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

More

Cathartic Method

Therapy benefits thru release of pent-up

tensions, catharsis

Some inherent value in the talking curebeing 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

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)
Basic Principles
The Cathartic Method
Primary vs. Secondary Gain
Transference and Countertransference
Ego-Syntonic vs. Ego-Dystonic

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

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)

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

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

world, known as ego functions

Enable people to function in coherent,

organized manner

List of ego functions:

Reality testing

Judgment

Sense of reality of the world & the self

Modulating & controlling drives, affects, &

impulses

Object or interpersonal relations

Thought processes

Adaptive regression in the service of the

ego

Defensive functioning

Autonomous functioning

Mastery-competence
Conflicts of Personality Components

Conflicts between the Id, Superego and Ego

arise in unconscious mind

Cant be reached bc in unconscious

Come out in various ways

Slips of tongue (Freudian slip)

Dreams

Jokes

Anxiety

1. Mature
Altruism
Unselfishly assisting others to avoid
negative personal feelings
Anticipation
Thinking ahead and planning
appropriately
Humor
Sublimation
Healthiest defense mechanism
Compromise
Takes socially unacceptable impulses
and turns them into something positive
& acceptable
Suppression
2.

Immature
Acting Out
Somatization
Regression
Blocking
Introjection
Hypochondriasis

3.

Narcissistic
Denial
Distortion
Projection

4.

Neurotic
Dissociation
Reaction Formation
Repression
Displacement
Isolation of Affect
Intellectualization
Rationalization

Defense Mechanisms
Ego Defense Mechanisms

Result from interactions between the ID, Ego,

and Superego

Thus, theyre compromises:

Attempts to express an impulse (to

satisfy the ID) in a socially acceptable
or disguised way (so that the Superego
can deal with it)

Less mature defenses protect the person from

anxiety and negative feelings, but at price

Some defense mechanisms explain aspects of

psychopathology:
Ex. Identification with aggressor: can explain
tendency of some abused kids to grow into
abusers
How defenses operate:

Defense mechanisms operate out of conscious

awareness, while coping mechanisms are
conscious

Defenses protect individuals from intolerable or

unacceptable impulses

Effective defenses enable optimal functioning

without undue anxiety, while maladaptive
defenses distort reality & impair overall ego
functioning
Primary Repression

Conflict arises when the IDs drives threaten to

overwhelm the controls of the Ego and
Superego

Ego pushes ID impulses deeper into the

unconscious via repression

Material pushed into unconscious does not sit

quietly- causes symptoms
Anna Freudian Ego Defenses

Repression

Reaction formation

Projection

Isolation

Undoing

Regression

Introjection (internalization)

Turning against the self

Reversal

Sublimation

Displacement
Classification of Defenses

Repression
Internal impulses and memories too
threatening so bared from entering awareness
Denial
Refusal to accept external realities because
too threatening to enter awareness
Displacement

Shifting attention from one target that is no

longer available to a more acceptable or
safer substitute
Redirection of unacceptable feelings, impulses
from their source onto a less threatening
person or object
Ex. Mad at your teacher, so you go home and kick the
dog
Projection

Attribute unacceptable thoughts or impulses

onto others (project these inappropriate
thoughts etc onto others)

Falsely attributing ones own unacceptable

impulses or feelings onto others

Can manifest as paranoia

Rationalization
Explaining an unacceptable behavior in a way
that overlooks present shortcomings or failures
Giving seemingly reasonable explanations for
unacceptable or irrational feelings
Reaction Formation
Converting unacceptable and dangerous
impulses into something positive to reduce
anxiety
Transforming an unacceptable impulse into a
diametrically opposed thought, feeling,
attitude, or behavior; denying unacceptable
feelings and adopting opposite attitudes
Ex. Person who loves pornography leads a
movement to outlaw its sale in the
neighborhood
Regression

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Reverting to behavior that is characteristic to
an earlier stage of development when
confronted with stress or anxiety
Return to earlier level of functioning (childlike
behaviors) during stressful situations
Ex. Kids regress after trauma

Somatization

Unconscious transformation of unacceptable

impulses or feelings into physical symptoms
Magical Thinking

A thought is given great power, deemed to

have more of a connection to events than is
realistic

Ex. Thinking about a disaster can bring

it about

Can manifest as obsessions

Psychosexual Development

Children pass thru a series of age-dependent

stages during development

Each stage has a designated pleasure zone

and primary activity

Each stage requires resolution of a particular

conflict/task

Stages of development in which conflict over

Ids impulses plays out

Ego must control these impulses

If not resolved, psychological issues can

emerge later in life
Psychosexual Stages

Failure to successfully navigate a stages

particular conflict/ task is known as Fixation

Leaving some energy in a stage

Specific problems result from Fixation,

depending on which stage is involved

Fixation may result from environmental

disruption

Freud's stages are based on clinical observations

of his patients

The Stages are:

Oral

Anal

Phallic

Latency

Genital
Freudian Psychosexual Stages

Oral stage (First year of life)

Focus on primary
gratification through oral means
Anal stage (2-3 yrs)

Focus on primary
gratification through holding on &
letting go, corresponds with toilet
training
Phallic (Oedipal) stage (3-5 yrs)

Focus on primary
gratification through genitals;
awareness of erotic feelings for
parents; emergence of triangular
relationships
Latency stage (5 or 6 through puberty)

Focus on repression of
erotic feelings
Genital stage (puberty through
adulthood)

Focus on primary
gratification though meeting adult
sexual needs

Psychosexual Stages

Oral Stage (0-18 months)

Pleasure centering around the mouth

(sucking, biting etc)

Focus: weaning- becoming less

dependent

Not resolved? aggression or

dependency later in life-- fixation with
oral activities (smoking, drinking, nail
biting etc.
Anal (18-35 months)

Fixation on bowel and bladder

elimination

Focus: search for control

Not resolved? anal retentive (rigid and
obsessive personality) or anal expulsive (messy
and disorganized personality
Phallic (3-6 years)

Focus: genital area and difference btwn

males and females

Electra Complex or Oedipus Complex

Oedipus Complex (boys)

Unconscious sexual desires towards

mother, father is competition

Simultaneously fears the dadcastration anxiety

Electra Complex (girls)

Unconscious sexual desires towards

father and mother is completion

Penis envy
Resolution?

Kid identifies with same sex parent

Latency (6 yrs to puberty)

Sexual interest is repressed

Kids play with same sex others-- until

puberty
Genital (puberty and beyond)

Sexual urges awaken

If developed properly develop these

urges towards opposite sex members
with fixation on the genitals

Key Contributions of Freud

Psychic Determinism/ Dynamic Model

Topographical Model of the Mind

Unconscious, Preconscious, Conscious

Stages of Psychosexual Development

Structural Model of the Mind

Defense Mechanisms

Transference and Countertransference

Eriksonian Ego Psychology

The work of Erikson not only grew out of a

critique of Freud's psychsexual stages, it also
integrated observations from post-Freudian ego
psychology.

Epigenetic Stages
Virtue

Basic trust vs. mistrust (0-18 mo) HOPE

Autonomy vs. shame & doub (18-3 yr) WILL
Initiative vs. guilty (3-6 yr)SENSE OF
PURPOSE
Industry vs. inferiorit (6-11 yr)COMPETENCE
Identity vs. confusion (11-18 yr)PERSONALITY
IDENTITY
Intimacy vs. isolation (young adulthood)LOVE
Generativity vs. stagnation (middle
dulthood)CARE
Integrity vs. despair (old age)WISDOM

Ages

What is a crisis?
An upset in psychological equilibrium triggered
by:
outside harm or threat from the
environment
internal developmental or biological
changes
interpersonal challenges, conflicts, or
losses
Symptoms may include anxiety, guilt, shame,
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 & selfunderstanding, 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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