40

41.  In the internal world intense relations
 Anxiety of being rejected;of being
persecuted;of desintegration
 A lot of splitting
 Fairbairn: internal life compensates deficits in
external life → inner life is pathological
 Balint: Inadequate mothering → basic fault
41

42. 42
PersonalityPersonality
DisorderDisorder
SchizoidSchizoid
View ofView of
selfself
Self-sufficient. LonerSelf-sufficient. Loner
View ofView of
othersothers
IntrusiveIntrusive
MainMain
beliefsbeliefs
Others are unrewarding.Others are unrewarding.
Relationships are messy, undesirable.Relationships are messy, undesirable.
MainMain
strategystrategy
Stay away!Stay away!
TherapeutiTherapeuti
cc
strategiesstrategies
Realize that he is basically very insecure and that contactRealize that he is basically very insecure and that contact
with people is a real threat.with people is a real threat.
So let him decide how much contact he wants.So let him decide how much contact he wants.
Do everything to increase his sense of self-efficacy.Do everything to increase his sense of self-efficacy.

43. The same as Schizoid but also:
 Ideas of reference
 Suspicious/paranoid,excessive social anxiety
 Magical thinking
 Eccentric and odd behavior
43

44. 44
PersonalityPersonality
DisorderDisorder
SchizotypalSchizotypal
View ofView of
selfself
Unreal, detached, loner.Unreal, detached, loner.
Vulnerable, socially conspicuous.Vulnerable, socially conspicuous.
Supernaturally sensitive and gifted.Supernaturally sensitive and gifted.
View ofView of
othersothers
Untrustworthy. Malevolent.Untrustworthy. Malevolent.
MainMain
beliefsbeliefs
(irrational, odd, superstitious, magical thinking; e.g. belief in(irrational, odd, superstitious, magical thinking; e.g. belief in
clairvoyance, telepathy or ‘sixth sense’.)clairvoyance, telepathy or ‘sixth sense’.)
““It is better to be isolated from others.”It is better to be isolated from others.”
MainMain
strategystrategy
Watch for and neutralize malevolent attention from others.Watch for and neutralize malevolent attention from others.
Stay to self.Stay to self.
Be vigilant for supernatural forces or events.Be vigilant for supernatural forces or events.
TherapeutiTherapeuti
cc
strategiesstrategies
See next slide.See next slide.

45. 45
How to deal with SchizotypicalsHow to deal with Schizotypicals
 Realize that he is basically very insecure and thatRealize that he is basically very insecure and that
contact with people is a real threat.contact with people is a real threat.
 So let him decide how much contact he wants.So let him decide how much contact he wants.
 Do everything to increase his sense of self-efficacy andDo everything to increase his sense of self-efficacy and
his reality testing.his reality testing.
 Don’t argue about telepathy, but simply state that youDon’t argue about telepathy, but simply state that you
don’t have such experiences.don’t have such experiences.

46.  A pervasive mistrust and suspiciousness of
others
 Fixated in the paranoid/schizoid position
 Reads hidden meanings in everything
 Externalizing, others are aggressors
 No trust in others → problems with basic trust
4646

47.  The dominant dyade is that of victim and
persecutor
 Emotional cold in intimate relations
 Arrogant on the outside feelings of inferiority in
the inside
 Hyperalert
 In a way they are right the problem is in the
enlargement
47

48.  Splitting as defense mechanism
 Continuous Anxiety
 Concrete Magic Thinking → Taking things at
face value
 Projective Identification
 Problems with Object Constancy
 Relations are in it self dangerous and
discontinuous
48

49. 49
PersonalityPersonality
DisorderDisorder
ParanoidParanoid
View ofView of
selfself
Righteous, innocent, noble, vulnerableRighteous, innocent, noble, vulnerable
View ofView of
othersothers
Interfering, malicious, discriminatory, abusive motivesInterfering, malicious, discriminatory, abusive motives
MainMain
beliefsbeliefs
Others’ motives are suspect.Others’ motives are suspect.
I must always be on guard.I must always be on guard.
I cannot trust people.I cannot trust people.
MainMain
strategystrategy
Be wary. Look for hidden motives.Be wary. Look for hidden motives.
Accuse. Counterattack.Accuse. Counterattack.
TherapeutiTherapeuti
cc
strategiesstrategies
Realize that he is basically very insecure.Realize that he is basically very insecure.
So accept the suspiciousness.So accept the suspiciousness.
Accept that you have to earn his trust, by being extremelyAccept that you have to earn his trust, by being extremely
transparant and open about what you are doing.transparant and open about what you are doing.
Do everything to increase his sense of self-efficacy.Do everything to increase his sense of self-efficacy.

50.  Cluster B
50

51.  Pervasive pattern of instability of interpersonal
relationships, self image and affects and
marked impulsivity
 Anaclytical / internalizing pathology
51

52.  Alternating between idealizing and devaluating
 Chronic feelings of emptiness
 Inappropriate intense anger
 Self-mutilation
52

53.  Frantic efforts to avoid real or imagined
abandoment
 Identity disturbances
 Impulsivity / problems with bounderies
 Affective instability / moodswings including
anxiety
 Paranoid ideation
53

54. 54
PersonalityPersonality
DisorderDisorder
BorderlineBorderline
View ofView of
selfself
Vulnerable (to rejection, betrayal, domination)Vulnerable (to rejection, betrayal, domination)
Deprived (of needed emotional support)Deprived (of needed emotional support)
Powerless. Out of control.Powerless. Out of control.
Defective. Unlovable. Bad.Defective. Unlovable. Bad.
View ofView of
othersothers
(idealized:) poweful, loving, perfect.(idealized:) poweful, loving, perfect.
(devaluated:) rejecting, controlling, betraying, abandoning.(devaluated:) rejecting, controlling, betraying, abandoning.
MainMain
beliefsbeliefs
I cannot cope on my own. I need someone to rely on.I cannot cope on my own. I need someone to rely on.
If I rely on someone I will be mistreated, found wanting, andIf I rely on someone I will be mistreated, found wanting, and
abandoned.abandoned.
The worst possible thing would be to be abandoned.The worst possible thing would be to be abandoned.
I cannot bear unpleasant feelings.I cannot bear unpleasant feelings.
It is impossible for me to control myself.It is impossible for me to control myself.
I deserve to be punished.I deserve to be punished.
MainMain
strategystrategy
Subjugate own needs to maintain connection.Subjugate own needs to maintain connection.
Protest dramatically, threaten and/or become punitive toward thoseProtest dramatically, threaten and/or become punitive toward those
that signal possible rejection.that signal possible rejection.
Relieve tension through self-mutilation and self-destructiveRelieve tension through self-mutilation and self-destructive

55. 55
How to deal with borderlines.How to deal with borderlines.
 They provoke intense countertransference feelings: Anxiety ,They provoke intense countertransference feelings: Anxiety ,
Compassion, Powerlessness,Rage.Compassion, Powerlessness,Rage.
 They constantly test the limits. So stop them in time, in spite ofThey constantly test the limits. So stop them in time, in spite of
their vehement emotions, reproaches, suicide threats.their vehement emotions, reproaches, suicide threats.
 The basic rule is:The basic rule is: setting clear and consistent limits.setting clear and consistent limits.
 Keep in mind that their life-long dilemma is: fear of utter lonelinessKeep in mind that their life-long dilemma is: fear of utter loneliness
↔ fear of engulfment and loss of identity.↔ fear of engulfment and loss of identity.
 This causes the instability between intense need for contact andThis causes the instability between intense need for contact and
intense rejection when you try to be helpful.intense rejection when you try to be helpful.
 Be clear about the conditions by which you can help her.Be clear about the conditions by which you can help her.
 Be consistent in maintaining these conditions and setting limits.Be consistent in maintaining these conditions and setting limits.
 This helps you to prevent your anger.This helps you to prevent your anger.

56.  Pervasive pattern of grandiosity, need for
admiration, for being loved
 Introjective / Externalizing pathology
56

57. Oblivious: need for being loved / admired
arrogant; thick skinned; phallic narc. char.
 No awareness of reactions of others
 Arrogant / Agressive
 Self centered, need to be the center
 Lack of empathy
 untouchable
57

58. Hypervigilant: need to be loved / admired
Depressed; thin skinned; shy narcissist.
 Highly sensitive to reactions of others
 Inhibited or shy
 Directs attention to others instead of himself
 Shuns to be the center
 Listens to others for evidence or criticism
 Easily hurt
58

59. 59
PersonalityPersonality
DisorderDisorder
Narcissistic.Narcissistic.
View ofView of
selfself
Special, unique, superior.Special, unique, superior.
Deserves special rules.Deserves special rules.
Is above the rules.Is above the rules.
View ofView of
othersothers
Inferior.Inferior.
Admirers.Admirers.
MainMain
beliefsbeliefs
Since I am special ISince I am special I deservedeserve special rules.special rules.
I am above the rules.I am above the rules.
I am better than others.I am better than others.
MainMain
strategystrategy
Use others. Transcend rules, manipulate, compete.Use others. Transcend rules, manipulate, compete.
TherapeutiTherapeuti
cc
strategiesstrategies
See next slide.See next slide.

60. 60
How to deal with narcissists.How to deal with narcissists.
 Keep in mind that their arrogance is needed in order notKeep in mind that their arrogance is needed in order not
to feel inferior.to feel inferior.
 Therefore accept the fact that there can be only oneTherefore accept the fact that there can be only one
grandiose person in the room.grandiose person in the room.
 So overcome your own narcissistic hurt and use praiseSo overcome your own narcissistic hurt and use praise
and flattery to get things done.and flattery to get things done.
 But resist unreasonable demands, for then they looseBut resist unreasonable demands, for then they loose
respect.respect.
 But tolerate their rage when you don’t fulfil theirBut tolerate their rage when you don’t fulfil their
demands.demands.

61.  Pervasive pattern of disregard for and violation
of the rights of others
 Introjective /Externalizing pathology
61

62.  Failure to conform to social norms
 Impulsivity or failure to plan ahead
 Irratability / agression
 No empathy
 No responsability for their behavior
62

63.  Strong genetic factor
 Failing in emotional attunement → no
caring/soothing objects
 Lack of remorse
 Grandiose Self is an agressive introject
 Lack of basic trust
63

64. Passive or Parasitic
 Anaclitic
 Dependent, less agressive, relatively non-
violent manipulator
Agressive
 Introjective
 Explosive, violent offender
64

65. 65
PersonalityPersonality
DisorderDisorder
AntisocialAntisocial
View ofView of
selfself
A lonerA loner
View ofView of
othersothers
VulnerableVulnerable
MainMain
beliefsbeliefs
““I am entitled toI am entitled to breakbreak rules.”rules.”
MainMain
strategystrategy
Attack. Rob. Steal.Attack. Rob. Steal.
TherapeutiTherapeuti
cc
strategiesstrategies
See next slide.See next slide.

66. 666666
How to deal with antisocialsHow to deal with antisocials
 Don’t let yourself be flattered by his charm.Don’t let yourself be flattered by his charm.
 Be aware that he always wants something from you.Be aware that he always wants something from you.
 So be especially suspicious if he offers you to participateSo be especially suspicious if he offers you to participate
in some partly illegal, but very profitable offer.in some partly illegal, but very profitable offer.
 As he has no conscience, teaching morals makes noAs he has no conscience, teaching morals makes no
sense.sense.
 So teach him to become a better psychopath, moreSo teach him to become a better psychopath, more
clever and long-sighted, directed to his best interests.clever and long-sighted, directed to his best interests.

67.  Pervasive pattern of excessive emotionality
and attention seeking
 Anaclytical / Internalizing pathology
67

68. Histrionic
 Weak internal structure
 Dyadic relations
 Archaic defense
 Need satisfying relations
 Flamboyant; seductiveness; sexual
impulsiveness; dramatization
68

69. Hysterical
 Adequate internal structure
 Triadic relations
 Mature defense
 Take and give relations
 Emotional reserve; sexual naiveté; conversions
and somatizations
69

70. 70
PersonalityPersonality
DisorderDisorder
Histrionic.Histrionic.
View ofView of
selfself
Glamorous. Impressive.Glamorous. Impressive.
View ofView of
othersothers
Seducible. Receptive. Admirers.Seducible. Receptive. Admirers.
MainMain
beliefsbeliefs
People are there to serve me or to admire me.People are there to serve me or to admire me.
People have no rights to deny me what I deserve.People have no rights to deny me what I deserve.
I can go by my feeling.I can go by my feeling.
MainMain
strategystrategy
Use dramatics, charm, temper tantrums, crying, suicideUse dramatics, charm, temper tantrums, crying, suicide
gestures.gestures.
TherapeutiTherapeuti
cc
strategiesstrategies
See next slide.See next slide.

71. 71
How to deal with histrionics.How to deal with histrionics.
 Natural reactions to them are: Rescuer phantasies,Natural reactions to them are: Rescuer phantasies,
Sexual desire, Irritation.Sexual desire, Irritation.
 So be wary of the intense emotional contact they seemSo be wary of the intense emotional contact they seem
to promise.to promise.
 Resist the temptation to become the all-powerfulResist the temptation to become the all-powerful
rescuer.rescuer.
 Interrupt their impressionistic, dramatic style of thinking.Interrupt their impressionistic, dramatic style of thinking.
 Teach them toTeach them to think throughthink through,, in order to be able to makein order to be able to make
their own decisions, and totheir own decisions, and to decatastrophizedecatastrophize the futurethe future
and to improve their problem solving skills.and to improve their problem solving skills.

72.  Cluster C
72

73.  Pervasive pattern of preoccupation with
orderliness, perfectionism, mental and
interpersonal control. Less flexibility, openness
and efficiency.
 In Control
 Details, rules, procedures, organization
 Rigid, stubbornness
73

74.  Intimacy is dangerous
 They were never good enough
 Severe internal parental objects
 Workaholics
 Love is related to high performances
 Selfdoubt
 deep depression when they realize that
perfection doesn’t exist
74

75. 75
PersonalityPersonality
DisorderDisorder
Obsessive-compulsive.Obsessive-compulsive.
View ofView of
selfself
Responsible. Accountable. Fastidious. Exacting. Competent.Responsible. Accountable. Fastidious. Exacting. Competent.
View ofView of
othersothers
Irresponsible. Casual. Incompetent. Self-indulgent.Irresponsible. Casual. Incompetent. Self-indulgent.
MainMain
beliefsbeliefs
I know what is best.I know what is best.
Details are crucial.Details are crucial.
PeoplePeople shouldshould do better, try harder.do better, try harder.
MainMain
strategystrategy
Apply rules. Perfectionism. Evaluate, control.Apply rules. Perfectionism. Evaluate, control.
““shoulds”. Criticize. Punish.shoulds”. Criticize. Punish.
TherapeutiTherapeuti
cc
strategiesstrategies
See next slide.See next slide.

76. 76
How to deal with obsessive-compulsivesHow to deal with obsessive-compulsives ..
 Respect his meticulousness, but state clearly whenRespect his meticulousness, but state clearly when
things are clear enough.things are clear enough.
 Do behavioral experiments to let him discover that doingDo behavioral experiments to let him discover that doing
something less-than-perfect does not bring the fearedsomething less-than-perfect does not bring the feared
catastrophy.catastrophy.

77.  Pervasive pattern of social inhibition, feelings
of being inadequate, hypersensitive for
negative evaluation
 Introjective /Externalizing pathology
77

78.  Anxious for being related because of the
anxiety to be rejected
 Avoids getting involved with people unless
certain of being liked
 Low self esteem, intense need for affection and
appreciation
78

79.  Feelings of inferiority related to shame →
related to narcissistic p.d. → sensitive type
 Shame related to Self Exposure which is
avoided
 Neurotic variant of the Schizoid P.D.
 Phobic Personality
 Often in conjunction with Axis I diagnosis
79

80. 80
PersonalityPersonality
DisorderDisorder
AvoidantAvoidant
View ofView of
selfself
Vulnerable to depreciation, rejection.Vulnerable to depreciation, rejection.
Socially inept. Incompetent.Socially inept. Incompetent.
View ofView of
othersothers
Critical. Demeaning. Superior.Critical. Demeaning. Superior.
MainMain
beliefsbeliefs
It is terrible to be rejected or put down.It is terrible to be rejected or put down.
If people know the ‘real’ me, they will reject me.If people know the ‘real’ me, they will reject me.
I cannot tolerate unpleasant feelings.I cannot tolerate unpleasant feelings.
MainMain
strategystrategy
Avoid evaluative situationsAvoid evaluative situations
Avoid unpleasant feelings or thoughts by keeping everythingAvoid unpleasant feelings or thoughts by keeping everything
vague.vague.
TherapeutiTherapeuti
cc
strategiesstrategies
See next slide.See next slide.

81. 81
How to deal with avoidant patients.How to deal with avoidant patients.
 How much you do your best to be accepting, keep inHow much you do your best to be accepting, keep in
mind that they can only see you as critical, and so theymind that they can only see you as critical, and so they
will try to be as vague as possible, in order not to bewill try to be as vague as possible, in order not to be
caught.caught.
 Show them the price they pay by avoiding and help themShow them the price they pay by avoiding and help them
to confront the feared situations in small steps, and toto confront the feared situations in small steps, and to
tolerate the tension.tolerate the tension.
 Confront them with the fact that others will judge themConfront them with the fact that others will judge them
anyway.anyway.
 Offer social skills training.Offer social skills training.

82.  Pervasive need to be taken care of that leads
to submissive and clinging behavior related to
fears of separation or being abandoned
 Anaclytical /Internalizing pathology
82

83.  Difficulties in making decisions without
enormous advices from others
 Enormous need for appreciation and
encouragement
 Difficulties in expressing feelings of
disagreement because of fear of loss of
support or approval
83

84.  Enormous need for nurturance and support
 By being so dependent they provoke what they
want to avoid
 Passive-Agressive versions of dependent p.d.
84

85. 85
PersonalityPersonality
DisorderDisorder
DependentDependent
View ofView of
selfself
Needy. Weak. Helpless. Incompetent.Needy. Weak. Helpless. Incompetent.
View ofView of
othersothers
(Idealized:) Nurturant. Supportive. Competent.(Idealized:) Nurturant. Supportive. Competent.
MainMain
beliefsbeliefs
I need people to survive and be happy.I need people to survive and be happy.
I need to have a steady flow of support and encouragement.I need to have a steady flow of support and encouragement.
MainMain
strategystrategy
Cultivate dependent relationships.Cultivate dependent relationships.
TherapeutiTherapeuti
cc
strategiesstrategies
Resist the invitation to take the initiative and to become theResist the invitation to take the initiative and to become the
all-powerful magical helper, but make a deal:all-powerful magical helper, but make a deal:
““I can only help you if you gradually do things on your own.”I can only help you if you gradually do things on your own.”
Promote small steps toward autonomy.Promote small steps toward autonomy.
Offer assertiveness training.Offer assertiveness training.

86. 86
PersonalityPersonality
DisorderDisorder
Passive-aggressivePassive-aggressive
View ofView of
selfself
Self-sufficient.Self-sufficient.
Vulnerable to control, interference.Vulnerable to control, interference.
View ofView of
othersothers
Intrusive, demanding, interfering, controlling, dominating.Intrusive, demanding, interfering, controlling, dominating.
MainMain
beliefsbeliefs
Others interfere with my freedom of action.Others interfere with my freedom of action.
Control by others is intolerable.Control by others is intolerable.
I have to do things my own way.I have to do things my own way.
MainMain
strategystrategy
Passive resistance.Passive resistance.
Surface submissiveness.Surface submissiveness.
Evade, circumvent rules.Evade, circumvent rules.
TherapeutiTherapeuti
cc
strategiesstrategies
Avoid power struggles and being pushed into theAvoid power struggles and being pushed into the
authoritarian role. Focus explicitely on collaboration.authoritarian role. Focus explicitely on collaboration.

87.  Based on psychoanalytical theory
87

88. Introjective ( melancholic)
 Guilt, self criticism, perfection
 Depressive personality disorder those people
suffer fromchronic dysphoric affect and have a
disposition for feeling guilty and/or ashamed
 Looking inside to find explanations
 “Mood disorders”
88

89. Anaclitical
 shame; high reactivity to loss and rejection;
vague feelings of inadequacy and emptiness;
weak capacity to be alone
 Looking in the outside for explanation
 Dependent; narcissistic or borderline
personality disorder.
89

90.  Depressive P.D. : a pervasive and repetitive
pattern that intensifies under stress → more
chronic state
 Major depression : the vegetative symptoms
are on the foreground (decreased
appetite,decreased sexual desire; sleep
disturbances; psychomotor retardation etc)
90

91. Introjective
 Concerned with self definition, autonomy, self
worth,self critical thoughts
Anaclitic
 Concerned with relatedness, trust, preservation
of attachments
91

92. 92
Somatization P.D.Somatization P.D.
Anxiety neurosisAnxiety neurosis (Actual Neurosis(Actual Neurosis))
 Somatic (hartbeating; sweating; trembling;Somatic (hartbeating; sweating; trembling;
nausea; problems with respiration etc.)nausea; problems with respiration etc.)
 Not related to mental representationsNot related to mental representations
 Related to mental process disordersRelated to mental process disorders
 DSM IV; somatization,somatoform disordersDSM IV; somatization,somatoform disorders
panic disorders and PTSD.panic disorders and PTSD.

93. 93
Somatization P.D.Somatization P.D.
Mental Process disordersMental Process disorders
 No psychological Self but the body is the selfNo psychological Self but the body is the self
 No Somatization as a defense but SomaNo Somatization as a defense but Soma
 Alexithymia: medically unexplained physicalAlexithymia: medically unexplained physical
symptoms/ conversionssymptoms/ conversions
 They live in a frightened world instead of a worldThey live in a frightened world instead of a world
they are experiencing as frighteningthey are experiencing as frightening

94. 94
Somatization P.D.Somatization P.D.
1.1. Anxiety neurosis instead of psycho-Anxiety neurosis instead of psycho-
neurosisneurosis
2.2. Panic / momentaneous anxietyPanic / momentaneous anxiety
3.3. External Regulated / MotivatedExternal Regulated / Motivated
4.4. The area of the personality disordersThe area of the personality disorders
Axis 2 cluster A and BAxis 2 cluster A and B
5.5. Somatization, Somatoform disorder,Somatization, Somatoform disorder,
Panic disorder and PTSD.Panic disorder and PTSD.

95. Dissociative Identity Disorder
 Dissociation as reaction to trauma
 Vertical split
 Dissociative amnesia → problems in
remembering specific episodes related to the
trauma
 Dissociative fugue → problems in remembering
the own history, past or identity confusion.
95

96. Appearance of alters
 Distinct identities or personality states each
with his own relatively enduring pattern of
percieving,relating to and thinking about the
environment and the self.
 They recurrently take control of the persons
behavior
96
Dissociative P.D.Dissociative P.D.

97. Ever met a normal person ?
And did you like it ?
mdw@wxs.nl
97