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작성자  simonshin 작성일  2016.10.04 20:09 조회수 1029 추천 0
 신현근 박사 강의안 - 망상성 성격 장애  
첨부파일 : f1_20161004200920.pdf

과목:  진단과 평가

주제:  Paranoid Personality Disorders

강사: 신현근 박사 (<a href="mailto:simonhkshin@gmail.com" target="_blank">simonhkshin@gmail.com</a>)

내용: 강의안 - 망상성 성격 장애

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


1.      Developmental level and projective mechanism

1.1.    Paranoid personality disorders may be considered as among the more severe personality disorders, found at the borderline level of organization, though it is possible that higher-functioning paranoid individuals exist, but are not often seen clinically (given the paranoid person’s problem with trust, he or she has to be suffering greatly to seek help).

1.2.    Paranoid psychology is characterized by unbearable affects, impulses, and ideas that are disavowed and attributed to others, and are then viewed with fear and/ or outrage. Paranoid psychologies are on the introjective, self-definition end of the continuum from relatedness to self-definition.


2.      Projected feelings

2.1.   Projected feelings may include hostility, as in the common paranoid conviction that one is being persecuted by hostile others; dependency, as inthe sense of being deliberately rendered humiliatingly dependent by others; and attraction, as in the belief that others have sexual designs on the self or the people to whom one is attached (for example, in the common phenomenon of paranoid jealousy or the syndrome of erotomania).

2.2.   Other painful affects such as hatred, envy, shame, contempt, disgust, and fear may also be disowned and projected.

2.3.   Although this disorder is described in somewhat one-dimensional ways in the DSM, persons with paranoid personality disorder have complex subjective experiences.


3.      Preemptive attack, suspiciousness, and power

3.1.   Because pathologically paranoid individuals tend to have histories marked by felt shame and humiliation (Meissner, 1978), they expect to be humiliated by others and may attack first in order to spare themselves the agony of waiting for the “other shoe to drop,” the inevitable attack from outside.

3.2.   Their expectation of mistreatment creates the suspiciousness and hypervigilance for which they are noted, attitudes that sadly tend to evoke the humiliating responses that they fear.

3.3.   Their personality is defensively organized around the theme of power, either the persecutory power of others or the megalomanic power of the self.


4.      Anxious conflict between feeling panicky when alone and anxious in relationship

4.1.   Paranoid patients tend to have trouble conceiving that thoughts are different from actions, a belief possibly encouraged because in their formative years, they were criticized or humiliated for attitudes rather than behavior.

4.2.    Some clinical reports suggest that they have experienced a parent as seductive or manipulative and are consequently alert to the danger of being exploited in a seductive way by the therapist and others.

4.3.   They exist in an anxious conflict between feeling panicky when alone (afraid that they will be damaged by an unexpected attack and/ or afraid that their destructive fantasies will damage or already have damaged others) and anxious in relationship (afraid that they will be used and destroyed by the agenda of the other).


5.      Transference and countertransference

5.1.   Therapeutic experience attests to the rigidity of the pathologically paranoid person (Shapiro, 1981).

5.2.   A therapist’s countertransference may include strong feelings that mirror those that the paranoid person disowns and projects, such as becoming afraid when a patient expresses only the angry aspects of his or her emotional reaction and shows no sense of personal vulnerability or fear.


6.      Treatment implication

6.1.   The clinical literature emphasizes the importance of maintaining a patient, matter-of-factly respectful attitude, the communication of a sense of strength (lest paranoid patients worry unconsciously that their negative affects could destroy the therapist), a willingness to respond with factual information when the paranoid patient raises questions (lest the patient feel evaded or toyed with), and attending to the patient’s private conviction that aggression, dependency, and sexual desire— and the verbal expressions of any of these strivings— are inherently dangerous.

6.2.   It is best not to be too warm and solicitous, as such attitudes may stimulate a terror of regression and consequent elaborate suspicions about why the therapist is “really” being so nice.


7.      Summary

7.1.   Contributing constitutional-maturational patterns: Possibly irritable/ aggressive

7.2.   Central tension/ preoccupation: Attacking/ being attacked by humiliating others

7.3.   Central affects: Fear, rage, shame, contempt

7.4.   Characteristic pathogenic belief about self: Hatred, aggression and dependency are dangerous.

7.5.   Characteristic pathogenic belief about others: The world is full of potential attackers and users.

7.6.   Central ways of defending: Projection, projective identification, denial, reaction formation

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