dsm 5 | The Psychotherapist

Diagnosis of Obsessive-Compulsive Personality from the Gestalt Therapy Perspective

The DSM V describes obsessive-compulsive personality disorder (OCPD) as a pervasive pattern of preoccupation with

orderliness,
perfectionism, and
mental and interpersonal control.

Individuals with presenting phenomena of OCPD give up their flexibility of behavior and thought. They become “closed up”, showing lack of openness to the environment around them.

The consequence of being in a constant state of obsession-compulsion is chronic inefficiency in doing daily tasks resulting from the preoccupation on distracting details or rules and schedules which leaves the main tasks undone. The quest for having tasks done perfectly also leaves tasks unfinished. While everything takes longer to complete, there is also an added obsession with work and productivity. This leaves the individual with little energy left for leisure activities and relationships. Relationships eventually suffer because there is a tendency to be overconscientious and inflexible, oftentimes about matters of ethics. Many individuals with OCPD tend to hold on steadfastly to religious or ideological stance. They may also have fixed ideas of how things should be done while not delegating their work to others. Some individuals may exhibit tendencies of holding on to unnecessary objects or being miserly. A certain feature of this personality style is the display of stubborn rigidity.

Obsessive Compulsive Personality Disorder Explained with Gestalt Therapy

Looking at this condition through the gestalt therapy lens, we may be able to appreciate the complexity of the client’s treatment process. In seeing the process at each stage and the resistances of the individual towards change, we can follow the clients’s path with more understanding and patience.

At the sensory stimulation phase (the initial phase): one’s own needs are ignored. Habitual behavior and thoughts take the place of present needs. Feelings that arise in the foreground become interrupted by background noise of routine activity. The patient may find difficulty articulating needs or accessing emotions. Difficult emotions are avoided. In place of this is the need to continue habitual behavior.

At this phase of treatment, focus on arising emotions is the work. Often the patient is able to recount difficult life situations, but the narration lacks emotional content. The therapist’s job at this point is to support the patient in embodying the denied emotions, instead of blocking them out with compulsive thought.

At the Orientation phase: There is seeking of external rules. The self has to be perfect, and be right. “I must do it right”. “I must check this…”

There is a sense that being not perfect may lead to loss of love, rejection and helplessness. Control to avoid touching these feelings are directed towards the external environment.

Experiment with words, making statements and dealing with projections (e.g. other people will judge me if ….) plus dealing with emotions is the work at this stage.

At the Action phase: This is the phase that occurs when the individual is guided to act on behalf of his/her needs rather than acting on his/her impulses. This can bring about anxiety. OCPD actions are acts out of fear of helplessness. The behavior and thoughts are triggered in order to avoid the possibility of situations that leads to helplessness. This requires the attempt at controlling and perfecting the environment and external self. Ultimately nothing suffices.

Therapy at this phase brings to light the anxiety that arises. There is also projections (attributing thoughts of the self on other people) and retroflections (holding the self back, or blaming the self) that need to be worked through.

At the Assimilation phase: At this phase, the individual would have tried to change his/her behavior. This is possible through practicing will-power, or having behavioral-style therapy. However, attempts to change behavior get quickly sabotaged by introjected messages (like “this is wrong”, “it will not work”) that lead to the individual rationalizing the attempt, denying the point of attempting change, feeling contempt for the effort or try playing down the problem. This is the reason why in gestalt therapy, we are aware that behavior modification attempts alone does not resolve the issues of OCPD.

At this stage, it would be better to check with the patient about his/her introjects, and feelings of guilt or shame that may arise from taking appropriate action.

At the release phase: Let’s say that the patient has managed to overcome the first four phases, the next tendency would be to hold on to the identification of the self with OCPD. The need would be to hold on to the habitual thoughts and action as if these were the “right thing to do”. This is a protection mechanism against the grief that can arise from feelings of loss and feelings of loneliness.

At this phase, the patient may seem very sad or look depressed or angry. He/she shows strong emotions. The therapist supports the patient by being present and acknowledging the client’s difficult emotions, and helping him/her work through the mourning process.

Treatment Focus

The treatment process in Gestalt therapy for OCPD, when done in it thoroughness, with the above phases worked through requires a good amount of patience within the psychotherapeutic alliance. At each phase, difficult emotions need to be acknowledged and processed.

Treatment of symptoms arising from personality disorders take time. Patience is essential for both therapist and patient. Where dealing with loss is concerned, the mourning process is an important, positive step to healing.

Phenomenology

Physical appearance is usually thin, haggard, not enjoying, gray, tensed.

The emotions include fear, anxiety, loneliness, helplessness, defiance, vulnerability. Initial emotionality may look flat, and restrained.

Psychosomatic reactions may include stomach and gastro pain and symptoms, constipation, circulatory system problems (e.g. myocardial infarction).

Polarities to work through are :

Powerfulness – Helplessness
Fear – Aggression, Anger, Bitterness
Control – Chaos
Obedience – Defiance, unruliness

Sources

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Anger, H. (2018) Gestalt Diagnostics. Private Lecture at the Sigmund Freud University, Vienna.

Differentiation between the Healthy Process of Grief and Depression

This information is lifted off the Diagnostic and Statistical Manual of Mental Disorders ( DSM 5). Interestingly, this passage, which I consider to hold very important information, is written as a footnote on page 134 of the Manual.

What is the difference between grief and major depression, anyway?

For one thing, grief is a natural, healthy reaction to loss. It is an emotional response to something that has happened in our lives. We cannot escape encountering losses, and we cannot escape feelings of grief when it happens. Just because one feels terrible in a state of grief, does not mean that one has a mental / psychological disorder.

My reason for highlighting this, is with the hope that in grief, one one learns to find the right kind of self-support: find someone to talk to, try to not be alone, cry, find creative outlet and let time heal the wound (although it may leave the scar).

A potentially detrimental method of avoiding grief is to turn to drugs or narcotics, blame the self/self judgement for feeling bad, or any kind of harming the self or others.

grief and depression psychotherapy — Grief vs. Depression

Here’s what is written in the DSM-5 footnote:

“In distinguishing grief from a major depressive episode (MDE), it is useful to consider that in grief the predominant affect is feelings of emptiness and loss, while in a MDE it is persistent depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in grief is likely to decrease in intensity over days to weeks and occurs in waves, the so-called pangs of grief. These waves tend to be associated with thoughts or reminders of the deceased. The depressed mood of a MDE is more persistent and not tied to specific thoughts or preoccupations. The pain of grief may be accompanied by positive emotions and humor that are uncharacteristic of the pervasive unhappiness and misery characteristic of a MDE. The thought content associated with grief generally features a preoccupation with thoughts and memories of the deceased, rather than the self-critical or pessimistic ruminations seen in a MDE. In grief, self-esteem is generally preserved, whereas in a MDE feelings of worthlessness and self-loathing are common. If self-derogatory ideation is present in grief, it typically involves perceived failings vis-à-vis the deceased (e.g., not visiting frequently enough, not telling the deceased how much he or she was loved). If a bereaved individual thinks about death and dying, such thoughts are generally focused on the deceased and possibly about “’joining” the deceased, whereas in a MDE such thoughts are focused on ending one’s own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression.”

Mental Illness: DSM definition of what is mental disorder is and what isn’t

This is the definition of the term “mental disorder” according to the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS FIFTH EDI T ION DSM-5 (pg.20):

A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.

Mental disorder is a syndrome

The definition describes what mental disorder is. It is a syndrome, which is a group of related symptoms that the individual might encounter. Mental disorders are observable as clinically significant disturbances. This means that if the emotional regulation, behavior or cognitive processes of an individual is not clinically seen as significant, it is not a mental disorder. The mental disorder has to reflect a dysfunction that has underlying causation.

Mental disorders affect daily functioning

A mental disorder is considered as such only when it has consequences to the daily functioning of the individual. This means that even if a person suffers from schizophrenia, if this individual is able to work, live, have relationships and play, he/she does not have a mental disorder.

Distress Caused by Life Situations are Not Mental disorders

Distressing events e.g. death of a loved one, or a divorce can cause emotional /and physical pain. These emotional setbacks that a person faces are unpleasant but is does not mean that the person has a mental disorder.

Socially Deviant Behavior is Not Always the Result of Mental Disorder

Socially deviance is not considered a product of mental disorder unless this behavior is accompanied by a person who has the above-said mental disorder.

Psychotherapy is not only in the business of working with mental disorder.

Psychotherapy is different from psychiatry in the sense that it is not a profession that works only in the face of mental disorder. Even if mental disorder diagnosed, the therapy is focussed on the persons’ emotional state and self support.

Most of my clients are not in my office because of a mental disorder, but because of life events that they need to cope with. Psychotherapy lends the client a space to be heard, to introspect, interact and experiment; so that he/she can realize the choices he/she has to live a stable, functional and even thriving life.

How do we classify mental diseases?

There are 2 main classifications standards that are used today in the western world to diagnose psychopathological symptoms.

In the field psychotherapy, the concept of diagnostics is controversial. The reason being that unlike some physical problems, psychological issues are individual. For example, there is no one single cause of borderline personality disorder (BPD), but an array of situations that occur in the patient’s life that leads up to the symptoms. Diagnosing the symptoms are also complex, since each patient has his/her own way of dealing with the psychological trauma that leads to the condition. However putting labels onto observable psychological and behavioral conditions are necessary for professional to communicate with administrative bodies like psychiatrists, insurance companies, the courts, etc.

The ICD-10 by the World Health Organization (WHO)

The ICD-1o is also known as the International Statistical Classification of Diseases. It is the most recognized diagnostic classification system in the medical profession, and is provided by the WHO.

In the ICD-10 classification of mental disorders (or psychopathology) is categorized in Chapter F. Click here to have a complete online list of the ICD-10 classification of mental disorders.

This chapter contains the following blocks:

F00-F09Organic, including symptomatic, mental disorders
F10-F19Mental and behavioural disorders due to psychoactive substance use
F20-F29Schizophrenia, schizotypal and delusional disorders
F30-F39Mood [affective] disorders
F40-F48Neurotic, stress-related and somatoform disorders
F50-F59Behavioural syndromes associated with physiological disturbances and physical factors
F60-F69Disorders of adult personality and behaviour
F70-F79Mental retardation
F80-F89Disorders of psychological development
F90-F98Behavioural and emotional disorders with onset usually occurring in childhood and adolescence
F99-F99Unspecified mental disorder

ICD-11 is due to be out in 2018.

The DSM-5 by the American Psychiatric Association (APA)

DSM-5 is the short form for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

The DSM-5 was published in May 2013.