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Formulazione psicodinamica del caso clinico Integrare la teoria, la pratica, e perché no, anche la scienza

Formulazione psicodinamica del caso clinico Integrare la teoria, la pratica, e perché no, anche la scienza. Jonathan Shedler, PhD University of Colorado Denver School of Medicine. Psychodynamic Diagnostic Manual.

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Formulazione psicodinamica del caso clinico Integrare la teoria, la pratica, e perché no, anche la scienza

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  1. Formulazione psicodinamica del caso clinicoIntegrare la teoria, la pratica,e perché no, anche la scienza Jonathan Shedler, PhDUniversity of Colorado Denver School of Medicine

  2. Psychodynamic Diagnostic Manual

  3. Shedler-Westen Assessment Procedure (SWAP)

  4. The Dog, the Tail, and the DSM

  5. Three Axes • Adult Personality Patterns (P Axis) • Mental Functioning Profile (M Axis) • Symptom Patterns (S Axis) (internal experience)

  6. Level of personality organization Healthy Neurotic Level Borderline Psychotic

  7. Personality Style hysterical obsessional paranoid psychopathic etc.

  8. Healthy Neurotic hysterical obsessional paranoid psychopathic Etc. Personality Style Borderline Psychotic

  9. Borderline Personality Organization • Affect Dysregulation • Defenses based on Splitting • Splitting • Primitive Projection • Projective Identification • Identity Diffusion

  10. Adult Personality Patterns(P Axis) • P101 - Schizoid Personality Disorder • P102 - Paranoid Personality Disorder • P103 - Psychopathic (Antisocial) Personality Disorder • P103.1 – Passive/Parasitic • P103.2 – Aggressive • P104 - Narcissistic Personality Disorder • P104.1 – Arrogant/Entitled • P104.2 – Depressed/Depleted

  11. Adult Personality Patterns(P Axis) • P105 - Sadistic and Sadomasochistic Personality Disorders • P105.1 - Intermediate Manifestation: Sadomasochistic Personality Disorder • P106 - Masochistic (Self-Defeating) Personality Disorder • P106.1 – Moral Masochistic • P106.2 – Relational Masochistic • P107 - Depressive Personality Disorder • P107.1 – Introjective • P107.2 – Anaclitic • P107.3 – Converse Manifestation: Hypomanic Personality Disorder

  12. Adult Personality Patterns(P Axis) • P108 - Somatizing Personality Disorder • P109 - Dependent Personality Disorder • P109.1 - Passive-Aggressive Versions of Dependent Personality Disorder • P109.2 - Converse Manifestation: Counterdependent Personality Styles • P110 - Phobic (Avoidant) Personality Disorder • P110.1 - Converse Manifestation: Counterphobic Personality Disorder • P111 - Anxious PersonalityDisorder

  13. Adult Personality Patterns(P Axis) • P112 - Obsessive-Compulsive Personality Disorder • P112.1 - Obsessive • P112.2 - Compulsive • P113 - Hysterical (Histrionic) Personality Disorder • P113.1 - Inhibited • P113.2 – Demonstrative or Flamboyant • P114 - Dissociative Personality Disorder (Dissociative Identity Disorder/Multiple Personality Disorder)

  14. Shedler-Westen Assessment Procedure (SWAP)

  15. “As for academic psychology, its methods give extensive and reliable data which are, in everybody’s subjective judgment, of minor importance.” (Brenner, 1982) “Per quanto riguarda la psicologia accademica, i suoi metodi danno dati esaustivi e affidabili che sono, nel giudizio soggettivo di ognuno, di minore importanza” (Brenner, 1982)

  16. “…impeccable ‘studies of nothing very much.” (Spence, 1994) “.....studi impeccabili....che non dicono un bel niente (Spense, 1994)

  17. The greater risk for the future of psychoanalysis is the decline and fall of the spirit of psychoanalysis” (Green, 2001) “…Il rischio maggiore per il futuro della psicoanalisi è il declino e la scomparsa dello spirito psicoanalitico” (Green, 2001)

  18. Analytic Objections to ResearchObiezioni alla ricerca

  19. Analytic Objections to ResearchObiezioni alla ricerca • impossible • unnecessary • irrelevant

  20. What’s Been Wrong with Empirical Research?Cosa è andato storto nella ricerca empirica? • Eliminate deduction, inference(or reduce to lowest common denominator)

  21. Real clinical data are messy • A thought experiment...

  22. I dati clinici reali sono un gran casino • A thought experiment...

  23. “Harnessing” Clinical Judgment “Domare” il giudizio clinico • Common vocabulary • Attention to same spectrum of material

  24. Shedler-Westen Assessment Procedure (SWAP) *

  25. Seven-Year IterativeRevision process “Were you able to describe the things youconsider psychologically important aboutyour patient?”

  26. Items in Combination • Expresses contradictory feelings or beliefs without being disturbed by the inconsistency; has little need to reconcile or resolve contradictory ideas. • Tends to idealize certain others in unrealistic ways; sees them as “all good,” to the exclusion of commonplace human defects. • Tends to see certain others as “all bad,” and loses the capacity to perceive any positive qualities the person may have.

  27. Items in Combination • Esprime sentimenti o credenze contraddittorie senza essere disturbato dalla loro incoerenza; sente relativamente poco il bisogno di conciliare o risolvere idee contraddittorie. • Tende a idealizzare alcune persone in modi irrealistici; le vede come “totalmente buone”, fino a escludere la presenza anche dei difetti umani più comuni. • Tende a vedere alcune persone come “totalmente cattive” e perde la capacità di percepire le loro qualità positive.

  28. Items in Combination • Tends to see own unacceptable feelings or impulses in other people instead of in himself/herself. • Manages to elicit in others feelings or impulses similar to those s/he is experiencing (e.g., when angry, acts in such a way as to provoke anger in others; when anxious, acts in such a way as to induce anxiety in others). • Tends to draw others into scenarios, or “pull” them into roles, that feel alien or unfamiliar (e.g., being uncharacteristically insensitive or cruel, feeling like the only person in the world who can help, etc.).

  29. Items in Combination • Tende a vedere i suoi sentimenti e impulsi inaccettabili negli altri e non in se stesso/a. • Si comporta in modo da suscitare negli altri sentimenti simili a quelli che lui/lei stesso/a sta provando (per es., quando è arrabbiato/a, agisce in un modo che provoca rabbia negli altri; quando è angosciato/a, agisce in un modo che induce angoscia negli altri). • Tende ad attrarre gli altri in scenari, o a “spingerli” in ruoli, che sente estranei e poco familiari (per es. essere stranamente insensibile e crudele, sentirsi l’unica persona al mondo che possa aiutarli ecc.)

  30. Multiple Meanings • When upset, has trouble perceiving both positive and negative qualities in the same person at the same time (e.g., may see others in black or white terms, shift suddenly from seeing someone as caring to seeing him/her as malevolent and intentionally hurtful, etc.). • Tends to stir up conflict or animosity between other people (e.g., may portray a situation differently to different people, leading them to form contradictory views or work at cross purposes).

  31. Multiple Meanings • Quando è turbato/a, ha difficoltà a percepire allo stesso tempo le qualità positive e negative della stessa persona; vede le altre persone in termini di “tutto bianco o tutto nero” (per es., prima pensa che l’altra persona si stia prendendo cura di lui/lei e poi che sia maligna e gli/le voglia fare del male). • Tende a scatenare conflitti o a suscitare animosità nelle altre persone (per es., può raccontare versioni diverse della stessa situazione a persone diverse facendo sì che esse abbiano visioni contraddittorie o lavorino per raggiungere obiettivi contrastanti).

  32. What is it? • Has difficulty directing both tender feelings and sexual feelings toward the same person (e.g., sees others as nurturing and virtuous or sexy and exciting, but not both). • Tends to become involved in romantic or sexual “triangles” (e.g., is drawn to people who are already attached, sought by someone else, etc.). • Tends to feel guilty or ashamed about his/her sexual interests or activities (whether consciously or unconsciously). • Tends to be sexually seductive or provocative (e.g., may be inappropriately flirtatious, preoccupied with sexual conquest, prone to “lead people on,” etc.).

  33. What is it? • Fa fatica a rivolgere contemporaneamente sentimenti di tenerezza e sentimenti sessuali verso la stessa persona (per es. vede gli altri come rispettabili e virtuosi oppure sensuali ed eccitanti, ma non riesce ad attribuire queste caratteristiche a una stessa persona). • Tende a coinvolgersi in situazioni romantiche o sessuali “a tre” (per es., è più interessato a partner che hanno già una relazione, che sono corteggiati da qualcun altro, ecc.). • Tende a sentirsi in colpa o a provare vergogna per i propri interessi o attività sessuali (sia consciamente sia inconsciamente). • Tende a essere seduttivo/a o provocante dal punto di vista sessuale (per es., può flirtare in modo inopportuno, essere completamente assorbito/a dalle conquiste sessuali, ed essere incline a "tenere sulla corda").

  34. What is it? (cont’d) • Expresses emotion in exaggerated and theatrical ways. • Tends to use his/her physical attractiveness to an excessive degree to gain attention or notice. • Beliefs and expectations seem cliché or stereotypical, as if taken from storybooks or movies. • Seems naïve or innocent; appears to know less about the ways of the world than might be expected given his/her intelligence or background. • Tends to perceive things in global and impressionistic ways (e.g., misses details, glosses over inconsistencies, mispronounces names). • Tends to develop somatic symptoms in response to stress or conflict (e.g., headache, backache, abdominal pain, asthma, etc.).

  35. What is it? (cont’d) • Esprime le proprie emozioni in modi esagerati e teatrali. • Tende a usare troppo il proprio aspetto fisico per attirare l’attenzione altrui ed essere notato/a. • Le sue credenze e aspettative sembrano cliché o stereotipi, come fossero uscite da un libro di fiabe o da un film. • Sembra che di come vanno le cose nel mondo ne sappia meno di quanto ci si aspetterebbe da una persona con la sua intelligenza, il suo background ecc.; appare naif o innocente. • Le sue percezioni sembrano globali e impressionistiche; non nota i dettagli, trascura le incoerenze e sbaglia a pronunciare i nomi. • Tende a sviluppare sintomi somatici in risposta a stress o conflitti (per es., mal di testa, mal di schiena, dolori addominali, asma, ecc.).

  36. How comprehensive? • ~85% of clinicians (n=1201) agreed or strongly agreed:“The SWAP-II allowed me to express the things I consider important about my patient’s personality”

  37. Are psychodynamic observations reliable? “…if we compare the results produced by correctly trained analysts”–Freud (1916-1917)

  38. SWAP Personality Profile

  39. Inter-Rater Reliability • r = .75 to .81 • Between independent clinicians • Between interviewers and treating therapists • r = .89 (Marin-Avellan & Fonagy)

  40. Higher reliability than structured research interviews that just “stick to the facts” (i.e., DSM criteria)

  41. Psychodynamic clinicians can make reliable observations and inferences about personality organization given a suitable technology for harnessing their judgments.

  42. The widely held view among researchers— that psychoanalytic constructs cannot be assessed reliably—is mistaken.

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