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작성자  simonshin 작성일  2016.10.09 09:48 조회수 1393 추천 0
 신현근 박사 강의안 - 해리성 성격 장애  
첨부파일 : f1_20161009094900.pdf

과목:  진단과 평가

주제Dissociative Personality Disorder (Dissociative Identity Disorder)

내용: 강의안 해리성 성격 장애

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

     Dissociative Personality Disorder (Dissociative Identity Disorder)

1.       Classification and causality

1.1.    What we label dissociative personality disorder is roughly identical with the DSM-IV-TR diagnosis of Dissociative Identity Disorder.

1.2.    Although the DSM-IV-TR places this condition with other dissociative syndromes (under the general rubric of anxiety disorder) rather than in its section on personality disorders, dissociative identity disorder is a dissociative syndrome that dominates an individual’s personality.

1.3.    When dissociative defenses are relied upon as a person’s primary and habitual response to stress and negative affect, dissociation becomes characterological in the same way that any other defense can become locked into personality (Brenner, 2001; Bromberg, 1998/ 2001).

1.4.    When someone is repeatedly traumatized (abused to such an extent that the abuse constitutes torture) during early childhood and has the constitutional capacity to go into trance, or grows up in a family in which dissociation is adaptive, with little opportunity to process traumatic experiences in words and with feeling, the basis for a dissociative personality disorder exists (Kluft, 1985).


2.        History and controversies

2.1.    While the phenomenon that for many decades was called multiple personality disorder has evoked psychiatric interest for well over a century, its sometimes dramatic manifestations have spawned many controversies about incidence, etiology, relationship to other conditions, and treatment.

2.2.    In some decades, dissociative individuals have been virtually ignored by the mental health community, whereas during others, especially those marked by war and other catastrophes that draw attention to trauma, they have elicited passionate interest.

2.3.    Currently, professionals are divided as to whether individuals with dissociative personality disorder constitute a significant mental health population or whether they are “created” by credulous therapists who unwittingly encourage dissociative reactions in suggestible people.


3.       Clinical evidence and diagnosis

3.1.    Our reading of the evidence is that dissociative personality disorder is not rare (see, e.g., Brenner, 2001; Bromberg, 1998/ 2001).

3.2.     The traumatic history that engenders this condition, usually involving abuse by a primary caregiver, creates in its victims a disposition to placate authorities, including therapists, from whom grave mistreatment is unconsciously feared.

3.3.    Thus, clinicians who convey skepticism about amnesia and altered states of consciousness unwittingly discourage dissociative patients from revealing the dissociative symptoms from which they suffer.

3.4.    Practitioners with the polar opposite attitude, a fascination with the drama of identity shifts and intrusive memories, may unwittingly encourage patients with dissociative defenses to dissociate more and more.

3.5.    Thus, dissociation may be either iatrogenically suppressed and underdiagnosed or iatrogenically provoked.


4.       Developmental level and symptoms

4.1.    This disorder exists in the neurotic through the borderline ranges and may involve temporary dissociative reactions with psychotic features.

4.2.    Behavior, affect, bodily experience, or knowledge and memory can be dissociated (Braun, 1988).

4.3.    Patients who dissociate may feel troubled by parts of the body or self they experience as alien or by aspects of personality they experience as “alter.”

4.4.    Amnesia for certain states of mind, often described by the patient as “losing time,” is a prime indicator of dissociative personality disorder.

4.5.    With this psychology goes an oscillating doubt about which experiences can be trusted and which are confabulated, an uncertainty that may be felt by both patient and therapist.

4.6.    Individuals with this personality disorder may experience profound hopelessness about developing any sense of continuity of self states and feel repeatedly blindsided by shifts in consciousness that they cannot explain.


5.       Countertransference and treatment

5.1.    Dissociative individuals may induce confusion and a sense of futility in the therapist, especially during the early diagnostic process, when attempts to take a history elicit vague, disjointed narratives (Davies & Frawley, 1993).

5.1.1. Once they have revealed their history of trauma, dissociative patients may inspire powerful sympathetic wishes to save and rescue.

5.2.    Given the patient’s underlying fear of abuse, it is critical that treatment proceed slowly, with consistent attention to maintaining the therapeutic alliance and scrupulous preservation of boundaries.

5.2.1. Premature efforts to accomplish the emotional processing or “abreaction” of early trauma risk overwhelming and retraumatizing the dissociative person.

5.2.2. Eventually, however, cognitive, emotional, behavioral, and somatic aspects of experience that have been dissociated need to be addressed and reintegrated, at a pace controlled by the client.

6.       Summary

6.1.    Contributing constitutional-maturational patterns: Constitutional capacity for self-hypnosis; early, severe, and repeated physical and/ or sexual trauma

6.2.    Central tension/ preoccupation: Acknowledging trauma/ disavowing trauma

6.3.    Central affects: Fear, rage

6.4.    Characteristic pathogenic belief about self: I am small, weak, and vulnerable to recurring trauma

6.5.    Characteristic pathogenic belief about others: Others are perpetrators, exploiters, or rescuers

6.6.    Central ways of defending: Dissociation

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