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작성자  simonshin 작성일  2016.09.22 21:12 조회수 1232 추천 0
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 신현근 박사 강의안 - 히스테리성 성격 장애  
 

과목:  진단과 평가

주제히스테리성 (연극성) 성격 장애

강사:  신현근 박사 

내용:  강의안

교재:  PDM Task Force. (2006). Psychodynamic Diagnostic Manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations 

 

Hysterical (Histrionic) Personality Disorders (PDM)

1.      Overview

1.1.   Patients with hysterical personality disorder are preoccupied with issues of gender, sexuality, and power.

1.2.   They may come across as flamboyant and attention-seeking, as in the DSM description, or they may strike the interviewer as curiously naive, conventional, and inhibited.

1.3.   Unconsciously, they tend to regard themselves as weak, defective, and devalued on the basis of their gender, and see individuals of the opposite sex as powerful, exciting, frightening, and enviable (Horowitz, 1991).

1.4.   Before DSM-III applied the termhistrionic” to patients with unconscious gender preoccupations, most psychoanalytic practitioners used the term “hysterical” for neurotically organized individuals with these dynamics, and the term “histrionic” or “hysteroid” for those in the borderline range.

1.5.   The DSM diagnosis of Borderline Personality Disorder is essentially a description of a histrionic person at the borderline level of severity (cf. Zetzel, 1968).

 

2.      Developmental background

2.1.   Clinical experience suggests that heterosexual individuals who grow up disappointed by the same-sex parent and overstimulated by the opposite-sex parent may become hysterically organized.

2.2.   Thus, hysterical women tend to describe their mothers as depressed or overburdened and their fathers as larger than life.

2.3.   The opposite-sex parent may have been seductive or sexually inappropriate, sometimes to the point of molestation.

2.4.    In gay and lesbian children with hysterical dynamics, the same-sex parent is often reported as powerful, problematic, or frightening.

2.5.   Unlike transgendered individuals, the hysterical or histrionic person accepts his or her biological gender, but feels that it confers significant disadvantages.

 

3.      Seductiveness  and power

3.1.   Hysterical and histrionic individuals may seek power via seductiveness (“ pseudohypersexuality”) toward persons of the overvalued gender.

3.2.   Sexual intimacy, however, is a source of significant conflict because of unconscious shame about one’s gendered body and fears of being damaged by the more powerful other.

3.3.   Some people with hysterical psychologies are sexually avoidant or unresponsive, while others flaunt their sexuality in an exhibitionistic way, in an effort to counteract unconscious shame and fear.

3.4.   In terms of general personality style, some people with hysterical dynamics resemble the self-dramatizing DSM depiction, while others are inhibited and reserved.

3.5.   Cultural factors may encourage the predominance of one type or the other; for example, hysterical people in Western societies are more likely to dramatize, while those in cultures that try to control the sexuality of people of their gender are apt to be inhibited.


4.      Fear of overstimulation from inside

4.1.   Like schizoid individuals, hysterical patients fear overstimulation, but from inside rather than from outside, and thus view their own feelings and desires with anxiety.

4.2.   The dread of being overwhelmed by affect may be expressed in a self-dramatizing style of speaking, as if emotion is being unconsciously derided by being exaggerated.

4.3.   Cognitive style may be impressionistic (Shapiro, 1965), as the hysterical person prefers not to look too closely at details for fear of seeing too much and being overwhelmed.

4.4.   Medically inexplicable physical symptoms expressing dissociated conflicts (conversion) may be present.

4.5.   Behavior, especially sexual behavior, may be impulsive or driven yet regarded by the hysterical person as curiously unrelated to identifiable internal states.

4.6.   Like narcissistic individuals, hysterical patients may compete for attention that reassures them of their value, but their exhibitionistic and excessively competitive qualities are limited to the realm of sexuality and gender.

4.7.    Outside that arena they are capable of warm and stable attachments.

 

5.      Countertransference

5.1.   Therapists’ initial responses to neurotic-level hysterical patients tend to be positive.

5.2.   Later, clinicians may feel that attitudes related to their own gender are being evoked.

5.3.   Therapists whose gender is devalued by the patient may feel slightly demeaned, while those whose gender is overvalued may feel narcissistically inflated.

5.4.    At the borderline level, histrionic patients evoke exasperation and apprehension in the therapist, as their intense unconscious anxiety impels them to act out rather than talk.

5.5.   With a therapist of the gender they see as powerful, they may be flagrantly seductive.

 

6.      Treatment modality

6.1.   Because the psychology of hysterically and histrionically organized patients is so centrally anaclitic, it tends to be the relational aspects of psychotherapy that help them the most.

6.2.   At the same time, because hysterical individuals need to balance their anaclitic orientation with an increase in self-definition, they may respond well to interpretive aspects of treatment.

6.3.   Traditional psychoanalytic therapies that encourage the patient’s gradual, self-paced exploration of thoughts and feelings are likely to be helpful to hysterically organized individuals in the neurotic range, whereas treatment of those at the borderline level requires more deliberate handling of boundary issues, confrontation about destructive enactments, and explicit psychoeducation.

 

7.      Summary

7.1.   Contributing constitutional-maturational patterns: Possibly sensitivity, sociophilia

7.2.   Central tension/ preoccupation: Power and sexuality in own gender/ other gender

7.3.   Central affects: Fear, shame, guilt (over competition)

7.4.   Characteristic pathogenic belief about self: My gender makes me weak, castrated, vulnerable

7.5.   Characteristic pathogenic belief about others: People of my own gender are of little value; people of the other gender are powerful, exciting, potentially exploitative and damaging

7.6.   Central ways of defending: Repression, regression, conversion, sexualizing, acting out

7.7.   Subtypes:

7.7.1.      P113.1 Inhibited

7.7.1.1.            More common in highly structured, moralistic cultures and subcultures, this manifestation of hysterical personality is characterized by emotional reserve, sexual naiveté, inexperience and inhibition, conversion symptoms and somatization.

7.7.2.      P113.2 Demonstrative or Flamboyant

7.7.2.1.            More common in liberal and chaotic cultures and subcultures, this manifestation is characterized by a tendency toward repeated crises and dramatizations, seductiveness, and sexual impulsiveness.

7.7.2.2.            Problems with achieving a full sexual response are common.

 
 
 
 
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