TABLE OF CONTENTS
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TABLE OF CONTENTS
Adapted from The Psychodynamic Diagnostic Manual:
The Psychodynamic Diagnostic Manual (PDM) avoids the pitfalls of the DSM by conceptualizing disorders as holistic conditions that have both their strengths and weaknesses. Instead of describing disorders by what one PDM contributor has called “a Chinese menu of symptoms,” the PDM describes conditions along several continuums—behavioral symptoms, thought and feeling patterns, the subjective experience of the person and—especially important for therapists—how the therapist is likely to experience sitting with someone with each disorder. Disorders are seen not as separate, discrete conditions, but part of a tapestry, which recognizes the prevalence of comorbidity and the fact that very few mental disorders exist in a pure state. The PDM also views disorders on a continuum that may stretch from normal to severely pathological.
The PDM conceptualizes anxiety disorders as either Anxious Personality Disorders or Anxiety Disorders.
Anxious Personality Disorders
The PDM says that, “Many individuals currently diagnosed with Generalized Anxiety Disorder are better understood as having a personality disorder in which anxiety is the psychologically organizing experience. Although the anxious personality disorder is not included in most nosologies, we regard this omission as unfortunate.” Because characterological anxiety is found in the “neurotic through borderline ranges.” by itself, even if chronic or severe, it is not enough to qualify as an Anxious Personality Disorder.
Anxiety is often a component of other personality disorders, so it’s important to note that the mere presence of anxiety, even when it is overwhelming, does not necessarily lead to a diagnosis of Anxious Personality Disorder. “Toward the border with psychosis,” says the PDM , “individuals with anxiety-driven psychologies become so filled with dread that defenses such as projection and denial become central to their functioning. In such instances, the diagnosis of paranoid personality disorder may be more appropriate.
“In many cases, patients with an anxious personality structure appear to be either at first hysterical (hence the old diagnosis of anxiety hysteria) or obsessional, depending upon how they attempt to deal with their pervasive sense of fear. Unlike individuals with either hysterical or obsessive-compulsive personality disorders, however, they are chronically aware of their anxiety because their efforts at defenses fail to keep their apprehensiveness out of consciousness. Unlike phobia patients, whose anxieties attach to specific objects or situations, characterologically anxious individuals experience a “free-floating,” global sense of anxiety, often with no idea of what frightens them.” An important distinguishing characteristic, therefore of Anxious Personality Disorder, is that the person is aware of his or her anxiety.
The PDM distinguishes between different types of anxiety, and it is important to know these types because they can help determine the most effective treatment. The types are:
All of these may be present in patients with anxious personality disorder, whereas in anxiety disorders, one of these tends to predominate.
“In general,” says the PDM, “the more severe the level of organization of the anxious person, the more likely it is that annihilation anxiety dominates the clinical picture (Hurvich, 2003). The proximal source of characterological anxiety lies in affective dysregulation (Schore, 2003) and failure to have developed coping strategies or defenses that mitigate normal developmental fears. Individuals with anxious personality disorders typically report having had a primary caregiver who, because of the caregiver’s own anxiety, could no adequately comfort them or convey a sense of security or support a sense of agency.”
One of the realities of therapy which the PDM addresses, while the DSM does not, is that therapists primarily diagnose from their own feelings, intuitions and experiences and turn to the symptom checklists secondarily. Therefore, it’s important to understand countertransference reactions caused by people with anxiety personality disorders. “Countertransference with chronically anxious patients may include a responsive anxiety, including a degree of annihilation anxiety severe enough to make the therapist feel overwhelmed, and hence impelled to do something that promises relief to the patient. Although therapists naturally wish to ease the anxious person’s suffering as fast as possible, anxiolytic medications for people with this personality disorder should be prescribed with caution because of the risk of addiction. The therapist should evince an attitude of confidence in the patient’s own capacities to tolerate and reduce anxiety. It is also important to preserve the therapeutic context by trying to formulate the patient’s affective experience and give words to previously inchoate states of feeling (Stern, 1997).” Although the PDM, as its name implies, is psychodynamically oriented, it notes the usefulness of other treatments. “Systematic relaxation training, education in meditative disciplines, and cognitive-behavioral techniques to promote anxiety reduction are helpful adjuncts to the process of understanding, naming, and mastering previously unformulated emotional states.
As it does for other disorders, the PDM summarizes anxious personality disorders in the schema of six organizing principles:
Anxiety Disorders
“Anxiety is fear in the absence of obvious danger. Psychodynamically oriented clinicians, who have found anxiety lurking behind virtually all psychopathological symptoms, have distinguished carefully between potential danger and present danger, between the evaluation of danger and the response to danger, and between and an adaptive response to actual danger (which may or may not include fear/anxiety) and an anxiety response, in which the human fight/flight system is activated in the expectation of disaster.” The PDM again differentiates between anxiety disorders and anxiety personality disorders by stating that when “some individuals suffer pervasive, chronic, and disabling anxieties, we regard generalized anxiety disorder as a personality disorder rather than a symptom syndrome.”
As it did for anxious personality disorders, the PDM differentiates between different kinds of anxiety, each of which may be conscious or unconscious:
The PDM also mentions persecutory anxiety and irrational fears of harm to loved ones, but it regards those as “the outcomes of projection and denial of one’s own hostile feelings” and does not consider these as anxieties typical of anxious personalities or anxious personality disorders.
The presence of anxiety does necessarily constitute a disorder. “In certain contexts, and in bearable amounts, all these anxieties are normal,” it says. “But when unremitting or disproportionate, they constitute psychopathology.”
Prevalence of anxiety disorders. Women are twice as likely as men to have anxiety disorders, with the exception of obsessive-compulsive disorder and possibly social anxiety. The PDM hypothesizes several reasons for this disparity: “hormonal factors, cultural pressures on women to meet the needs of others before their own, and fewer self-restrictions on women in reporting anxiety to physicians and therapists.”
As with so many other disorders, the biological view of anxiety disorders has been gaining currency, which obscures the fact that the interplay of biology, emotions and cognitions is an inextricable tangle of cause and effect. The PDM traces the development of anxiety from early “diffuse somatic excitation, to pervasive psychic anxiety, to a more mature signal function. Signal anxiety, a concept similar to ‘learned expectations’ in contemporary learning theory, is a state of arousal signaling that past experience has identified an object or situation as a danger. It involves both anticipation and an attenuated affect level. This developmental progression is to some extent fluid and reversible. Thus, under sufficient psychic threat, the progressive desomatization of anxiety tends to revert to somatic expression or ‘resomatization.'”
In this view, anxiety involves cognition and emotional and physical experience. Psychodynamic psychotherapy helps by integrating “the affective and the cognitive components, along with the reduction of any somatization of anxiety or acting out of anxiety-based self-harm. Although anxiety may be treated with a variety of symptom-focused approaches, a psychoanalytically informed exploration of the nature and possible origins of anxiety can increase a patient’s sense of mastery and may prevent future outbreaks of anxiety, somatic suffering, and self-destructive defenses against anxiety.”
The Internal Experience Of Anxiety Disorders
In describing the internal experience of people who suffer from anxiety disorders, the PDM breaks it into four components.
Affective states arise from Freud’s four basic danger situations: “(1) a loss of significant other, resulting in feelings of abandonment that express themselves as anger, anxiety, depression, and/or guilt; (2) loss of love, experienced as rejection, and usually accompanied by rage, anxiety, depression, guilt, and feelings of being unworthy and even unlovable; (3) loss of bodily integrity, often with associated fears of mutilation or damage to the genital organs; and (4) loss of affirmation by one’s own conscience, resulting in anxiety, guilt, shame, or depressed feelings, In addition, fear of loss of self-regulation (e.g., loss of control of one’s feelings, thoughts, sensations of movements, actions, etc.)…. The anxiety association with the anticipation of these dangers may be controlled or uncontrolled. When the anxiety is out of control, it may trigger annihilation concerns.
“Cognitive patterns may include distractedness, confusion, and difficulty thinking. Anxiety can also produce specific fears of all sorts: separation, abandonment or rejection; being devoured or engulfed; losing mental or bodily control; falling; having multiple selves; injury; and dying. Some patients have fears of overwhelming catastrophe and report a disorganizing sense of confusion over their body boundaries and sense of identity. People with anxiety may suffer intense worry over losing financial security or the presence of someone they depend upon. Fear of fear itself is common among those who have had panic attacks; they begin avoiding certain things for fear they will have another attack.
“Somatic states may include tension, sweaty palms, the sense of butterflies in one’s stomach or a tight band around one’s head, bladder and bowel urgency, breathing difficulties, or a feeling of being disconnected from one’s body. Anxiety can be associated with varying degrees of autonomic or physiological arousal.
“Relationship patterns may include expressions of fears of rejection, such as clinging and seeking reassurance; expressions of guilt, such as blaming, guilt assignment, and blame avoidance; and expressions of conflicts about dependency, such as feelings of being smothered or suffocating, drowning, or choking, and vacillation between pulling others closer and pushing them away.
Finally, the PDM presents the voices of people who suffer from anxiety disorders, letting them describe their own experiences and symptoms. These examples come from people with anxious personality disorders and anxiety disorders.
References
Hurvich, M (2003). The place of annihilation anxiety in psychoanalytic theory. Journal of the American Psychoanalytic Association,51, 579-616.
PDM Task Force (2006). Psychodynamic Diagnostic Manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations
Schore, A.N. (2003), Affect dysregulation and disorders of the self. New York: Norton
Stern, D.B. (1997). Unformulated experience: From dissociation to imagination in psychoanalysis. Hillside, NJ: Analytic Press