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Formulazione psicodinamica del caso clinico Integrare la teoria, la pratica, e perché no, anche la scienza Jonathan Shedler, PhD University of Colorado.

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Presentazione sul tema: "Formulazione psicodinamica del caso clinico Integrare la teoria, la pratica, e perché no, anche la scienza Jonathan Shedler, PhD University of Colorado."— Transcript della presentazione:

1 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

2 Psychodynamic Diagnostic Manual

3 Shedler-Westen Assessment Procedure (SWAP )

4 The Dog, the Tail, and the DSM

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

6 Healthy Neurotic Psychotic Borderlin e Level of personality organization Level

7 Personality Style hystericalobsessionalparanoidpsychopathicetc.

8 Healthy Neurotic Psychotic Borderline hystericalobsessionalparanoidpsychopathicEtc. Personality Style

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

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

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

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

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

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15 Shedler-Westen Assessment Procedure (SWAP )

16 As for academic psychology, its methods give extensive and reliable data which are, in everybodys 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 )

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

18 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)

19 Analytic Objections to Research Obiezioni alla ricerca

20 impossible impossible unnecessary unnecessary irrelevant irrelevant

21 Whats Been Wrong with Empirical Research? Cosa è andato storto nella ricerca empirica? Eliminate deduction, inference (or reduce to lowest common denominator) Eliminate deduction, inference (or reduce to lowest common denominator)

22 Real clinical data are messy A thought experiment... A thought experiment...

23 I dati clinici reali sono un gran casino

24 Harnessing Clinical Judgment Domare il giudizio clinico Common vocabulary Common vocabulary Attention to same spectrum of material Attention to same spectrum of material

25 Shedler-Westen Assessment Procedure (SWAP) *

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28 Seven-Year Iterative Revision process Were you able to describe the things you consider psychologically important about your patient?

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30 Items in Combination Expresses contradictory feelings or beliefs without being disturbed by the inconsistency; has little need to reconcile or resolve contradictory ideas. 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 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. Tends to see certain others as all bad, and loses the capacity to perceive any positive qualities the person may have.

31 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. 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 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. Tende a vedere alcune persone come totalmente cattive e perde la capacità di percepire le loro qualità positive.

32 Items in Combination Tends to see own unacceptable feelings or impulses in other people instead of in himself/herself. 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). 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.). 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.).

33 Items in Combination Tende a vedere i suoi sentimenti e impulsi inaccettabili negli altri e non in se stesso/a. 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). 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 lunica persona al mondo che possa aiutarli ecc.) 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 lunica persona al mondo che possa aiutarli ecc.)

34 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.). 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). 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).

35 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 laltra persona si stia prendendo cura di lui/lei e poi che sia maligna e gli/le voglia fare del male). 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 laltra 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). 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).

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37 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). 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 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 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.). Tends to be sexually seductive or provocative (e.g., may be inappropriately flirtatious, preoccupied with sexual conquest, prone to lead people on, etc.).

38 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). 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 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 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"). 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").

39 What is it? (contd) Expresses emotion in exaggerated and theatrical ways. Expresses emotion in exaggerated and theatrical ways. Tends to use his/her physical attractiveness to an excessive degree to gain attention or notice. 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. 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. 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 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.). Tends to develop somatic symptoms in response to stress or conflict (e.g., headache, backache, abdominal pain, asthma, etc.).

40 What is it? (contd) Esprime le proprie emozioni in modi esagerati e teatrali. Esprime le proprie emozioni in modi esagerati e teatrali. Tende a usare troppo il proprio aspetto fisico per attirare lattenzione altrui ed essere notato/a. Tende a usare troppo il proprio aspetto fisico per attirare lattenzione 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. 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. 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. 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.). Tende a sviluppare sintomi somatici in risposta a stress o conflitti (per es., mal di testa, mal di schiena, dolori addominali, asma, ecc.).

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42 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 patients personality ~85% of clinicians (n=1201) agreed or strongly agreed: The SWAP-II allowed me to express the things I consider important about my patients personality

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44 Are psychodynamic observations reliable? … if we compare the results produced by correctly trained analysts – Freud ( )

45 SWAP Personality Profile SWAP Item Rater 1 Rater 2 1. Tends to feel guilty (e.g., may blame self or feel responsible for bad things that happen) Is able to use his/her talents, abilities, and energy effectively and productively Takes advantage of others; has little investment in moral values (e.g., puts own needs first, uses or exploits people with little regard for their feelings or welfare, etc.) Has an exaggerated sense of self-importance (e.g., feels special, superior, grand, or envied) Tends to be emotionally intrusive (e.g., may not respect other peoples needs for autonomy, privacy, etc.). 55 through #200 through #200

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

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

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

49 The widely held view among researchers that psychoanalytic constructs cannot be assessed reliablyis mistaken.

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51 Applications (What can you do with the SWAP?) Clinical communication & supervision Clinical communication & supervision An alternative to DSM that is both scientifically based and psychodynamically meaningful An alternative to DSM that is both scientifically based and psychodynamically meaningful Integrate diagnosis and case formulation Integrate diagnosis and case formulation Treatment planning Treatment planning Assess structural change in treatment Assess structural change in treatment

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53 Clinical Communication

54 Facets of identity diffusion Lacks a stable sense of who s/he is (e.g., attitudes, values, goals, and feelings about self seem unstable or ever-changing). Lacks a stable sense of who s/he is (e.g., attitudes, values, goals, and feelings about self seem unstable or ever-changing). Appears to experience the past as a series of disjointed or disconnected events; has difficulty giving a coherent account of his/her life story. Appears to experience the past as a series of disjointed or disconnected events; has difficulty giving a coherent account of his/her life story. Is prone to painful feelings of emptiness (e.g., may feel lost, bereft, abjectly alone even in the presence of others, etc.). Is prone to painful feelings of emptiness (e.g., may feel lost, bereft, abjectly alone even in the presence of others, etc.). Seems unable to settle into, or sustain commitment to, identity- defining life roles (e.g., career, occupation, lifestyle, etc.). Seems unable to settle into, or sustain commitment to, identity- defining life roles (e.g., career, occupation, lifestyle, etc.). Tends to identify with admired others to an exaggerated degree, taking on their attitudes, mannerisms, etc. (e.g., may be drawn into the orbit of a strong or charismatic personality). Tends to identify with admired others to an exaggerated degree, taking on their attitudes, mannerisms, etc. (e.g., may be drawn into the orbit of a strong or charismatic personality).

55 Facets of identity diffusion Non ha unimmagine stabile di chi è o di chi vorrebbe diventare (per es., gli atteggiamenti, i valori, gli obiettivi o i sentimenti relativi a se stesso/a possono essere instabili e mutevoli). Non ha unimmagine stabile di chi è o di chi vorrebbe diventare (per es., gli atteggiamenti, i valori, gli obiettivi o i sentimenti relativi a se stesso/a possono essere instabili e mutevoli). Fa esperienza del passato come di una serie di eventi privi di rapporti e connessioni reciproche; ha difficoltà a fornire un racconto coerente della storia della propria vita. Fa esperienza del passato come di una serie di eventi privi di rapporti e connessioni reciproche; ha difficoltà a fornire un racconto coerente della storia della propria vita. È portato a provare dolorosi sentimenti di vuoto (per es., può sentirsi perso, privato di qualcosa di importante, orrendamente solo anche in presenza di altre persone ecc.). È portato a provare dolorosi sentimenti di vuoto (per es., può sentirsi perso, privato di qualcosa di importante, orrendamente solo anche in presenza di altre persone ecc.). Sembra incapace di immedesimarsi e impegnarsi in ruoli di vita che definiscono la sua identità (per es. la carriera, loccupazione, lo stile di vita ecc.) Sembra incapace di immedesimarsi e impegnarsi in ruoli di vita che definiscono la sua identità (per es. la carriera, loccupazione, lo stile di vita ecc.) Tende a identificarsi in modo eccessivo con altre persone che ammira, assumendo i loro atteggiamenti, modi di fare, ecc. (per es., può essere attratto nellorbita di una personalità forte o carismatica). Tende a identificarsi in modo eccessivo con altre persone che ammira, assumendo i loro atteggiamenti, modi di fare, ecc. (per es., può essere attratto nellorbita di una personalità forte o carismatica).

56 identity diffusion (contd.) Sense of identity revolves around a cause, movement, or label (e.g., adult child of alcoholic, adult survivor, environmentalist, born-again Christian, etc.); may be drawn to extreme or all- encompassing belief systems. Sense of identity revolves around a cause, movement, or label (e.g., adult child of alcoholic, adult survivor, environmentalist, born-again Christian, etc.); may be drawn to extreme or all- encompassing belief systems. Is unable to soothe or comfort him/herself without the help of another person (i.e., has difficulty regulating own emotions). Is unable to soothe or comfort him/herself without the help of another person (i.e., has difficulty regulating own emotions). Believes that some important other has a special, seemingly magical ability to know his/her innermost thoughts or feelings (e.g., imagines rapport is so perfect that ordinary communication is superfluous). Believes that some important other has a special, seemingly magical ability to know his/her innermost thoughts or feelings (e.g., imagines rapport is so perfect that ordinary communication is superfluous). Tends to feel s/he is not his/her true self with others; may feel false or fraudulent. Tends to feel s/he is not his/her true self with others; may feel false or fraudulent.

57 identity diffusion (contd.) Il suo senso di identità ruota attorno a una causa, a un movimento o a unetichetta (per es., figlio/a di un alcolista, sopravvissuto/a, ambientalista, convertito/a al cristianesimo ecc.); può essere attratto/a da sistemi di credenze estremi o onni-comprensivi. Il suo senso di identità ruota attorno a una causa, a un movimento o a unetichetta (per es., figlio/a di un alcolista, sopravvissuto/a, ambientalista, convertito/a al cristianesimo ecc.); può essere attratto/a da sistemi di credenze estremi o onni-comprensivi. È incapace di calmarsi o tranquillizzarsi senza laiuto di unaltra persona (cioè, ha difficoltà nella regolazione delle proprie emozioni). È incapace di calmarsi o tranquillizzarsi senza laiuto di unaltra persona (cioè, ha difficoltà nella regolazione delle proprie emozioni). Sente che alcune delle persone per lui importanti hanno una capacità speciale e quasi magica di capire i suoi pensieri e i suoi sentimenti più intimi (per es., può immaginare che lintesa fra lui e questa persona sia così perfetta da rendere superflui i normali sforzi di comunicazione). Sente che alcune delle persone per lui importanti hanno una capacità speciale e quasi magica di capire i suoi pensieri e i suoi sentimenti più intimi (per es., può immaginare che lintesa fra lui e questa persona sia così perfetta da rendere superflui i normali sforzi di comunicazione). Tende a sentire di non essere veramente se stesso/a con gli altri; tende a sentirsi falso/a o fraudolento/a. Tende a sentire di non essere veramente se stesso/a con gli altri; tende a sentirsi falso/a o fraudolento/a.

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59 Applications (What can you do with the SWAP?) Clinical communication & supervision Clinical communication & supervision An alternative to DSM that is both scientifically based and psychodynamically meaningful An alternative to DSM that is both scientifically based and psychodynamically meaningful Integrate diagnosis and case formulation Integrate diagnosis and case formulation Treatment planning Treatment planning Assess structural change in treatment Assess structural change in treatment

60 A scientifically based and clinically meaningful diagnostic system Personality prototypes describe diagnostic syndromes in their ideal form (paranoid, schizoid, narcissistic, borderline, obsessional, etc.) Personality prototypes describe diagnostic syndromes in their ideal form (paranoid, schizoid, narcissistic, borderline, obsessional, etc.)

61 SWAP Personality Profile SWAP Item Patient Diagnostic Prototype 1. Tends to feel guilty (e.g., may blame self or feel responsible for bad things that happen) Is able to use his/her talents, abilities, and energy effectively and productively Takes advantage of others; has little investment in moral values (e.g., puts own needs first, uses or exploits people with little regard for their feelings or welfare, etc.) Has an exaggerated sense of self-importance (e.g., feels special, superior, grand, or envied) Tends to be emotionally intrusive (e.g., may not respect other peoples needs for autonomy, privacy, etc.). 55 through #200 through #200

62 DSM-V Score Profile

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64 A scientifically based and clinically meaningful diagnostic system

65 SWAP Personality Profile SWAP Item Patient Diagnostic Prototype 1. Tends to feel guilty (e.g., may blame self or feel responsible for bad things that happen) Is able to use his/her talents, abilities, and energy effectively and productively Takes advantage of others; has little investment in moral values (e.g., puts own needs first, uses or exploits people with little regard for their feelings or welfare, etc.) Has an exaggerated sense of self-importance (e.g., feels special, superior, grand, or envied) Tends to be emotionally intrusive (e.g., may not respect other peoples needs for autonomy, privacy, etc.). 55 through #200 through #200

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67 Toward DSM-V: A scientifically based and clinically meaningful diagnostic system N=496 clinicians N=496 clinicians 2/3 psychologists, 1/3 psychiatrists 2/3 psychologists, 1/3 psychiatrists 18 years practice experience 18 years practice experience All theoretical orientations All theoretical orientations

68 Factor Analysis vs. Q-Analysis V1sadnessV2 loss of interest in activities V3 trouble concentrating V4delusionsV5hallucinations Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6

69 Integrating Descriptive Psychiatry and Clinical Case formulation Personality prototypes describe empirically derived diagnostic syndromes in their ideal form (depressive, paranoid, obsessional, etc.) Personality prototypes describe empirically derived diagnostic syndromes in their ideal form (depressive, paranoid, obsessional, etc.)

70 SWAP Personality Profile SWAP Item Patient Diagnostic Prototype 1. Tends to feel guilty (e.g., may blame self or feel responsible for bad things that happen) Is able to use his/her talents, abilities, and energy effectively and productively Takes advantage of others; has little investment in moral values (e.g., puts own needs first, uses or exploits people with little regard for their feelings or welfare, etc.) Has an exaggerated sense of self-importance (e.g., feels special, superior, grand, or envied) Tends to be emotionally intrusive (e.g., may not respect other peoples needs for autonomy, privacy, etc.). 55 through #200 through #200

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72 Diagnostic Prototypes Antisocial-Psychopathic Antisocial-Psychopathic Paranoid Paranoid Schizoid-Schizotypal Schizoid-Schizotypal Obsessional style* Obsessional style* Histrionic Histrionic Narcissistic Narcissistic Depressive Depressive Hostile-Oppositional Dysregulated (Borderline) Avoidant Dependent-Victimized

73 Key Findings of Q-Analysis Some Axis II categories confirmed empirically Some Axis II categories confirmed empiricallyBut… Carves nature differently Carves nature differently (low comorbidity)

74 Key Findings of Q-Analysis Includes intrapsychic processes (not just manifest behavior) Includes intrapsychic processes (not just manifest behavior)

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76 Paranoid Personality Is quick to assume that others wish to harm or take advantage of him/her; tends to perceive malevolent intentions in others words and actions Is quick to assume that others wish to harm or take advantage of him/her; tends to perceive malevolent intentions in others words and actions Tends to avoid confiding in others for fear of betrayal; expects things s/he says or does will be used against him/her. Tends to avoid confiding in others for fear of betrayal; expects things s/he says or does will be used against him/her.

77 Paranoid Personality È subito portato a pensare che gli altri vogliano danneggiarlo/a o approfittarsenedi lui/lei; tende a cogliere intenzioni malevole nelle parole e nelle azioni degli altri. È subito portato a pensare che gli altri vogliano danneggiarlo/a o approfittarsenedi lui/lei; tende a cogliere intenzioni malevole nelle parole e nelle azioni degli altri. Tende a evitare di fare confidarsi con gli altri per paura di essere tradito/a; si aspetta che le cose che dice e fa siano poi usate contro di lui/lei. Tende a evitare di fare confidarsi con gli altri per paura di essere tradito/a; si aspetta che le cose che dice e fa siano poi usate contro di lui/lei.

78 Paranoid Personality Tends to be angry or hostile (whether consciously or unconsciously). Tends to be angry or hostile (whether consciously or unconsciously). Tends to see own unacceptable feelings or impulses in other people instead of in him/herself. Tends to see own unacceptable feelings or impulses in other people instead of in him/herself. Tends to blame others for own failures or shortcomings; tends to believe his/her problems are caused by external factors. Tends to blame others for own failures or shortcomings; tends to believe his/her problems are caused by external factors. Tends to see certain others as all bad, and loses the capacity to perceive any positive qualities the person may have. Tends to see certain others as all bad, and loses the capacity to perceive any positive qualities the person may have. Has little empathy; seems unable to understand or respond to others needs and feelings unless they coincide with his/her own. Has little empathy; seems unable to understand or respond to others needs and feelings unless they coincide with his/her own. Tends to become irrational when strong emotions are stirred up; may show a noticeable decline from customary level of functioning. Tends to become irrational when strong emotions are stirred up; may show a noticeable decline from customary level of functioning.

79 Paranoid Personality Tende a essere arrabbiato/a o ostile (sia consciamente sia inconsciamente). Tende a essere arrabbiato/a o ostile (sia consciamente sia inconsciamente). Tende a vedere i suoi sentimenti e impulsi inaccettabili negli altri e non in se stesso/a. Tende a vedere i suoi sentimenti e impulsi inaccettabili negli altri e non in se stesso/a. Tende a incolpare gli altri per i propri fallimenti o difetti; tende a credere che i suoi problemi siano causati da fattori esterni. Tende a incolpare gli altri per i propri fallimenti o difetti; tende a credere che i suoi problemi siano causati da fattori esterni. Tende a vedere alcune persone come totalmente cattive e perde la capacità di percepire le loro qualità positive. Tende a vedere alcune persone come totalmente cattive e perde la capacità di percepire le loro qualità positive. Ha poca empatia; sembra incapace di capire o rispondere ai bisogni e ai sentimenti degli altri a meno che non coincidano con i propri. Ha poca empatia; sembra incapace di capire o rispondere ai bisogni e ai sentimenti degli altri a meno che non coincidano con i propri. Le emozioni forti tendono a farlo diventare irrazionale; può mostrare un notevole declino del proprio livello di funzionamento abituale. Le emozioni forti tendono a farlo diventare irrazionale; può mostrare un notevole declino del proprio livello di funzionamento abituale.

80 Schizoid Personality Lacks close friendships and relationships. Lacks close friendships and relationships. Appears to have little need for human company or contact; is genuinely indifferent to the presence of others. Appears to have little need for human company or contact; is genuinely indifferent to the presence of others. Appears to have a limited or constricted range of emotions. Appears to have a limited or constricted range of emotions. Appearance or manner seems odd or peculiar (e.g., grooming, hygiene, posture, eye contact, speech rhythms, etc. seem somehow strange or off). Appearance or manner seems odd or peculiar (e.g., grooming, hygiene, posture, eye contact, speech rhythms, etc. seem somehow strange or off).

81 Schizoid Personality Tends to avoid social situations because of fear of embarrassment or humiliation. Tends to avoid social situations because of fear of embarrassment or humiliation. Tends to be anxious. Tends to be anxious. Tends to feel inadequate, inferior, or a failure. Tends to feel inadequate, inferior, or a failure. Tends to feel unhappy, depressed, or despondent. Tends to feel unhappy, depressed, or despondent.

82 Psychopathic Personality Takes advantage of others; is out for number one; has minimal investment in moral values. Takes advantage of others; is out for number one; has minimal investment in moral values. Tends to be deceitful; tends to lie or mislead. Tends to be deceitful; tends to lie or mislead. Tends to show reckless disregard for the rights, property, or safety of others. Tends to show reckless disregard for the rights, property, or safety of others.

83 Psychopathic Personality Sfrutta gli altri; cerca di essere sempre il numero uno; dà pochissima importanza ai valori morali. Sfrutta gli altri; cerca di essere sempre il numero uno; dà pochissima importanza ai valori morali. Tende a essere disonesto; tende a mentire o ingannare le altre persone. Tende a essere disonesto; tende a mentire o ingannare le altre persone. Tende a dimostrare una sconsiderata indifferenza verso i diritti, la proprietà o la sicurezza degli altri. Tende a dimostrare una sconsiderata indifferenza verso i diritti, la proprietà o la sicurezza degli altri.

84 Psychopathic Personality Has little empathy; seems unable to understand or respond to others needs and feelings unless they coincide with his/her own. Has little empathy; seems unable to understand or respond to others needs and feelings unless they coincide with his/her own. Appears to experience no remorse for harm or injury caused to others. Appears to experience no remorse for harm or injury caused to others. Tends to seek power or influence over others. Tends to seek power or influence over others. Appears to gain pleasure or satisfaction by being sadistic or aggressive toward others. Appears to gain pleasure or satisfaction by being sadistic or aggressive toward others. Has an exaggerated sense of self-importance. Has an exaggerated sense of self-importance.

85 Psychopathic Personality Ha poca empatia; sembra incapace di capire o rispondere ai bisogni e ai sentimenti degli altri a meno che non coincidano con i propri. Ha poca empatia; sembra incapace di capire o rispondere ai bisogni e ai sentimenti degli altri a meno che non coincidano con i propri. Sembra non provare alcun rimorso per i danni o le ferite che ha arrecato ad altre persone. Sembra non provare alcun rimorso per i danni o le ferite che ha arrecato ad altre persone. Cerca di avere potere o di esercitare la sua influenza sugli altri (sia in modi benefici sia in modi distruttivi). Cerca di avere potere o di esercitare la sua influenza sugli altri (sia in modi benefici sia in modi distruttivi). Sembra trarre piacere o soddisfazione comportandosi in modo sadico o aggressivo con gli altri (sia consciamente sia inconsciamente). Sembra trarre piacere o soddisfazione comportandosi in modo sadico o aggressivo con gli altri (sia consciamente sia inconsciamente). Si sente esageratamente importante. Si sente esageratamente importante.

86 Depressive Personality (!) Tends to feel unhappy, depressed, or despondent. Tends to feel unhappy, depressed, or despondent. Tends to feel s/he is inadequate, inferior, or a failure. Tends to feel s/he is inadequate, inferior, or a failure. Appears to find little or no pleasure, satisfaction, or enjoyment in lifes activities. Appears to find little or no pleasure, satisfaction, or enjoyment in lifes activities. Tends to blame self or feel responsible when bad things happen. Tends to blame self or feel responsible when bad things happen.

87 Depressive Personality (!) Tende a sentirsi infelice, depresso o abbattuto. Tende a sentirsi infelice, depresso o abbattuto. Tende a sentirsi inadeguato/a, inferiore o falllito/a. Tende a sentirsi inadeguato/a, inferiore o falllito/a. Sembra provare poco piacere, soddisfazione o godimento nelle attività della vita, o non ne prova affatto. Sembra provare poco piacere, soddisfazione o godimento nelle attività della vita, o non ne prova affatto. Tende a incolparsi o a sentirsi responsabile delle cose negative che succedono. Tende a incolparsi o a sentirsi responsabile delle cose negative che succedono.

88 Depressive Personality Tends to be angry or hostile (whether consciously or unconsciously). Tends to be angry or hostile (whether consciously or unconsciously). Has difficulty acknowledging or expressing anger. Has difficulty acknowledging or expressing anger. Tends to express aggression in passive and indirect ways (e.g., may make mistakes, procrastinate, forget, become sulky, etc.). Tends to express aggression in passive and indirect ways (e.g., may make mistakes, procrastinate, forget, become sulky, etc.). Appears to want to punish self; creates situations that lead to unhappiness, or actively avoids opportunities for pleasure and gratification. Appears to want to punish self; creates situations that lead to unhappiness, or actively avoids opportunities for pleasure and gratification. Has trouble acknowledging or expressing anger toward others, and instead becomes depressed, self-critical, self-punitive, etc. (i.e., turns anger against self). Has trouble acknowledging or expressing anger toward others, and instead becomes depressed, self-critical, self-punitive, etc. (i.e., turns anger against self).

89 Depressive Personality Tende a essere arrabbiato/a o ostile (sia consciamente sia inconsciamente). Tende a essere arrabbiato/a o ostile (sia consciamente sia inconsciamente). Ha difficoltà a riconoscere o esprimere la propria rabbia. Ha difficoltà a riconoscere o esprimere la propria rabbia. Tende a esprimere la propria aggressività in modi passivi e indiretti (per es., può fare errori, procrastinare, dimenticare, tenere il muso, ecc.). Tende a esprimere la propria aggressività in modi passivi e indiretti (per es., può fare errori, procrastinare, dimenticare, tenere il muso, ecc.). Sembra volersi punire; crea situazioni che procurano infelicità, o evita attivamente occasioni di piacere e gratificazione. Sembra volersi punire; crea situazioni che procurano infelicità, o evita attivamente occasioni di piacere e gratificazione. Ha problemi nel riconoscere o nellesprimere la sua rabbia verso altre persone, e invece di farlo diventa depresso, auto-critico, auto-punitivo ecc. (cioè, rivolge la rabbia contro se stesso). Ha problemi nel riconoscere o nellesprimere la sua rabbia verso altre persone, e invece di farlo diventa depresso, auto-critico, auto-punitivo ecc. (cioè, rivolge la rabbia contro se stesso).

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91 Comparison with DSM Axis II Empirically derived Empirically derived Dimensional, not categorical Dimensional, not categorical Includes intrapsychic & dynamic factors Includes intrapsychic & dynamic factors Minimizes comorbidity Minimizes comorbidity Reliable, valid Reliable, valid Clinically relevant (a roadmap for treatment) Clinically relevant (a roadmap for treatment)

92 Reliability and Validity Interrater reliability median ~.80 Interrater reliability median ~.80 Test-retest reliability median ~.80 Test-retest reliability median ~.80 In research to date, scales predict In research to date, scales predict Independent interview SWAP diagnosis Independent interview SWAP diagnosis Adaptive functioning (e.g., GAF, Kernberg ratings) Adaptive functioning (e.g., GAF, Kernberg ratings) History of suicide, hospitalization, arrest, involvement in abusive relationships History of suicide, hospitalization, arrest, involvement in abusive relationships Family and developmental history Family and developmental history Treatment response Treatment response

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94 Concluding Thoughts The psychoanalytic clinician is the most sensitive diagnostic instrument in the world The psychoanalytic clinician is the most sensitive diagnostic instrument in the world SWAP enables us to harness this instrument SWAP enables us to harness this instrument Provides a language all can speak– an antidote to Tower of Babel syndrome Provides a language all can speak– an antidote to Tower of Babel syndrome Refines case formulation in ways that inform treatment Refines case formulation in ways that inform treatment Assesses change– demonstrating efficacy of psychoanalysis in the era of evidence based treatment Assesses change– demonstrating efficacy of psychoanalysis in the era of evidence based treatment

95 For copies of the SWAP-200 and related publications, visit or


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