4 Classification and assessment in psychiatry4.3 Clinical assessment
4.3.5.1 Dynamic psychopathology
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Written by Resident Doctor Committee · Published
Descriptive and dynamic psychopathology
Descriptive psychopathology only observes and describes behaviour and subjective experience.
Dynamic psychopathology is explanatory: it attributes symptoms to unconscious processes, conflicts and relationship patterns.
A symptom can be read as a compromise between a wish and the defence against it. Such readings are theoretical and can sit alongside learning, cognitive and biological explanations.
Freud's models of the mind
Topographical model (1900)
The topographical model divides the mind by access to awareness.
Level | Content | Access |
|---|---|---|
Conscious | Current awareness | Immediate |
Preconscious | Material outside awareness that can be recalled | With attention |
Unconscious | Wishes and conflicts outside awareness | Inferred only |
The preconscious acts as the censor that maintains the repressive barrier at the border of the unconscious.
Structural model (1923)
The structural model divides the mind by function.
Structure | Function | Mode of working |
|---|---|---|
Id | Drives and wishes | Primary process thinking under the pleasure principle; present from birth and wholly unconscious |
Ego | Mediates between drives and reality | Secondary process thinking under the reality principle; delays discharge until the outside world permits it |
Superego | Internalised conscience, prohibitions and ideals | Moral demands and self-evaluation |
Defence mechanisms are unconscious operations of the ego.
The superego takes its values chiefly from internalised parental ideals, formed by identification with the parents as the Oedipus complex resolves at about 5 to 6 years.
The superego becomes a settled internal agency during the latency stage.
Freud placed the Oedipus complex and castration anxiety in the phallic stage of psychosexual development.
Free association and dreams
Free association is the technique Freud made central to psychoanalysis for reaching unconscious material.
Dream work is the unconscious process that turns latent dream thoughts into the manifest dream as remembered. Its mechanisms are condensation, displacement and secondary revision.
Interpretation runs the other way, working back from the manifest dream to its latent meaning.
Condensation compresses several latent wishes or thoughts into one element of the manifest dream.
Symbolism is the unconscious use of an object or image to stand for repressed thoughts, feelings or impulses.
Defences: principles
Defences protect against anxiety, which signals an internal danger, but become costly when rigid or poorly matched to circumstances.
Most defences are unconscious; suppression is the deliberate, conscious exception.
Freud treated repression as the original, central defence, with other defences described later as part of normal development.
No single defence diagnoses a personality disorder. Judge a defence by its flexibility, context and consequences.
Vaillant's hierarchy of defences
Vaillant arranged defences in four levels of increasing adaptiveness.
Level | Defences |
|---|---|
Psychotic | Delusional projection, psychotic denial, distortion |
Immature | Acting out, projection, passive aggression, hypochondriasis, schizoid fantasy, splitting |
Neurotic | Repression, displacement, intellectualisation, isolation, rationalisation, reaction formation |
Mature | Suppression, altruism, anticipation, asceticism, humour, sublimation |
Acting out is an immature defence, and it is the least mature of the defences it is compared with.
Distortion reshapes external reality to fit inner needs, as in grandiose or wish-fulfilling beliefs. Kaplan and Sadock group it as narcissistic, with denial and projection, which Vaillant called psychotic.
Repression is neurotic and unconscious; suppression is mature and conscious.
Individual defence mechanisms
Defence | What it does | Example |
|---|---|---|
Repression | Unconsciously excludes unacceptable internal wishes, impulses or memories from awareness; the material persists, still exerts influence and may return disguised as symptoms | Motivated (catathymic) forgetting |
Suppression | Consciously postpones attention to a distressing matter; the facts are accepted and the problem kept available for later | |
Denial | Unconsciously refuses to accept a threatening fact about external reality | |
Displacement | Shifts an emotion, unchanged, from the person who provoked it onto a safer substitute target | Anger at a powerful figure released on a lower-status person |
Sublimation | Unconsciously channels an unacceptable impulse into a socially valued, constructive activity that keeps partial gratification | Aggression channelled into a constructive pursuit |
Projection | Unconsciously attributes one's own disowned feeling or impulse to another person, who is not changed by it | |
Projective identification | Places a disowned feeling in another person, who is induced to feel and act on it; often first noticed through countertransference | Introduced by Klein in 1946 |
Splitting | Fails to hold good and bad in one view of a person, so people are all good or all bad and the view can flip | Staff divided into opposing camps |
Reaction formation | Keeps an unacceptable impulse out of awareness by adopting and exaggerating its opposite towards the same person, in a sustained, rigid pattern | |
Undoing | A discrete, symbolic act cancels an earlier impulse, thought or deed | Caretaking after an outburst; touching wood after a harmful thought |
Intellectualisation | Holds emotion at a distance through excessive abstract reasoning, facts and technical detail, while the diagnosis is accepted | |
Isolation of affect | Keeps the memory or idea fully conscious while its emotion is detached | |
Rationalisation | Builds a plausible, self-serving justification after the event to make an unwelcome outcome acceptable | Sour grapes |
Regression | Returns under stress to the behaviour of a younger developmental stage, which lowers anxiety | Childlike dependence and clinging |
Acting out | Discharges an unconscious conflict directly through impulsive behaviour, bypassing awareness of both idea and affect | Action stands in for reflection and speech |
Passive aggression | Expresses covert hostility through obstruction while speech stays pleasant | Forgetting, lateness, small errors |
Dissociation | Temporarily and drastically alters identity, memory or consciousness to keep overwhelming distress out of experience | Predominant defence in fugue states and conversion reactions |
Turning against the self | Redirects aggression onto one's own body instead of the person who provoked it | |
Altruism | Meets one's own needs through constructive service to others | |
Humour | Acknowledges distress through tolerable humour |
Identification remodels the self-representation to resemble a valued, admired other, so the person genuinely feels as the other does. Introjection only takes the other in as an internal representation.
Magical thinking is the belief that one's own thoughts or actions can cause or prevent outside events beyond accepted causality. It is typical of obsessive-compulsive disorder (OCD).
Dissociative amnesia is a sudden retrograde loss of autobiographical (episodic) memory for a circumscribed period after psychological trauma. Identity, general knowledge, skills and new learning are preserved.
Telling neighbours apart
Sublimation changes the aim of the impulse; displacement keeps the feeling unchanged and moves it to a substitute target.
Reaction formation is a sustained, rigid pattern; undoing is a discrete cancelling act.
Projection leaves the other person unchanged; projective identification induces them to feel and act on the feeling.
Projection is a defence and is distinct from the cognitive distortions.
Repression targets internal material; denial targets external reality.
Intellectualisation keeps feeling away by abstract reasoning; isolation of affect leaves the idea in plain view but strips its feeling.
Defences linked to conditions
Condition | Characteristic defence |
|---|---|
Borderline personality disorder | Splitting with projective identification |
Suspicious, grievance-holding personality; paranoid states | Projection |
Compulsions | Undoing (Freud) |
Phobia, as in Freud's Little Hans | Displacement |
In borderline personality disorder, carers who come to feel and enact the roles assigned to them are showing projective identification.
Klein and object relations
Object relations theory examines internal representations of self and others, and places the search for relationships, not drive discharge, at the root of motivation.
Fairbairn held that libido is object-seeking, not pleasure-seeking.
Melanie Klein is principally credited with founding object relations theory, with internal objects, part-objects and the split good and bad breast. She kept drive theory while emphasising early relationships and unconscious phantasy.
Klein's positions
Position | When | How the object is held | Anxiety and defences |
|---|---|---|---|
Paranoid-schizoid | Earliest mode, first 3 to 4 months | Split into idealised and denigrated part-objects | Persecutory anxiety; primitive defences |
Depressive | Follows the paranoid-schizoid | Mother related to as one whole object | Ambivalence, concern and guilt; manic defences |
The positions are modes of organising experience that can recur, not fixed stages.
Primitive defences of the paranoid-schizoid position follow the mnemonic SIPDOG: splitting, introjection, projective identification, denial, omnipotence and grandiosity.
Mature defences do not belong to the paranoid-schizoid position, because they need stable whole-object relating.
In the depressive position the infant must tolerate ambivalence, loving and hating the same object.
Manic defences (control, triumph and contempt, with denial, omnipotence and idealisation) guard against depressive anxiety by denying the value of, and dependence on, the loved object.
If the move to the depressive position is not consolidated, good and bad representations stay split, with alternating idealisation and devaluation and no concern for the attacked object.
Bion
Container-contained is the cycle in which a carer or therapist takes in unbearable raw emotion, bears it and returns it in a manageable form, which the person gradually internalises.
Alpha function transforms raw sensory and emotional experience (beta elements) into material that can be thought about. The caregiver supplies it first, and the infant later internalises it.
Reverie is the carer's receptive state that allows alpha function.
Nameless dread is the objectless, wordless terror that results when a carer fails to contain and transform an infant's projected distress.
Winnicott and Kernberg
Winnicott's concepts include the holding environment (Winnicott's, not Bion's), transitional objects, good-enough caregiving and the false self.
The false self is a compliant, defensive structure built when a child adapts to the caregiver's needs instead of having spontaneous gestures met. It hides the true self and leaves an adult who feels empty and unreal.
Do not confuse the false self with Kernberg's identity diffusion.
Kernberg describes levels of personality organisation by identity integration, defences and reality testing.
Kernberg separates borderline from psychotic organisation by reality testing, which is preserved in borderline organisation, shown by the ability to reappraise a transient odd belief.
Hierarchy of anxiety
The psychodynamic hierarchy of anxiety runs from disintegration anxiety, the most primitive, through persecutory anxiety, separation anxiety, fear of loss of love and castration anxiety, to superego anxiety, the most mature.
Jung's analytical psychology
Jung divided the unconscious into a personal unconscious and a collective unconscious, an inherited layer shared by all humankind.
The collective unconscious is made up of archetypes, universal symbolic patterns that appear across cultures.
Individuation is the process of becoming an integrated, undivided self, more fully individual yet still related to others.
The anima is the contrasexual figure in a man's psyche, often appearing as a guide to the unconscious. Anima and animus are both Jung's terms.
The shadow holds the disowned, darker sides of the personality, projected as strong unexplained loathing; it can also hold unlived creative potential.
The persona is the adapted public face or role, and over-identifying with it cuts a person off from the rest of the psyche.
Jung also developed the concepts of introversion and extraversion.
Jungian concepts must not be credited to another early dissenter from Freud: the collective unconscious is Jung's, not Adler's.
Adler and the neo-Freudians
Psychodynamic concepts are tied to their originators, who include Jung, Erikson, Klein, Winnicott, Kohut, Adler and Bleuler, and each concept is credited to its own originator.
Alfred Adler's individual psychology owns the reasoning-centred terms about the beliefs that drive behaviour, not Freud or the cognitive therapists.
The neo-Freudians kept Freud's unconscious but moved the weight to social and interpersonal forces.
Theorists whose work rests on observation, learning or cognitive-developmental stages fall outside the neo-Freudian group.
Transference, countertransference and formulation
Transference is the expression of earlier relational expectations in current relationships.
Countertransference is the clinician's emotional and behavioural response, such as rescue impulses, irritation or hopelessness. It can inform hypotheses but does not prove the patient's motives.
Enactment is a relational pattern taking shape between patient and clinician or within a team.
A psychodynamic formulation links experience and current context to a proposed conflict, trigger, feelings, defences and implications for care. A coherent formulation is not proof.
Check practical and medical explanations first: a missed bus is not resistance, and physical illness must not be reduced to symbolic meaning.