PSYCHODYNAMIC THEORY IN
MEDICAL PRACTICE
Sigmund Freud (1856-1939)
• When a member of my family
complains to me of having bitten
his tongue, pinched a finger, or the
like, he does not get the sympathy
he hopes for but instead the
question: Why did you do that?”
Freud was originally trained as a Neurologist - biological
approach to illness
Treated mostly Hysteria (conversion disorders)
Applied findings from abnormal patients to “normal”
development
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Freud: A Sign of the Times?
Time period: late 1800’s
Victorian times: conservative, repressed society
Prohibitions against sex
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Key Contributions of Freud
Psychic Determinism/ Dynamic Model
Topographical Model of the Mind
Unconscious, Preconscious, Conscious
Stages of Psychosexual Development
Structural Model of the Mind
Defense Mechanisms
Transference and Counter transference
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Basic Principles of Psychodynamics
Freud sees people as passive; behaviors determined
by interaction of external reality and internal drives
Psychic Determinism: all behaviors driven by
antecedent events, experiences.
There are no accidents; nothing happens by chance
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Basic Principles
Pleasure Principle: constant drive to reduce tension
through expression of instinctual urges
Mind is a dynamic (changing/active) process based on the
Pleasure Principle
Libidinal (sexual, aggressive) instincts drive people
In children “libido” isn’t purely sexual, it’s pleasure through
sensations (oral, anal gratification, etc.)
Behaviors result from conflicts:
Between instinctual libidinal drives (aggression, sex) and efforts
to repress them from consciousness)
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More Basic Principles
The Cathartic Method
Primary vs. Secondary Gain
Transference and Countertransference
Ego-Syntonic vs. Ego-Dystonic
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Cathartic Method
Therapy benefits through release of pent-up
tensions, “catharsis”
Some inherent value in the “talking cure”- being
able to “unload”, or “get stuff off your mind”
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Primary vs. Secondary Gain
Primary Gain:
Symptoms serve a purpose: they function to decrease
intra-psychic conflict and distress by keeping such
unpleasantries from conscious awareness.
Example
Comfort of being taken care of through assumption of
the sick role
Conversion Disorder- Psychological conflict is
converted into physical symptom that allows for more
acceptable expression of an unacceptable wish
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Secondary Gain
Actual or external advantages that patients gain
from their symptoms, or from being ill:
Relief from duties, responsibilities (work)
Prescription drugs (ex. Opiates)
Manipulation in relationships
Deferring of legal proceedings, exams
Food, shelter, money (financial gain)
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Transference
Displacement (false attribution) of feelings,
attitudes.
Behavioral expectations and attributes from
important childhood relationships to current ones
Traditionally refers to what the patient projects onto
the therapist, but applies to other situations as well-
ex. relationships in general
“emotional baggage”
Occurs unconsciously (person’s unaware they’re
doing it)
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Counter Transference
Feelings toward another are based on your own past
relationships/ experiences.
Traditionally refers to the therapist projecting their
own feelings (“issues”, “emotional baggage”) onto
their patient
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Ego-Syntonic vs. Dystonic
Neurotic symptoms are distressing to the person,
or Ego-dystonic
Vs.
Character pathology, which is Ego-syntonic;
patient doesn’t perceive as a problem; only
problematic in dealings with others/ external world
Homosexuality
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Topographical Model
Freud’s first model of psychopathology
Division of the mind into three different layers of
consciousness:
Unconscious
Preconscious
Conscious
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Unconscious
Contains repressed thoughts and feelings
( Mainly Sexual and Aggressive contents)
Unconscious shows itself in:
Dreams (Royal Road to The unconscious)
Hypnosis :-Under hypnosis, a woman who has no
conscious memory of the event reveals that she was
sexually abused as a child by her father.
Parapraxes (Freudian slips) A woman who
unconsciously fears the responsibilities of her new
and lucrative position states, "My new job is a
landmine... I mean a goldmine.“
Driven by Primary Process Thinking
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Primary Process Thinking
Child like thinking; Not cause-effect; illogical; Fantasy
Only concern is immediate gratification (drive satisfaction)
Does not take reality into account
Seen in
Dreams
During hypnosis
Some forms of psychosis
Young children
Psychoanalytic psychotherapy
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Freudian Slips (Parapraxes)
A “slip of the tongue”
Errors of speech or hearing that reveal one’s true but
unconscious feelings
A person who is uneasy about an appointment that's
scheduled for Tuesday and "accidentally" says to the
person with whom the appointment is scheduled
"okay, I'll be there Wednesday", perhaps meaning
that he/she wishes the appointment were scheduled
later or even that he/she wishes to miss the meeting
entirely.
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Preconscious
Accessible, but not immediately available
Always running in the background/ behind the
scenes
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Conscious
Fully and readily accessible
Conscious mind does not have access to the
unconscious
Utilizes Secondary Process Thinking:
Reality-based (takes external reality into
consideration), logical, mature, time-oriented
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Psychosexual Development
People pass through a series of age-dependent
stages during development
Each stage has a designated “pleasure zone” and
“primary activity”
Each stage requires resolution of a particular
conflict/task
Failure to successfully navigate a stage’s particular
conflict/ task is known as Fixation
Leaving some energy in a stage
Specific problems result from Fixation, depending
on which stage is involved
Fixation may result from environmental disruption 21
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Psychosexual stages of
development
Freud heavily emphasized on
- Biological development in general &
- Sexual development in particular
In theory of child development he described a
succession of stages revolving around body zones.
From birth there is an innate tendency to seek pleasure,
especially through physical stimulation of parts of the
body that are sensitive to touch such as the
MOUTH
ANUS
GENITALS.
Oral stage: birth to 1 yr
The infant obtains sensual pleasure first by sucking & later by
biting
Feeding & contact with the mother, mouthing new objects- all help
to make the mouth the focus of pleasure during the 1st yr
Early oral stage-A baby given too little opportunity or too much
to suck, or made anxious about it, may acquire an oral fixation
This in adulthood may foster excessive oral behaviour such as
excessive smoking, drinking kissing etc in adulthood.
such people are known as oral-incorporative or oral-ingestive.
Later oral stage- children begin to cut teeth and
experience pleasure from biting and chewing.
Fixation at this later part of the stage results in adult
hood behaviours such as:
CHEWING OBJECTS
NAIL-BITING
BEING SARCASTIC
CRITICAL
Freud called those fixated at this level
ORAL-AGGRESSIVE OR ORAL-SADISTIC.
Anal Phase (12 months- 3yrs)
Pleasure Zone: Anus
Primary Activity: Toilet training
Failure to produce on schedule arouses parental
disappointment.
Parental disappointment, in turn, arouses feelings in child of
anger and aggression towards caregivers, which are
defended against.
Fixation may result in either:
Anal retentiveness: perfectionism, obsessive-compulsive
tendencies
Anal expulsive: sloppy, messy, disorganized
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First part of anal stage -involves pleasure
From EXPULSION OF FEACES
Latter part- involves PLEASURE FROM RETENTION
Fixation at the first substage-
Adulthood messiness & disorder
Anal expulsive characters
Fixation at the later substage –
Excessive compulsiveness, overconformity, &
Exaggerated self control
Anal-retentive characters
Phallic (Oedipal) Phase
Ages 3-6
Pleasure Zone: Genitals
Primary Activity: Genital fondling
Must successfully navigate the Oedipal Conflict
Boys want to marry mom and kill father, (Oedipal Complex),
but fear retaliation from father (castration anxiety);
ultimately resolved through identification with father
Girls have penis envy, want to marry dad, (“Electra
Complex”); identify with mom to try to win dad’s love
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Phallic (Oedipal) Phase:
Resolution of the Oedipal Conflict results in formation
of the Superego.
Fixation results in attraction to unattainable partners
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Latency Phase Ages 6-11
Pleasure Zone: Sex drive is re-routed into socialization and
skills development
Primary Activity: Same sex play; identification of sex role
Don’t like opposite sex (has “cooties”)
Fixation results in
lack of initiative
low self esteem
environmental incompetence
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Genital Phase
Ages (13years - adulthood)
Pleasure Zone: Genitals
Primary Activity: Responsible Adult sexual
relationships
Fixation results in regression to an earlier stage,
lack of sense of self
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Structural (Tripartite) Theory
(1900’s)
Freud’s second model of the mind to explain
psychopathology
THE ID
Home of instinctual Drives
“I want it and I want it NOW”
Completely unconscious
Present at birth
Operates on the Pleasure Principle and employs
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Pleasure Principle: constant drive to reduce tension
through expression of instinctual urges.
Primary Process Thinking:
Not cause-effect
Illogical
Fantasy
only concern is immediate gratification (drive
satisfaction)
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The Super Ego
Internalized morals / values- sense of right and wrong
Suppresses instinctual drives of ID (through guilt and
shame) and serves as the moral conscience.
Largely unconscious, but has conscious component
Develops with socialization, and through identification
with same-sex parent (via introjection) at the
resolution of the Oedipal Conflict.
Introjection: absorbing rules for behavior from role
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The Superego- 2 Parts:
Conscience: Dictates what is proscribed (should not
be done); results in guilt.
Ego-Ideal: Dictates what is prescribed (should be
done); results in shame.
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The Ego
Created by the ID to help it interface with external
reality
Mediates between the ID, Superego, and reality
Partly conscious
Uses Secondary Process Thinking:
Logical, rational
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“Ego” Defense Mechanisms
They serve to protect an individual from unpleasant
thoughts or emotions
Keep unconscious conflicts unconscious
Defense Mechanisms are primarily unconscious
Result from interactions between the ID, Ego, and
Superego
Thus, they’re compromises:
Attempts to express an impulse (to satisfy the ID) in a
socially acceptable or disguised way (so that the Superego
can deal with it)
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“Ego” Defense Mechanisms
Less mature defenses protect the person from anxiety
and negative feelings, but at price
Some defense mechanisms explain aspects of
psychopathology:
Ex. Identification with aggressor: can explain tendency of
some abused kids to grow into abusers
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Primary Repression
Conflict arises when the ID’s drives threaten to
overwhelm the controls of the Ego and Superego
Ego pushes ID impulses deeper into the unconscious
via Repression
Material pushed into unconscious does not sit
quietly- causes symptoms
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Classification of Defenses
Mature
Altruism
Humor
Sublimation
Suppression
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Altruism
Unselfishly assisting others to avoid negative
personal feelings
Humor
Expressing personally uncomfortable feelings
with-out causing emotional discomfort.
A patient who is un-comfortable about his erectile
problems makes jokes about Viagra (sildenafil
citrate).
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Sublimation
Rerouting an unacceptable drive in a socially
acceptable way; redirecting the energy from a
forbidden drive into a constructive act
A healthy, conscious defense
Ex. Martial Arts
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Suppression
Deliberately (consciously) pushing anxiety-provoking
or personally unacceptable material out of conscious
awareness.
A prostate cancer patient who mentally changes the
subject when his mind wanders to the possibility of
relapse, yet seeks appropriate treatment for his illness
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Immature Defenses
Acting Out Dissociation
Somatization Reaction Formation
Regression Repression
Denial Isolation of Affect
Projection Intellectualization
Splitting Rationalization
Displacement Undoing
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Acting out
Behaving in an attention-getting, often socially
inappropriate manner to avoid dealing with
unacceptable emotions or material
A teenager with a terminally ill younger sibling begins
to do badly at school and argues with her parents at
home.
Somatization
Unconscious transformation of unacceptable
impulses or feelings into physical symptoms.
A man who is anxious about a new job develops a
headache the morning of the first day of work.
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Regression
Return to earlier level of functioning (childlike
behaviors) during stressful situations
Ex. Kids regress after trauma. Nail Biting, Bed wetting
Denial
Unconsciously discounting external reality
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Projection
Falsely attributing one’s own unacceptable impulses
or feelings onto others
Can manifest as paranoia
A man who has sexual feelings for his brother‘s wife begins
to believe that his own wife is cheating on him.
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Splitting
Selectively focusing on only part of a person to meet
a current need state; seeing people as either all-
good or all-bad .
Serves to relieve the uncertainty engendered by the
fact that people have both bad and good qualities
Considered normal in childhood
A woman who believed her physician was godlike
begins to think he is a terrible physician after he is
late for an appointment with her. 51
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Displacement
Redirection of unacceptable feelings, impulses from
their source onto a less threatening person or object
Ex. Mad at your boss, so you go home and kick the dog
A man whose son was killed by a drunk driver attacks and
seriously injures a drunken street-person.
Dissociation
Mentally separating part of consciousness from
reality; can result in forgetting certain events
Ex. Dissociative amnesia
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Reaction Formation
Transforming an unacceptable impulse into a
diametrically opposed thought, feeling, attitude, or
behavior; denying unacceptable feelings and adopting
opposite attitudes
E.g.. Person who loves pornography leads a movement to
outlaw its sale in the neighborhood
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Repression
Keeping an idea or feeling out of conscious
awareness.
The primary ego defense
Freud postulated that other defenses are employed
only when repression fails
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Isolation of Affect
Stripping an idea from its accompanying feeling or
affect
Idea is made conscious but the feelings are kept
unconscious.
The person who expresses no emotion when talking
about the loss of a loved one has isolated his emotions
from the sad event.
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Intellectualization
Using higher cortical functions to avoid experiencing
uncomfortable emotions; thinking without
accompanying emotion
using cognition to avoid negative emotions.
The pilot of a doomed flight who explains the
technical details of the engine failure to the
passengers
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Rationalization
Unconscious distortion of reality so that it’s negative
outcome seems reasonable or “not so bad, after all”
(making lemonade out of lemons)
Giving seemingly reasonable explanations for
unacceptable or irrational feelings
Sour grapes
A woman who starts dating a man she really, likes is
suddenly dumped by the man for no reason. She
reframes the situation in her mind with,
“I suspected he was a loser all along.” 57
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Undoing
Undoing is the attempt to take back an unconscious
behavior or thought that is unacceptable or hurtful.
After realizing you just insulted your Spouse
unintentionally, you might spend then next hour
praising their beauty, charm and intellect.
By “undoing” the previous action, the person is
attempting to counteract the damage done by the
original comment, hoping the two will balance one
another out.
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