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自恋型人格障碍的精神分析治疗案例-给力心理
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自恋型人格障碍的精神分析治疗案例

自恋型人格障碍的精神分析治疗案例
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发表时间:2015-02-06 14:57:31 360 0 0

来诊简况:P(指病人,下同)女性,23岁,护校毕业后没有留在当地参加工作,直接到远离家乡千里之外的哈尔滨打工,家里当时没人知道P到哪里去了,也不找P。半年后过春节P也不回家,电话也不打。P称来哈尔滨目的之一是远远逃离令她感到非常痛苦的家庭,之二是找心理医生治自己严重的心理疾病,听朋友说本院有心理门诊,快下班时未按预约自来诊。

  简要个人史:P是家中最小的孩子,有两个哥哥,大哥36岁,二哥29岁,均是工人。母亲患精神分裂症,无业。父亲是修汽车的,嗜酒、性格暴躁、乖戾、少语,不知关心、教育、照管孩子。对妻子粗暴,经常当着孩子们的面殴打妻子。P从小就是喂面糊长大,从记事起就经常目睹母亲犯病的样子。多次目睹母亲被巫医、父亲及亲属毒打时的情景,非常恐惧。P记得小时候跟父亲关系很好,经常由父亲搂着睡觉,父亲不打骂PP大哥十几岁就离家住校,二哥与P从小在一起长大,但二哥整天在外面玩,父亲的爱成了唯一的爱,虽然少得可怜。P10岁开始边上学,边做家务,边给全家人做饭。不管多累,家庭中其它的成员,很少帮P、关注P。用P的话:“爸爸整天上班、喝酒;妈妈除了犯病外整天象孩子一样对我撒娇或躺在床上重复做着某个动作;二哥总在外面玩,家里总是冷冰冰的……。”因此P总是感到孤独、寂寞、忧愁。

  首次晤谈及心理动力学分析:

  P在预约时间相隔12天以后来诊,事先没有提前告诉D(指心理治疗师,下同),又是在D下班时来诊,而D利用自己的休息时间接待P。按理P要说对不起,并感谢D休息时间接待她,但P什么也没说。说明P不能理解或感觉到别人也是一个人,也有自己的需求,P不能理解、尊重别人的要求和利益,这是P心理发育不成熟的一种表现。首次晤谈,P身着素白纱裙,摩登发型,身高1.50米左右,文静、白晰、圆脸、大眼睛、清秀可人,很讨人喜欢。主动倾诉,情绪略显烦躁,双眉紧皱,不停地拧手指,谈到痛苦处痛哭流涕,孤独、无助的样子。主要心理问题是:恐惧、不知怎样与人接触和交朋友,不能适应任何环境,无法与人建立感情,感觉自己被社会淘汰了。每天忧愁、压抑,像死人一样。想改变却难以自拔。痛苦挣扎到今天,常感到喉咙有东西堵着,胃总是收缩在一起,里面像有一块圆圆的、烫烫的石头似的一天比一天沉重,整天被坏情绪纠缠着。P一方面滔滔不绝地讲了一个多小时,叙述了很多的苦难,D几乎没有插话的余地,说明P要从D那里得到更多的东西。但是,另一方面,P却以令人不愉快,甚至损害D需求的方式来表现自己,此种自相矛盾的现象的发生有可能是P潜意识中想用这种方式来考验D(当时的假设),即:如果我一意孤行,一直按照我自己的方式想怎么做就怎么做,我看你还喜欢不喜欢我。因此,首次晤谈,D感觉到可能P的外表着装可能也是吸引人的注意。而且当P的这种需求非常强烈时,P就会忽略对方的需求和利益。这进一步说明P的心理发育不成熟。

  初步诊断:自恋型人格障碍。

  治疗时间和频率:每周一次,每次一小时。

  以后的治疗及综合心理动力学分析:

  在前十次的治疗中,D了解到P的生活经历确实是悲剧性的。P出生后,无法得到母亲的连续照料和保护,没有得到母亲对孩子的需要所给予的不停地关注。P无法与母亲建立起积极的,令人满意的“共生关系”。同时,母亲也无法满足孩子的口腔欲求(人工喂养)。于是口欲不足,情感和皮肤饥饿,导致P共生期心理发育不顺利,P将无法满足的欲望、冲动等压抑到潜意识。使P的心理发育“固着”在口腔期。因此,P无法发展同周围人群和社会环境的稳定的基本信任,自信心也无法建立,逐渐形成“自恋型人格障碍”---对批评的反应愤怒、诡辩或感到耻辱,喜欢他人为自己服务。过分地自高自大。对成功、美丽、爱情等有非分的不现实的幻想,渴望持久的关注与赞美,缺乏同情心,高度自我中心,很强的嫉妒心,强烈的不自信、不安全感、洁癖等。这导致成年后的P处理不好人际关系。在前十次与P的接触中,D逐渐感到PD产生了理想化和镜像移情,P说:“D的每一句话,都能说到点子上,让我看到了希望、信心,D成了我的精神支柱,感觉和D交往过程像恋爱……梦见有一个泥坑,掉进去一个小女孩,哭喊着妈妈,然后伸出小手拉住妈妈的手,慢慢地爬出泥坑……我哭醒了,觉得D能解决我的一切问题,将来要做D这样的人……”。

  在P的人格结构中,P有很强的本我,较弱的超我,非常弱的自我。P常用的主要的心理防御机制有:无所不能、外射、内射、退行和合理化等。

  在十次以后的治疗中,病人的情感表现占统治地位的负性移情是“遗弃焦虑”和“分离焦虑”。因为P在成长的过程中类似的经历被一再的“重演”:[1]父亲嗜酒越烈,P得到的爱和关注越少,幻想中二哥的爱又被新来的二嫂夺走,于是,唤起口欲期被遗弃的感觉,在二哥结婚当天离家出走。[2]P念护校期间在姑姑家住,姑姑因为其付了学费而像奴隶似地使唤P,因姑父曾偷着给P好吃的和钱引起姑的猜疑,姑父再也不敢管P,尚未毕业P就不得不搬走,再次体验被遗弃。[3]在实习医院住并实习期间,又遇到待P好的男老师和待P不好的女老师。但当P被女老师当众赶出正在实习的手术室时,男老师在旁并没有帮助P,以至P实习没通过,毕业证不能到手,没有正式分配而离开医院跑到哈尔滨打工,第三次体验被遗弃。[4]P曾在当地求助于一男性心理DD让其撕半年纸转移心理障碍,送一本《森田疗法》书后再也不管PP第四次体验被遗弃的滋味。

  P被屡次地“遗弃”,不被关注的体验,促使P更强烈地去索取爱、索取关注。亦即索取“心理乳汁”欲望更强。这导致P的行为模式变得非此即彼,“要么得到,要么得不到”,得到时拼命索取,忽略对方,从不考虑对方的要求和利益,按照自己的方式,我行我素,一意孤行;得不到时就“逃”到心理症状中,或“逃跑”---换环境。P的这种情绪体验贯穿在P的整个行为中,P意识不到在儿童期没有得到的母爱和足够的“心理乳汁”让她现在有足够理由从D那里或别人那里得到,这种行为模式是解决不了P的问题的,只能使问题越来越多。DP的初步关系,实际上是P正在检验D会给她多少,如果有一天D的乳汁用完了,P会再度“逃跑”,强迫性地、一次次重复其受伤的经历。P的人际关系始终处理不好,就是这些不现实的想法和行为造成的。随着D第二次开始重新“设置”治疗环境,节制好母亲的形象,在以后的治疗中,P逐渐走进更深层次的自我探索中,P的心理发育开始向成熟的方向趋动,这说明自恋型人格障碍只要有镜像移情、理想化移情的能力,就能够用心理动力学治疗方法治疗。

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本文作者

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长程个案

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续单率

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