To Prepare Review the Learning Resource, ‘The Case of Mrs. C.’ Review the Personality Theory Matrix information about the psychoanalytic and trait theo

PSYC 6220/5220/8221: Psychology of Personality

CREDIT LINE: SYSTEMS OF PYSCHOTHERAPY: A Transtheoretical Analysis, 9th Edition, by James O. Prochaska and John C. Norcross. Copyright 2018 by Oxford University Press. Reprinted by permission of Oxford University

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“The Case of Mrs. C” is excerpted from Systems of Psycotherapy: A Transtheoretical Analysis, 9th Edition,

by James O. Prochaska and John C. Norcross, and does not reflect a clinical assessment of the client and

the family members’ experiences.

THE CASE OF MRS. C Psychotherapy systems are not merely static combinations of change processes, theoretical contents, and research studies. The systems are, first and foremost, concerned with serious disorders afflicting fellow humans. In comparing systems, it is essential to picture how the psychotherapies conceptualize and treat the presenting problems of an actual client. The client selected for comparative purposes is Mrs. C. Mrs. C is a 47-year-old mother of six children: Arlene, 17; Barry, 15; Charles, 13; Debra, 11; Ellen, 9; and Frederick, 7. Without reading further, and astute observer might discern Mrs. C‘s personality configuration. The orderliness of children named alphabetically and of childbirths every 2 years are consistent with obsessive-compulsive disorder (OCD). For the past 10 years, Mrs. C has been plagued by compulsive washing. Her baseline charts, in which she recorded her behavior each day before treatment began, indicated that she washed her hands 25 to 30 times a day, 5 to 10 minutes at a time. Her daily morning shower lasted about 2 hours with rituals involving each part of her body, beginning with her rectum. If she lost track of where she was in her ritual, then she would have to start all over. A couple of times this had resulted in her husband, George, going off to work while his wife was in the shower only to return 8 hours later to find her still involved in the lengthy ritual. To avoid extended showers, George had begun helping his wife keep track of her ritual, so that at times she would yell out, “Which arm, George?” and he would yell back, “Left arm, Martha.” His participation in the shower ritual required George to rise at 5:00 A.M. in order to have his wife out of the shower before he left for work at 7:00 A.M. After 2 years of this schedule, George was ready to explode. George was, understandably, becoming increasingly impatient with many of his wife’s related symptoms. She would not let anyone wear a pair of underwear more than once and often wouldn’t even let the underwear be washed. There were piles of dirty underwear in each bedroom corner. When we asked her husband to gather up the underwear for the laundry, we asked him to count them, but he quit counting after the thousandth pair. He was depressed to realize that he had more than $2,000 invested in once-worn underwear. Other objects were scattered around the house because a fork or a can of food dropped on the floor could not be retrieved in Mrs. C‘s presence. She felt it was contaminated. Mrs. C had been doing no housework—no cooking, cleaning, or washing—for years. One of her children described the house as a “state dump,” and my (JOP) visit to the home confirmed this impression. Mrs. C did work part -time. What would be a likely job for her? Something to do with washing, of course. In fact, she was a dental technician, which involves washing and sterilizing all the dentist’s equipment.

PSYC 6220/5220/8221: Psychology of Personality

CREDIT LINE: SYSTEMS OF PYSCHOTHERAPY: A Transtheoretical Analysis, 9th Edition, by James O. Prochaska and John C. Norcross. Copyright 2018 by Oxford University Press. Reprinted by permission of Oxford University

Press via the Copyright Clearance Center.

As if these were not sufficient concerns, Mrs. C had become unappealing in appearance. She had not purchased new clothes in 7 years, and her existing clothes were becoming ragged. Never in her life had she been to a beautician and now she seldom combed her own hair. Her incessant washing of her body and hair led to a presentation somewhere between a prune and a boiled lobster with the frizzies. Mrs. C‘s washing ritual also entailed walking around the house nude from the waist up as she went from her bedroom bath to the downstairs bath to complete her washing. This was especially upsetting to Mr. C because of the embarrassment it was producing in their teenage sons. The children were also upset by Mrs. C‘s frequent nagging to wash their hands and change their underwear, and she would not allow them to entertain friends in the house. Consistent with OCD features, Mrs. C was a hoarder: she had two closets filled with hundreds of towels and sheets, dozens of unused earrings, and her entire wardrobe from the past 20 years. She did not consider this hoarding a problem because it was a family characteristic, which she believes she inherited from her mother and from her mother’s mother. Mrs. C also suffered from a sexual arousal disorder; in common parlance, she was “frigid.” She said she had never been sexually excited in her life, but at least for the first 13 years of her marriage she engaged in sexual relations to satisfy her husband. However, in the past 2 years they had intercourse just twice, because sex and become increasingly unpleasant for her. To complete the list, Mrs. C was clinically depressed. She had made a suicide gesture by swallowing a bottle of aspirin since she had an inkling that her psychotherapist was giving up on her and her husband was probably going to commit her to a psychiatric hospital. Mrs. C‘s compulsive rituals revolved around and obsession with pinworms. Her oldest daughter had come home with pinworms 10 years earlier during a severe flu epidemic. Mrs. C had to care for a sick family while pregnant, sick with the flu herself, and caring for a demanding 1-year-old child. Her physician told her that, to avoid having the pinworms spread throughout the family, Mrs. C would need to be extremely careful about the children’s underwear, clothes, and sheets and that she should boil all of these articles to kill any pinworm eggs. Mrs. C confirmed that both she and her husband were rather anxious about a pinworm epidemic in the home and were both preoccupied with cleanliness during this time. However, Mrs. C’s preoccupation with cleanliness and pinworms continued even after it was confirmed that her daughter’s pinworms were eliminated. The C couple acknowledged a relatively good marriage before the pinworm episode. They had both wanted a sizable family, and Mr. C‘s income as a business executive had allowed them to afford a large family and comfortable home without financial strain. During the first 13 years of their marriage, Mrs. C had demonstrated some of her obsessive-compulsive traits, but never to such a degree that Mr. C considered them a problem. Mr. C and the older children recalled many happy times with Mrs. C, and they kept alive the warmth and love that they had once shared with this now preoccupied person. Mrs. C hailed from a strict, authoritarian, and sexually repressed Catholic family. She was the middle of three girls, all of whom were dominated by a father who was 6 feet, 4 inches tall and weighed 250 pounds. When Mrs. C was a teenager, her father would wait up for her after dates to question her about what she had done; he once went so far is to follow her on a date. He tolerated absolutely no expression of anger, especially toward himself, and when she would try to explain her point of view politely, he

PSYC 6220/5220/8221: Psychology of Personality

CREDIT LINE: SYSTEMS OF PYSCHOTHERAPY: A Transtheoretical Analysis, 9th Edition, by James O. Prochaska and John C. Norcross. Copyright 2018 by Oxford University Press. Reprinted by permission of Oxford University

Press via the Copyright Clearance Center.

would have to tell her to shut up. Mrs. C‘s mother was a cold, compulsive woman who repeatedly regaled her daughters about her disgust with sex. She also frequently warned her daughters about diseases and the centrality of cleanliness. In developing a psychotherapy plan for Mrs. C, one of the differential diagnostic questions was whether Mrs. C was plagued with a severe obsessive-compulsive disorder or whether her symptoms were masking a latent schizophrenic process. A full battery of psychological testing was completed, and the test results were consistent with those from previous evaluations that had found no evidence of a thought disorder or other signs of psychotic processes. Mrs. C had previously undergone a total of six years of mental health treatment, and throughout that time the clinicians had uniformly considered her problems to be severe but nonpsychotic in nature. The only time schizophrenia was offered as a diagnosis was after some extensive individual psychotherapy failed to lead to any improvement. The consensus in our clinic was that Mrs. C was demonstrating severe OCD that was going to be extremely difficult to treat.

Personality Theory Matrix

Psychoanalytically Informed Approaches to the Treatment of Obsessive-Compulsive Disorder

G L E N O. G A B B A R D, M.D.

208

 Dr. Gabbard is Bessie Walker Callaway Distinguished Professor of Psycho-

analysis, Karl Menninger School of Psychiatry, Menninger Clinic; Director and Training and Supervising Analyst, Topeka Institute for Psychoanalysis.

As neuroscience research has uncovered the genetic/biological basis of obsessive-compulsive disorder (OCD), a broad consensus has been reached that behavior therapy and a selective serotonin reuptake inhibitor are the treatments of choice for the c o n d i t i o n . N e v e r t h e l e s s , p s y c h o a n a l y t i c a l l y i n f o r m e d approaches still have much to offer in an overall treatment plan. The biologically determined symptoms have unconscious meanings to the patient that may lead the patient to be highly invested in maintaining the symptoms. Also, psychodynamic factors may be involved in triggering an exacerbation of the symptoms. Moreover, the compulsions and obsessional thoughts almost always have interpersonal meanings that need to be addressed. Family members and others, including treaters, may feel compelled to accommodate themselves to the illness as a response to coercive behaviors by the patient. Finally, the characteriological features of individuals with OCD tend to undermine treatment efforts in many cases and may require psychoanalytically informed therapy to deal with them.

W O C L I N I C A L E N T I T I E S , hysterical neurosis and obsessive-Tcompulsive neurosis, have historically been considered the model conditions for psychoanalytic treatment. While psychoanalysis was born out of experiences with hysteria, Freud’s classic 1909 paper on the “Rat Man” brought obsessive-compulsive neurosis into the psychoanalytic literature with a rich and compelling psychodynamic formulation of the symptoms. Since that time, the classical formulation, widely accepted in analytic circles, was that the anxiety provoked by the oedipal situation led the obsessive-compulsive neurotic to regress to an anal-phase constellation of defenses, including reaction formation, doing and undoing, and isolation of affect. This regression was often viewed as more likely because of the longstanding presence of anal fixations resulting from disturb- ances during the phase of toilet training (Nemiah, 1988).

Despite the longstanding tradition of treating obsessive-compulsive neurosis with psychoanalysis, reports of symptomatic cures with psychoanalytic treatment are virtually nonexistent (Zetzel, 1970; Malan, 1979; Jenike, Baer, and Minichiello, 1986; Nemiah, 1988; Perse, 1988).

Parallel with the realization that psychoanalysis does not alter the obsessive-compulsive symptoms, there has been a growing tendency within psychiatry to view the disorder as one that has a largely biologically based etiology. Indeed, the change in nomenclature in D S M – I I I f r o m o b s e s s i v e – c o m p u l s i v e n e u r o s i s t o o b s e s s i v e – compulsive disorder (OCD) reflects a widely held view that neurotic mechanisms as traditionally defined by psychoanalytic theory are not particularly germane to the etiology of OCD.

The evidence for biological components to the etiology is convincing. OCD patients exhibit increased metabolism (as compared with normal control subjects) in the orbitofrontal cortex, the anterior cingulate cortex, and the caudate nuclei (Baxter et al., 1987; Swedo et al., 1989). Other lines of evidence include a higher rate of concordance for OCD in monozygotic and dizygotic twins, an increased prevalence in patients with Tourette’s Syndrome (and in their families), and a dramatic response in some patients to psychosurgery (Elkins, Rapopart, and Libsky, 1980; Lieberman, 1984; Turner, Bieder, and Nathan, 1985). In addition, Luxenberg et al. (1988) demonstrated with the use of computed tomography that the caudate nucleus volume is significantly less in OCD patients as

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compared to healthy controls. Patients with OCD also show significantly more signs of central nervous system dysfunction than controls (Hollander et al., 1990). One of the most striking recent findings about OCD patients that also suggests a biological component to the etiology is the fact that there is virtually no placebo response (Mavissakalian, Jones, and Olson, 1990). This finding is in stark contrast to conditions such as panic disorder that may have as much as a 25–40 percent placebo response (Gabbard, 1992).

Animal models for OCD are now emerging that suggest that serotonin abnormalities are significantly involved in the pathogenesis of OCD (Greist and Jefferson, 1995). Many of these, such as canine acral lick, a grooming behavior in large dogs that is remarkably similar to obsessive-compulsive behavior in humans, appears to respond to potent serotonin reuptake inhibitors (Rapoport, Ryland, and Kriete, 1992). In addition, potent serotonin reuptake inhibitors are also effective in the treatment of OCD in humans (Greist and Jefferson, 1995).

Part of the difficulty in the field stems from the disentangling of obsessive-compulsive personality disorder (OCPD), which is eminently responsive to psychoanalysis, and OCD. Although there has been a historical tendency to see the two conditions as part of the same continuum of illness, the evidence is now substantial that the two are rather distinct entities (Pitman and Jenike, 1989; Baer et al., 1990; Stein and Hollander, 1993). In fact, only about 6 percent of OCD patients also have obsessive-compulsive personality disorder. In general, OCD patients view their symptoms more egodystonically and therefore have greater suffering as a result. The traits of OCPD patients are often egosyntonic and may cause more distress in significant others than in the patient. This distinction does have certain limitations, and clinicians should keep in mind that some OCD patients also experience their symptoms as somewhat egosyntonic (Rasmussen and Eisen, 1989; McCullough and Maltsberger, 1995). In this paper I shall focus specifically on psychoanalytically informed approaches to OCD rather than OCPD.

In an era in which behavior therapy and serotonin reuptake inhibitors have become the widely accepted treatments of choice for OCD patients (Greist and Jefferson, 1995), we now are at risk for relegating psychoanalytically informed approaches to history and thereby shortchanging many of our patients from a necessary and

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valuable component to the therapeutic armamentarium brought to bear with OCD patients. Despite the impressive research in the neurosciences about the biological underpinnings of OCD, the psychoanalytically informed clinician still has much to contribute to a comprehensive treatment plan for such patients.

The treatment strategies for OCD that I shall articulate fall broadly in the category of psychodynamic psychiatry (as opposed to psycho- dynamic psychotherapy). Previously, I have defined psychodynamic psychiatry as follows: “an approach to diagnosis and treatment characterized by a way of thinking about both patient and clinician that includes unconscious conflict, deficits and distortions of intrapsychic structures, and internal object relations” (Gabbard, 1994b, pp. 4–5). As implied by this definition, the psychodynamic clinician is always thinking in terms of unconscious meaning, transference, countertransference, and resistance, even when not involved in formal psychoanalytic psychotherapy or psychoanalysis. For example, a psychodynamic clinician may be prescribing a serotonin reuptake inhibitor for a patient with OCD but thinking about the interactions with the patient from a psychodynamic perspective. This psychoanalytically informed approach implies a particular conceptual model for understanding the illness of OCD.

Stress Diathesis Model of OCD

Increasing evidence suggests that many of the major psychiatric disorders can best be understood based on a stress diathesis model (Gabbard, 1992, 1994a). While there are clearly genetic processes at work in the etiology and pathogenesis of OCD, psychosocial stressors appear to be important as well. Clinicians have long observed that increased stress or the recurrence of original precipitating problems can worsen symptoms of OCD while reduction in tension can improve them (Black, 1974). Some provocative research suggests that OCD symptoms may be significantly influenced by issues involving childcare and pregnancy. For example, Buttolph and Holland (1990) found that 69 percent of patients with OCD could relate the exacerbation or onset of their symptoms to parental care of their children, pregnancy, or childbirth. In a study of 106 female patients suffering from OCD, Neziroglu, Anemone, and Yaryura-Tobias (1992) noted that pregnancy was associated with the onset of OCD symptoms

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more than any other life event. In fact, 39 percent of those patients with children first experienced symptom onset during pregnancy. Five women in the study had had an abortion or a miscarriage, and four of those five noted exacerbation or onset of OCD symptoms while they were pregnant.

In my own clinical experience with OCD patients who are young mothers or who are pregnant, I have often noted a link between increased intensity of the OCD symptoms and a rise in unconscious or barely conscious aggression toward the child. For example, one OCD patient who was a new mother of a 6-month-old said that she immediately turned off the television whenever a news story or talk show featured a discussion of child abuse by parents. In the course of psychotherapy, she recognized the extent to which she struggled with overwhelming murderous wishes toward her child. While the form the obsessional thoughts took often suggested that a disaster from the outside would strike down the child, dynamic exploration helped the patient understand that the threat she feared really came from within rather than from external sources.

Part of this conceptual model is that symptoms, no matter how biologically influenced, nevertheless have meanings, conscious or unconscious, to the patient. As I noted in a previous communication (Gabbard, 1992), psychodynamic conflicts frequently appropriate the biochemical forces within the brain and use them as a vehicle of their expression. In that communication I described a young man who had completely controlled his mother’s life to the point where she quit her job to stay home with him and cater to his every need. Meanwhile, the father was forced by the young man to stay in a separate room in the house so that the father would not contaminate his son with “germs” from the outside world. In this regard, the OCD symptoms served as a way of facilitating an unconscious oedipal triumph in which the young man had his mother all to himself while his father was out of the picture.

Of great significance in this case was the patient’s resistance to any kind of psychiatric treatment. He had refused to go to psychiatrists and had refused medications with some proven efficacy for OCD. Only when his resistance could be addressed and understood was the patient capable of collaborating in an overall treatment program. Hence, the discovery of his intense dependency on his mother and his wish to continue in his conflictual oedipal triumph had to be taken

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up with him through psychodynamic understanding before he finally agreed to take clomipramine.

Treatment Implications

In considering treatment implications for OCD, the foregoing case vignette underscores an extraordinarily crucial point—namely, that many OCD patients tenaciously hang on to their symptoms because of their special meanings and because of the interpersonal control they exert on others. They thus may be uninterested in doing the work of behavior therapy or complying with medication regimens. Indeed, many controlled trials exclude such problematic patients because of their poor motivation or refusal to comply, and therefore empirical research on OCD may not adequately address this subgroup of patients.

Even when OCD patients are compliant with standard treatment regimens, the results are less than ideal. For example, in the c o m p r e h e n s i v e m u l t i c e n t e r p r o j e c t t o s t u d y t h e e ff i c a c y o f clomipramine, after 10 weeks of treatment the mean reduction of symptoms was only 38–44 percent (Clomipramine Collaborative S t u d y G r o u p , 1 9 9 1 ) . M o r e o v e r, m a n y p a t i e n t s r e l a p s e o n clomipramine or other serotonin reuptake inhibitors if they do not have associated behavior therapy (Zetin and Kramer, 1992). Behavior modification involving in vivo exposure combined with response prevention appears to have the best results (Barlow and Beck 1984), but a high relapse rate also occurs with this modality, which requires extensive cooperation from the patient (Marks, 1981).

Patients with OCD often have considerable difficulties in interpersonal relationships, both with family members and with those at work or in social settings. The diagnosis of OCD is associated with a high risk of separation or divorce (Zetin and Kramer, 1992). Psychodynamic approaches are extremely useful to help clarify and address the relationship problems encountered by the illness. Identification of the stressors and their particular meanings to patients may also help both the patient and family members to be aware of precipitating events and try to reduce their impact or avoid them as much as possible.

The neurobiological substrate of OCD leads to certain kinds of unconscious patterns in relationships that ultimately become

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internalized as the patient’s characteristic object relationships. These are then reexternalized in familial and extrafamilial relationships to create a host of problems. The advantage of a psychodynamic orientation in treatment is that the transference–countertransference developments can be systematically examined as a way of helping patients understand their relationship problems in other contexts.

Mr. A was a 26-year-old single man who was admitted to a psychiatric hospital unit because his symptoms had become virtually d i s a b l i n g a n d b e c a u s e h e h a d r e f u s e d t o c o o p e r a t e w i t h pharmacotherapy and behavior therapy approaches. He was preoccupied with the possibility that his mother and father had stepped on the AIDS virus on their way home from their respective jobs and was convinced that the house needed to be sprayed with disinfectants thoroughly to prevent his coming into contact with the virus. His parents had colluded with his insistence that every item of furniture in the house needed to be sprayed and scrubbed down. Each evening they would systematically go through the ritual of spraying and wiping off much of the household under the direction of the patient.

When Mr. A came into the hospital unit, he asked his primary nurse for details about the previous occupant of his room. The nurse explained that such information was confidential and could not be shared with him. Nevertheless, he persisted in asking questions, particularly regarding the previous occupant’s masturbatory habits. He became obsessed with the notion that there might be semen stains in his room that could transmit HIV infection to him. In my daily interviews with him, much of the time of our discussions was consumed with this possibility. Despite the absurdity of his fear, his insistence that we discuss the possibility of HIV contamination was powerfully coercive to the point that I found myself engaging in extensive efforts to argue from a rational, logical standpoint that his fears were essentially irrational. Mr. A’s demand that I participate with him in a dialogue about HIV had an obligatory quality associated with it. I felt invaded by it and “bullied” into a kind of folie à deux in which nothing else was important to the two of us. In short, I had become an extension of Mr. A.

On one morning, while making rounds, I walked into his room to find Mr. A’s primary nurse with disinfectant spray in one hand and a paper towel in the other, “decontaminating” the furniture in Mr. A’s room. The nurse appeared rather ashamed that he had been caught colluding with the patient’s fear of contamination.

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When I met with the nurse later, I explained to him that I could empathize with his dilemma—namely, that Mr. A’s need to discuss his obsession and to engage in rituals to assure himself that the room was decontaminated was so powerfully compelling that one could easily get drawn into colluding with it. I pointed out to the nurse, that via projective identification, he had become tyrannized by the patient in the same way that the patient’s parents had been tyrannized by Mr. A at home. I shared with the nurse the time-honored view of the psychoanalytic hospital as a place where a patient recreates his family situation (more precisely, his internal object world) in the milieu of the hospital with various staff members (Gabbard, 1988).

When the nurse refused to engage in such collusion following that incident, Mr. A became highly indignant. The extent of his entitlement was truly remarkable. He clearly had the expectation that others in his environment should behave as narcissistic extensions of himself. He massively denied the autonomy and subjectivity of anyone else in his life. They existed only to respond to his needs, and his omnipotent control was highly dehumanizing.

I spent a good deal of time in my meetings with him pointing out his pattern of object relatedness, both in his relationship with the nurse and with me on the unit and with his parents at home. I clarified with him that his sense of urgency about the catastrophic nature of his thoughts regarding contamination by HIV caused others to feel that they must do his bidding or there would be dire consequences. While this approach did not directly reduce his obsessive-compulsive symptoms, it was of extraordinary value in helping him develop greater empathy for others and to view them as subjects rather than objects under his omnipotent control. In the social worker’s sessions with the parents and Mr. A, a great deal of progress was made in h e l p i n g t h e p a r e n t s s e e t h a t c o l l u d i n g w i t h h i s n e e d s f o r “decontamination” were not in his best interests in the long run. The parents felt extraordinary relief in gaining permission from the social worker, and eventually from Mr. A, to act out of their own needs rather than to subject themselves to Mr. A’s controlling behavior.

Another cogent reason to incorporate psychodynamic strategies w i t h O C D p a t i e n t s i s t h e f a c t t h a t m a n y h a v e s i g n i f i c a n t characterological issues that serve as powerful resistances to forms of treatment such as behavior therapy or pharmacotherapy. In fact, Baer et al. (1990) found that the presence of schizotypal, borderline, and avoidant personality disorders predicted poor treatment outcome

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in patients with OCD treated by clomipramine. Moreover, even when patients fall short of meeting DSM-IV criteria for a personality disorder, they still may have prominent characterological features that interfere with the implementation of a comprehensive treatment program.

In another study (Aubuschon and Malatesta, 1994), 31 patients with OCD who were comorbid for a personality disorder were treated with comprehensive behavior therapy. Their outcomes were compared with a group of OCD patients without comorbid personality disorders. Those patients with personality disorders were rated as more difficult to treat, were more likely to terminate behavior therapy prematurely, and required more psychiatric hospitalizations than the OCD patients without personality disorders.

Mr. B was a 38-year-old divorced man who had been successful in a management position until he became unable to function effectively at work because of obsessional thoughts and compulsive rituals. Although he had a longstanding paranoid personality disorder and some mild symptoms of OCD, his functioning had never been impaired until his father’s illness and death 2 years prior to seeking t r e a t m e n t w i t h m e . H i s o b s e s s i o n s a n d r i t u a l i s t i c b e h a v i o r dramatically worsened at the time of his father’s death, to the point where he found he could not function effectively at work.

The patient had been angry at his father the last time he saw him before his death and felt extraordinarily guilty about the fact that their last meeting had been an angry one. The day preceding the fat

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