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작성자  simonshin 작성일  2016.11.09 15:59 조회수 1242 추천 0
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 신현근 박사 강의안 - 강박성 성격 장애  
첨부파일 : f1_20161109155954.pdf
 

과목:  진단과 평가

주제:  Obsessive-Compulsive Personality Disorders

강사: 신현근 박사

내용: 강의안 강박성 성격 장애

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

 

1.      Overview

1.1.   Obsessions and compulsions are relatively common symptoms, but in Western cultures, many clinicians believe that the neurotic-level syndrome of obsessive-compulsive personality disorder is becoming more subtle or rarer.

1.2.   The obsessive defenses of isolation of affect and intellectualization are common, especially among more cerebral and perfectionistic individuals.

1.3.   But as childrearing has become less authoritarian, fewer people may struggle with the issues of personal control and moral rectitude central to the obsessive-compulsive character.

1.4.   Because obsessive and compulsive traits can accompany other kinds of personality (especially narcissistic and introjective depressive psychologies), diagnosis of obsessive-compulsive personality disorder requires an understanding of the internal experience, not just the behavior, of the patient.

 

2.      Reluctance to feel emotions

2.1.   Central to an obsessive-compulsive psychology is a reluctance to feel emotions associated with being “out of control.”

2.2.   This attitude may originate in early dyadic struggles.

2.3.   Freud (1913) related the stubborn, punctilious, and hoarding tendencies of the obsessive-compulsive adult to battles over toilet training, but a controlling parent may also have set up power struggles around eating, sexuality, and general obedience.

2.4.   Obsessive-compulsive individuals, evocatively described by Reich (1933) as “living machines,” seem to have identified themselves with caregivers who expected them to be more grown-up than was possible at the time.

2.5.   They regard expressions of subjectivity and affect as “immature,” they overvalue rationality, and they suffer humiliation when they feel they have acted childishly.

2.6.    Only when an emotion is logically or morally “justified”— e.g., righteous anger— do they find it acceptable.

2.7.   Although they are generally more preoccupied with issues of self-definition than issues of relationship, there is an anaclitic version of obsessive-compulsive dynamics, exemplified by the compulsive people-pleaser people-pleaser who lives in horror of offending anyone by inappropriate behavior.

 

3.      Fear of loss of control of impulses

3.1.   Psychoanalytic clinical experience and research (Fisher & Greenberg, 1985; Salzman, 1980; Shapiro, 1965) suggest that obsessive-compulsive people fear that their impulses, especially their aggressive urges, will get out of control.

3.2.   Most obsessive thoughts and compulsive actions involve efforts to undo or counteract impulses toward destructiveness, greed, and messiness.

3.3.   Because guilt over unacceptable wishes is severe, the conscience of the pathologically obsessive-compulsive person is famously rigid and punitive.

3.4.   Self-criticism is harsh; such individuals hold themselves as well as others to a standard close to perfection.

3.5.    They follow rules literally, get lost in details, and have trouble making decisions because they want to make the perfect one.

3.6.   They are scrupulous to a fault but because of all they suppress, they have trouble relaxing, joking, and being fully intimate.

 

4.      Differentiation of obsessive and compulsive qualities

4.1.    Although obsessive and compulsive qualities tend to go together because they express similar unconscious fantasies, some people have an obsessive personality with little compulsivity while others have a compulsive personality with little obsessionality.

4.2.   Obsessive people are chronically “in their head”: thinking, reasoning, judging, and doubting.

4.3.   Compulsive people are chronically “doing and undoing”: cleaning, collecting, perfecting.

 

5.      Patients in the therapy

5.1.   In therapy, individuals with obsessive and/ or compulsive personalities try hard to be cooperative but resist the therapist’s efforts to explore their affective world.

5.2.   They may become subtly negativistic, expressing unconscious opposition by coming late, forgetting to pay, and prefacing responses to the therapist’s comments with “Yes, but . . . ”

5.3.   To the clinician, the relationship may feel like a power struggle.

5.4.   As the patient insists on tendentious argument rather than emotional expression and engagement, the therapist may become impatient and exasperated.

 

6.      Treatment modality

6.1.   Both cognitive-behavioral and pharmaceutical interventions may help pathologically obsessive-compulsive patients with specific problems, but improving their self-esteem and enriching their emotional life require considerable time with someone willing to help them explore and express those aspects of their personality that they otherwise spend inordinate energy trying to subdue.

6.2.   Given the introjective nature of obsessive-compulsive psychology, psychotherapies that attempt to facilitate insight into the patient’s problems are most likely to be helpful.

 

7.      Summary

7.1.   • Contributing constitutional-maturational patterns: Possible irritability, orderliness

7.2.   • Central tension/ preoccupation: Submission to/ rebellion against controlling authority

7.3.   • Central affects: Anger, guilt, shame, fear

7.4.   • Characteristic pathogenic belief about self: My aggression is dangerous and must be controlled

7.5.   • Characteristic pathogenic belief about others: Others try to exert control, which I must resist

7.6.   • Central ways of defending: Isolation of affect, reaction formation, intellectualizing, moralizing, undoing

7.7.   • Subtypes:

7.7.1.      P112.1 Obsessive

7.7.1.1.            Ruminative, cerebral; self-esteem depends on thinking, on intellectual achievements

7.7.2.      P112.2 Compulsive

7.7.2.1.            Busy, meticulous, perfectionistic; self-esteem depends on doing, on practical achievements

 

 
 
 
 
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