Jonathan Shedler, PhD University of Colorado Denver School of Medicine 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

Shedler-Westen Assessment Procedure (SWAP)

The Dog, the Tail, and the DSM

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

Level of personality organization Healthy Neurotic Level Borderline Psychotic

Personality Style hysterical obsessional paranoid psychopathic etc.

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

Borderline Personality Organization Affect Dysregulation Defenses based on Splitting Splitting Primitive Projection Projective Identification Identity Diffusion DSM-III criteria adopted from Gunderson research criteria. Except the crucial criterion, tends to become psychotic in the transference. A certain loss of perspective occurred, patient seemed unable to distinguish between inner experience and reality. E.g., Neurotic/healthier pt: Are you experiencing me like your mother? You ARE exactly like my mother, stop it you bitch. DSM describes a very flamboyant, drmatic, hysetroid type of borderline. But intrapsychic processes will aply to most Axis II pts.

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

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

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 Personality Disorder

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)

Shedler-Westen Assessment Procedure (SWAP)

“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)

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

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)

Analytic Objections to Research Obiezioni alla ricerca

Analytic Objections to Research Obiezioni alla ricerca impossible unnecessary irrelevant

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

Real clinical data are messy A thought experiment...

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

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

Shedler-Westen Assessment Procedure (SWAP) *

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

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.

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.

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.).

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.)

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).

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).

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.).

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").

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.).

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.).

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”

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

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). 1 2. Is able to use his/her talents, abilities, and energy effectively and productively. 6 7 3. 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.). 4. Has an exaggerated sense of self-importance (e.g., feels special, superior, grand, or envied). 5. Tends to be emotionally intrusive (e.g., may not respect other people’s needs for autonomy, privacy, etc.). 5 ↓ through #200 ↓

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

Higher reliability than structured research interviews that just “stick to the facts” (i.e., DSM criteria) Seven year iterative revision process.

Psychodynamic clinicians can make reliable observations and inferences about personality organization given a suitable technology for harnessing their judgments. Seven year iterative revision process.

The widely held view among researchers— that psychoanalytic constructs cannot be assessed reliably—is mistaken. Seven year iterative revision process.

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

Clinical Communication

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). 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.). 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).

Facets of “identity diffusion” Non ha un’immagine 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. 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, l’occupazione, 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 nell’“orbita” di una personalità forte o carismatica).

“identity diffusion” (cont’d.) 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). 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.

“identity diffusion” (cont’d.) Il suo senso di identità ruota attorno a una “causa”, a un movimento o a un’etichetta (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 l’aiuto di un’altra 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 l’intesa 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.

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

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

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). 1 2. Is able to use his/her talents, abilities, and energy effectively and productively. 6 7 3. 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.). 4. Has an exaggerated sense of self-importance (e.g., feels special, superior, grand, or envied). 5. Tends to be emotionally intrusive (e.g., may not respect other people’s needs for autonomy, privacy, etc.). 5 ↓ through #200 ↓

DSM-V Score Profile

A scientifically based and clinically meaningful diagnostic system

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). 1 2. Is able to use his/her talents, abilities, and energy effectively and productively. 6 7 3. 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.). 4. Has an exaggerated sense of self-importance (e.g., feels special, superior, grand, or envied). 5. Tends to be emotionally intrusive (e.g., may not respect other people’s needs for autonomy, privacy, etc.). 5 ↓ through #200 ↓

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

Factor Analysis vs. Q-Analysis sadness V2 loss of interest in activities V3 trouble concentrating V4 delusions V5 hallucinations Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6

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

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). 1 2. Is able to use his/her talents, abilities, and energy effectively and productively. 6 7 3. 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.). 4. Has an exaggerated sense of self-importance (e.g., feels special, superior, grand, or envied). 5. Tends to be emotionally intrusive (e.g., may not respect other people’s needs for autonomy, privacy, etc.). 5 ↓ through #200 ↓

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

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

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

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 Tends to avoid confiding in others for fear of betrayal; expects things s/he says or does will be used against him/her.

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. 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.

Paranoid Personality 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 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. 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.

Paranoid Personality 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 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. 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.

Schizoid Personality 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 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”).

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

Psychopathic Personality 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 show reckless disregard for the rights, property, or safety of others.

Psychopathic Personality 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 dimostrare una sconsiderata indifferenza verso i diritti, la proprietà o la sicurezza degli altri.

Psychopathic Personality 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. Tends to seek power or influence over others. Appears to gain pleasure or satisfaction by being sadistic or aggressive toward others. Has an exaggerated sense of self-importance.

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. 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). Sembra trarre piacere o soddisfazione comportandosi in modo sadico o aggressivo con gli altri (sia consciamente sia inconsciamente). Si sente esageratamente importante.

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

Depressive Personality (!) Tende a sentirsi infelice, depresso o abbattuto. 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. Tende a incolparsi o a sentirsi responsabile delle cose negative che succedono.

Depressive Personality Tends to be angry or hostile (whether consciously or unconsciously). 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.). 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).

Depressive Personality Tende a essere arrabbiato/a o ostile (sia consciamente sia inconsciamente). 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.). Sembra volersi “punire”; crea situazioni che procurano infelicità, o evita attivamente occasioni di piacere e gratificazione. Ha problemi nel riconoscere o nell’esprimere la sua rabbia verso altre persone, e invece di farlo diventa depresso, auto-critico, auto-punitivo ecc. (cioè, rivolge la rabbia contro se stesso).

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

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

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

For copies of the SWAP-200 and related publications, visit www For copies of the SWAP-200 and related publications, visit www.SWAPassessment.org or email jonathan@shedler.com