Richard C. Friedman, MD

This article reviews the organizing model of the brain, which is at the core of psychodynamic psychiatry.

At the end of this CE activity, participants should be able to:

1. Understand the psychodynamic perspective underlying psychiatry.

2. Recognize when psychotherapy must be provided by a psychiatrist and when it may be provided by an allied health professional.

3. Define what constitutes the psychodynamic approach in psychotherapy.

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Psychodynamic psychiatry is a psychiatric discipline that arose spontaneously as a result of clinical need and scientific necessity. Its roots are in academic psychiatry, neuroscience, extrapsychoanalytic psychology, and psychoanalysis.

To understand this unusual phenomenon, a historical perspective is necessary. During the years following World War II, when DSM-I and DSM-II were published, psychiatric thought about psychopathology was based on a psychoanalytic paradigm. There were advantages and disadvantages to this, but a crucial disadvantage was that it was not possible to achieve reliability of diagnoses. Independent health care professionals who interviewed the same patient often arrived at different diagnoses.

DSM-III (1980) abandoned the psychoanalytic perspective and replaced it with an atheoretical descriptive format. This led to increased diagnostic reliability, but it was not without limitations. One such was that many aspects of psychological functioning were not captured by the symptom list format. New developments led to substantial progress but also to knotty problems, including the pharmacological revolution; the evolving efforts to create an insurance-based system for psychiatric treatment; the emergence of time-limited, manual-based psychotherapies; the increasing emphasis of American medicine on a public health rather than a tertiary-care perspective; and the demedicalization of organized psychoanalysis in the US.

Taken together, these trends exerted a synergistic effect on the psychiatric climate. The professional identity of psychiatrists was and still is gradually being re-configured as a result. For example, there is currently great emphasis on the salience of time-limited symptom reduction. This influences the identity-role construction of psychiatrists as if psychiatry were a profession dedicated to the management of acute, relatively short-term problems using evidence-based treatments. It is not.

Although manual-based therapies prove useful for some patients and provide productive avenues of research, they do not offer adequate guidelines for the treatment of all or even most patients with psychiatric illness. Psychiatry must remain a profession defined by an organizing model of the mind, rather than by specific treatment techniques. Psychodynamic psychiatry offers such a model, and it is applicable to all psychiatric patients.

The recent attention of organized psychiatry has moved away from unconscious motivational influences on behavior. The way psychiatrists think about psychological functioning has changed radically in a relatively short time, and with it the education of psychiatry residents and the composition of psychiatry journals. Except for 

, it has become rare for major mainstream psychiatry journals to publish scholarly work on psychodynamic psychiatry (the discipline). As a result, modern psychiatry has been left with what might be termed an “unconscious” gap.

A vacuum in modern psychiatry has replaced assessment of the influence of unconscious irrational wishes and fears on psychopathology and coping behavior. This has occurred even as neuroscience makes rapid and dramatic progress in clarifying unconscious-conscious relationships and intermediate brain-mind mechanisms.

Perhaps the movement away from acknowledging the role of unconscious motivation was influenced by the demedicalization of psychoanalysis in the US. A positive aspect of this is that nonmedical colleagues are now able to use psychoanalytic techniques to treat the vast numbers of people with major psychiatric disorders with psychodynamically informed techniques.

An unhelpful consequence, however, which can be thought of as collateral damage, is a regrettably common belief that psychiatrists should treat disorders of the brain, and nonmedical colleagues, those of the mind. I reject this view as do most psychodynamically oriented psychiatrists. The idea that psychotherapy by nonphysicians can and should be provided to many patients is quite different from the notion that psychiatrists should never provide psychotherapy because nonmedical therapists can do it equally well and less expensively.

The belief that nonmedical therapists can provide psychotherapy to all patients is not evidence-based because the way in which patient diversity influences treatment choice and treatment outcome has not yet been adequately researched with appropriately designed studies. Optimal care for some patients, such as those with serious medical disorders comorbid with psychiatric disorders, with psychoses, or with frequent emergencies (eg, repetitive suicidal and/or violent behavior), mandates psychotherapy by a psychiatrists and, if necessary, the use of adjunctive pharmacotherapy.

My point here is not to suggest that administration of psychodynamically informed psychiatric interventions be restricted to specific providers, but to illustrate that so-called split treatment administered by nonmedical therapists and psychiatrists is not always practical or ideal.

Psychodynamic psychiatry emphasizes the need for psychiatrists to relate to the patient as a whole person, including his or her unconscious aspects. Treatment planning emphasizes not only drugs prescribed and standardized interventions implemented but also the importance of the therapeutic relationship. In that sense, psychodynamic psychiatry is part of the Hippocratic tradition of medical care. It applies and broadens the ideas of Adolph Myer,

Most behavior is influenced by unconscious factors. These are sometimes irrational wishes and fears that motivate maladaptive, repetitive patterns of activity. The relative weight that unconscious influences exert on conscious mental life varies from person to person. Such influences may be substantial (eg, in conversion reactions) or apparently less important than primary biological influences (melancholia). A closer look at a patient with melancholic depression, however, reveals the relevance for psychodynamic thinking.

Mrs H, who is 55 years old, presents with symptoms of melancholic depression that began on the anniversary of her husband’s death (5 years earlier). In addition to her melancholic symptoms, she complains of a foul vaginal odor and of hearing voices accusing her of being “a whore.” She has also been having thoughts of suicide to escape from her suffering.

Following hospital admission, findings from a gynecological examination are normal and symptoms remit with treatment. On further discussion with Mrs H, it emerges that shortly before her present illness, a friend of her late husband had asked her out on a date. Although the relationship did not progress romantically, she felt anxious that sexual feelings had been mobilized; the hallucinations and delusions manifested soon thereafter. Psychosocial and psychodynamic factors influenced the psychological context in which the biological determinants of melancholia were expressed. The treatment plan included psychodynamic psychotherapy to ameliorate her guilt and pharmaco-therapy to treat her psychotic and melancholic symptoms.

In thinking about Mrs H, one cannot cite research that proves that assessing and treating irrational guilt prevents recidivism. In fact, one would be hard put to find adequately designed studies that demonstrate that psychosocial context influences illness presentation and outcome. Common sense, clinical experience, and psychiatric judgment indicate that it often does, however. Much decision making about therapeutics, not only in psychiatry but in medicine and surgery, is based on judgments that take into account clinical experience as well as scientific advances.

A good deal of psychiatric practice does not involve the application of standardized techniques in specific and well-understood situations. Rather it involves using evidence to make inferential leaps in situations that are complex and often unpredictable.

“The past is never dead. It is not even past.”

 Psychiatrists are indebted to Faulkner for expressing so evocatively what we have traditionally understood. The past is folded into the present in many ways and influences both psychopathology, resilience, and coping.

Patients with serious psychiatric disturbances tend to suffer from multiple disorders, many of which have their onset in childhood or adolescence. They tend to have family histories of psychopathology and/or past histories of exposure to serious adverse events during early childhood. In a prospective study in New Zealand, 1037 consecutively born children were evaluated every 2 years from age 5 to age 21, with a follow-up at age 26. At age 26, about 20% had received treatment for a psychological problem, although usually not from a psychiatrist. Most of these individuals experienced the onset of the disorders before age 18 and 55% before age 15. The researchers recommended that clinicians who treat adults must assess the age of onset of disorders to formulate an adequate treatment strategy.

The onset of a psychiatric disorder is likely to be associated with adverse psychosocial events. In a nationally representative sample of 9282 adults, events such as parental death, divorce, neglect, and/or abuse were associated with adult psychiatric disorders.

 The more events experienced, the greater the association and the greater likelihood that the disorder would be chronic or recurrent.

Comorbidity is relatively common among psychiatric patients and is often associated with severity of illness.

 The National Comorbidity Survey revealed that about 14% of the population had severe disorders and that most of these had comorbidities.

 This figure illustrates how severe the problem of mental illness is in American society. A very broad, vigorous, and flexible approach to prevention, diagnosis, and treatment must be used. The presentation of a particular patient at a particular time must be understood, not only in an immediate psychosocial context but also longitudinally-as part of a timeline constructed in the past and extending into the future. Multiple adverse events have additive and cascading effects throughout development.

Virginia was hospitalized at age 19 following a suicide attempt precipitated by a lover’s rejection. Virginia was an only child whose parents divorced when she was 2 years old. Her mother could not take care of her, and by age 6 she was placed into foster care. At age 9, she was repeatedly sexually abused by a foster sibling-a boy several years older. This went on for 3 years, until he was arrested, never to return. Virginia was deeply attached to him and became severely depressed when he disappeared.

Eventually she was adopted and her depression abated. At age 14, she began a sexual relationship with her adoptive father. When her adoptive mother learned of this, Virginia was exiled from her home. She became seriously depressed as a result of her multiple losses but did not seek assistance from mental health professionals. Virginia traveled to a distant city, where she became a street prostitute. Her first suicide attempt at age 17 occurred after a beating by a pimp.

This vignette presents only a few snippets from Virginia’s life, but it illustrates the different and sequential trauma and deprivations she endured. Following her parents’ divorce when she was a toddler, she experienced the loss of her father, who had been somewhat involved with her before the divorce. Her mother withdrew as well and more or less vanished from her life. Virginia’s situation got worse after that and, over time, worse again. Sex became interwoven not only in the pattern of her recurrent psychopathology but in coping efforts as well. The many adversities she suffered occurred against a background of chronic poverty.

Unfortunately, histories similar to Virginia’s are the rule, not the exception, among the 15% or so of the most seriously disturbed segment of the population. One cannot adequately convey a sense of the circumstances patients like Virginia endure by listing past and present psychiatric diagnoses.

It is best to conceptualize treatment planning for patients like Virginia in terms of multiple, flexibly administered interventions provided in a caring context by professionals who are aware that some of Virginia’s behavior is likely to be shaped by unconscious factors. This may influence her conduct in therapeutic situations, including her motivation to participate in treatment(s). For example, Virginia’s sexually seductive interactions with a male therapist can be best understood in the context of her past sexual history. These experiences are intimately connected subconsciously to feelings of depression. She is not aware that her seductiveness is based on a pattern of relating to powerful authority figures that had been internalized since childhood.

Psychodynamic understanding of Virginia is partially based on decoding messages that influence her behavior, which she is not aware of and which are layered in her mind, sometimes in an apparently illogical manner. For example, one message might be, “If you have sex with this man he will not leave you,” whereas a contradictory message might be, “You deserve to be abandoned by sexual partners; this is fit punishment for a bad person like you.” Therefore, Virginia might think of herself as an alluring enchantress and simultaneously worthless-“like garbage.” Awareness of this type of complexity assists treatment planning, although it is not captured in DSM.

Psychodynamically informed interviewing is based on the idea that people tend to construct personal stories or narratives that attribute meaning to past experience and guide future action.

 Narrative construction begins in a familial or caregiver setting. One way of thinking about narrative construction is that it is a transmission of guidelines for interacting in the human environment, beginning with cross-generational (family) guidelines and later moving outside of the family setting.

Narratives involve not only simple interpersonal dramas but also the integration and regulation of emotions (affects). These narratives may be adaptive or maladaptive. Maladaptive narrative construction is more likely in settings of caregiver psychopathology and exposure to adverse life events.

Once maladaptive patterns of integrations of feelings and interpersonal relationships become part of internal programming, they may be repeated time after time impervious to immediate negative experiences. Psychodynamic assessment detects such patterned pathology and influences treatment planning.

The frequency with which psychiatrists administer psychotherapy is diminishing, and the frequency with which they prescribe psychoactive drugs is increasing.

 It is fortunate that many allied health professionals (eg, nurses, social workers, psychologists, pastoral counselors) are qualified to practice psychotherapy, given the high prevalence of psychiatric disorders and consequent disability in the general population.

 It is increasingly recognized in other countries that psychotherapy is an effective and cost-effective treatment for patients with diverse mental disorders, including lower-grade anxiety and depressive disorders and personality disorders.

 This has yet to be fully recognized in the US and acknowledged by third-party payers.

 Many individuals with psychological problems avoid seeking assistance from psychiatrists or other mental health professionals, most likely because of associated stigma.

Among the total population of patients, there are many who can and should be treated by psychiatrists-eg, patients with concurrent medical and psychiatric disorders; patients with psychotic disorders; and patients with multiple psychiatric disorders, such as addictions and personality disorders; as well as those with histories of complex trauma and those with multiple psychiatric and/or medical disorders. Across diagnostic categories, many patients with suicidal and/or homicidal potential would also be included. Many patients who need different combinations of psychotherapy and medication over time might be best treated by psychiatrists as well. These patients frequently need alteration in type and/or dose of drug and in frequency of psychotherapeutic sessions. Psychiatric residency training programs recognize that competence in psychotherapy should be part of every psychiatrist’s therapeutic armamentarium.

Although the assessment of every patient should include a psycho-dynamic component, many patients need some other type of treatment or combination of treatments than psychodynamic psychotherapy. The needs of patients who are severely and chronically psychiatrically disturbed may be different from those who are at the other end of a health-illness spectrum. One of the traits emphasized in psychotherapy is empathy. Other attitudes, including sympathy, compassion, practical realistic therapeutic judgment, unsentimentality, flexibility, readiness to recommend multimodal treatments, and willingness to collaborate with other therapists, are also useful. The notion of a weekly meeting in a therapist’s office may not be practical for many patients, but a psychodynamically informed attitude always will be!

Psychodynamic awareness may inform techniques such as confrontation, clarification, and psychoeducation. For example, a teenage girl with suicidal fantasies and borderline personality disorder might have a history of being relentlessly criticized by a verbally abusive father, with whom she feels embattled. She is frequently late to sessions with a male therapist. Because of the influence of transference, the patient expects to be criticized by the therapist. Indeed, she provokes criticism. The therapist must try to confront the patient about her lateness without seeming like her hypercritical father. He might do this by participating in the session as usual, perhaps concentrating on supporting his patient’s self-esteem but ending the session on time. If the patient objects and asks to stay overtime, he might respond: “I was hoping to have more time with you too. When you were delayed, I was concerned and hoped you were okay. We have to stop promptly today but perhaps next session we can get started a bit earlier so we can have more time to work on helping you feel better.”

The therapist would also need to understand the circumstances that led to the patient’s late arrival. Her lateness might have been a response to stressful events, not necessarily part of a repetitive pattern determined by her personality disorder. If she experienced a traumatic event immediately before the session, for example, the therapist’s approach would be different, but it would still be informed by the need to be unlike the patient’s transference expectation that he would act like her father.

Patients with histories of complex psychopathology often need treatment combinations that may change over time. For example, a patient with dysthymia and alcoholism might be treated with psychodynamic psychotherapy and participation in alcoholics anonymous. Either treatment might persist even if the other was temporarily or permanently discontinued. A patient with anxiety disorder and chronic depression who is the victim of spousal abuse might be treated with psychodynamic psychotherapy, antidepressant medication, and marital therapy. Any of these might be discontinued while the other treatments are continued. A patient with severe anxiety and depression and borderline personality disorder might be treated with transference- focused psychotherapy and psychotropic medication in combinations that vary over time. These are examples of combination therapy that often occur in clinical practice.

Most of these combination treatments have not been adequately researched. This is a point that deserves emphasis because it bears on data that are available to insurance companies and may influence reimbursement practices. The rationale for refusing to reimburse for combination of treatments for patients with complex disorders may be that controlled studies of particular treatment combinations have not been done. The insurance company might argue there is no evidence that a particular combination of therapeutic modalities will be effective. Centralized micromanagement (in the form of regulating reimbursement) must defer to the judgment of clinicians if the best interests of patients are to be preserved.

Psychodynamically informed psychotherapy may be from a single session to several years in duration. Researchers generally consider psychotherapy to be long-term if it lasts a year or longer, although this, too, is arbitrary. Psychotherapists tend to share the view that unconsciously motivated maladaptive behavior can be positively influenced in the context of a trusting and intimate relationship with a psychotherapist. The relationship must be organized around the patient’s needs and not the therapist’s.

In psychotherapy, patient and therapist work together as a team to further therapeutic goals. These goals include diminution of specific symptoms and of suffering in general, and increased functioning. Long-term psychodynamic psychotherapy with properly selected patients has been demonstrated to be an effective form of treatment.

 Sometimes it is administered without concurrent pharmacotherapy.

The usefulness of psychodynamically informed assessment of psychiatric patients is universal. It is especially necessary because of substantial diversity in all aspects of behavior and socioeconomic circumstances. The type of treatment recommended depends on assessment, and only some patients need psychodynamic psychotherapy. Of these, a substantial number are best treated by psychiatrists. Competency in psychodynamic assessment and treatment, including its usefulness in the treatment of the chronically mentally ill, must continue to be a core part of the identity of all psychiatrists.

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Dr Friedman is Clinical Professor of Psychiatry, Weill Medical College, Cornell University Medical School, New York.

 Friedman RC, Downey JI. Psychodynamic psychiatry and psychoanalysis. 

 Kalman TP, Kalman VN, Granet R. Do psychopharmacologists speak to psychotherapists? A survey of practicing clinicians. 

Psychoanalysis and American Medicine, 1894-1917: Medicine, Science, and Culture.

 New York: International Universities Press; 1967.

 Engel GL. The need for a new medical model: a challenge for biomedicine. 

 Kim-Cohen J, Caspi A, Moffitt TE, et al. Prior juvenile diagnoses in adults with mental disorder: developmental follow-back of a prospective-longitudinal cohort. 

 Green JG, McLaughlin KA, Berglund PA, et al. Childhood adversities and adult psychiatric disorders in the national comorbidity survey replication I: associations with first onset of DSM-IV disorders. 

 Friedman RC, Garrison WB 3rd, Bucci W, Gorman BS. Factors affecting change in private psychotherapy patients of senior psychoanalysts: an effectiveness study. 

 Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. 

From Psychoanalytic Narrative to Empirical Single Case Research: Implications for Psychoanalytic Practice. 

 Mojtabai R, Olfson M. National trends in psychotherapy by office-based psychiatrists. 

Psychotherapy Is Worth It: A Comprehensive Review of Its Cost-Effectiveness.

 Arlington, VA: American Psychiatric Publishing; 2010.

Articles

Psychiatry must remain a profession defined by an organizing model of the mind, rather than by specific treatment techniques. Psychodynamic psychiatry offers such a model, and it is applicable to all psychiatric patients.

Issues in Psychodynamic Psychiatry

In this article we discuss psychoneuroendocrine influences on sexual orientation and the psychodynamics of internalized homophobia. Because of space limitations, we focus on homosexual orientation, although research in this area sheds light on heterosexual and bisexual orientation as well.

Research that has been conducted on the relationships between hormones and behavior suggests that prenatal hormones might influence sexual orientation in some persons. Although this hypothesis still requires definitive proof, accumulating evidence has ever-increasing clinical significance.

It has long been recognized that male sex-stereotypical behavior in many animals-mounting, penile insertion, pelvic thrusting-is controlled by the medial preoptic area of the hypothalamus. Female sex-stereotypical behavior-lordosis (arching of the back)-is controlled by the ventromedial nucleus. These hypothalamic nuclei are organized by sex steroid hormones. During a critical period of prenatal or (depending on the species) perinatal life, the male fetal testis secretes androgen, which alters the structure of the hypothalamus, increasing male sex-stereotypical behavior later in development and diminishing female sex-stereotypical behavior. In humans, a testosterone surge occurs between the 8th and 24th week of pregnancy. If no testosterone surge occurs, the brain differentiates as female, and the sex-stereotypical behavior that develops is also typically female-organized around the lordosis response.

It is possible to experimentally manipulate prenatal sex steroid hormones to influence animals to demonstrate both female and male sex-stereotypical responses (lordosis and mounting).

 Based on this research, a number of investigators have speculated that human sexual orientation might be influenced by prenatal hormones.

This theory of hypothalamic influence on human sexual orientation has found some support; for example, some girls who are exposed to increased prenatal androgens because of congenital adrenal hyperplasia (CAH) have increased homosexual interest and diminished heterosexual interest later in life. Even though these findings are not robust and most such girls grow up to become heterosexual women, they point in a direction predicted by the prenatal androgen hypothesis.

 undertook a study that increased attention to this line of thinking. He observed that a particular hypothalamic nucleus (the third interstitial nucleus of the anterior hypothalamus [INAH 3]) in roughly the same location in humans as the sexual dimorphic nucleus (SDN) of rats was much smaller in homosexual than heterosexual men and, in fact, similar in size to that of women. Because this nucleus is prenatally influenced by androgens, he speculated that the object of sexual interest of rats and humans might be controlled by similar hormone-brain interactions. LeVay studied brain structure, not function, however, and a subsequent attempt to replicate his research by Byne and colleagues

 studied sheep, an animal species in which a small number of males prefer mounting other males to females. These male-oriented rams were shown to differ from female-oriented rams in one particular hypothalamic nucleus. This hypothalamic nucleus was located in roughly the same place as the rat SDN and INAH 3 in humans. However, the researchers emphasized that there was no way of knowing whether these hypothalamic nuclei are homologous across species. They called the sheep nucleus ovine (o)SDN.

However, ancillary evidence was found to strengthen the argument that this hypothalamic nucleus might influence the sexual object of sheep. In the brain, androgens are converted to estrogens, which then act on estrogen receptors to masculinize sexual behavior. The enzyme responsible for this steroid conversion is aromatase. The Roselli group found that messenger RNA levels for aromatase were higher in the oSDN in males than in females, and higher in those rams sexually oriented toward females than those sexually oriented toward males.

Among men motivated to have sex with other men, some might simply be expressing behavior prenatally determined by hypothalamic structures formed under the influence of sex steroid hormones whose ebbs and flows happened to differ from those of the mainstream. Although scant, some data do exist to support this theory in humans and to suggest that a similar line of reasoning may be applied to some women.

On the one hand, persons who have same-sex partners are quite diverse, and no psychobiological generalizations about their motivation can possibly be applied to all. On the other hand, the psychoneuroendocrine research only briefly outlined here is undeniably intriguing and, at the very least, indicates that psychiatrists must be cognizant of prenatal hormonal influences on brain structure and function in order to understand sexual behavior.

Prenatal androgen and gender-role behavior

Prenatal androgen also influences gender-role behavior. This is evident from the play patterns of girls with early corrected CAH. These children tend to play more like boys than unaffected girls do. They tend to be tomboys, for example, and enjoy rough-and-tumble activities more frequently than their sisters. Although their childhood gender-role behavior is somewhat boy-like, most of these girls see themselves as female and are not uncertain about their gender identity. Gender identity formation usually is the product of many interacting biological, psychological, and social influences, including intrafamilial relationships.

The play behavior of toddlers is also shaped by prenatal androgens.

 As children grow and acquire ever greater social experience and cognitive sophistication, their childhood play patterns become incorporated into gender-stereotypical play. During the juvenile phase of development, when gender-segregated play is the norm, the different play styles of the children of different sexes influence their peer relationships. Boys tend to form peer groups that are hierarchical, exclusive of adults, and frequently organized around team sports. Boys' groups are also likely to be intolerant of gender-atypical behavior in other boys and may stigmatize those drawn to such behavior as "sissies." In keeping with play styles present since toddlerhood, peer groups of girls tend to be less aggressive and walled off from adults and more tolerant of gender-atypical behavior. This is not to suggest that girls are somehow "nicer" than boys. Both sexes may be equally friendly or mean. They tend to differ in their attitudes toward gender-role behavior, however.

Boys and girls on a nonheterosexual developmental pathway are more likely than those on a heterosexual path to be drawn toward nonstereotypical gender-role activities. This developmental phenomenon occurs for reasons that have not been definitively determined, but it has been taken by some investigators as additional indirect evidence of prena- tal neuroendocrine influence on brain embryogenesis.

As noted above, there seems to be a tendency for boys with atypical gender-role interests to be penalized by other males in a way that is less common among girls. Such penalty comes in the form of bullying, threats of violence, or ostracism often beginning by the juvenile phase of development.

 Although the tolerance of girls for cross-gender behavior is greater than that of boys, it is not boundless. For example, a now famous case report discusses the development of a boy who was raised as a girl after an accidental penile amputation in early childhood.

 As a juvenile, she was tormented by female peers and was called "gorilla" because of extremely masculine gender-role behavior, which was incongruent with a female name and gender of her rearing. Such behavior appeared to be an innate attribute of the child's temperament (presumably due to masculinazation of the hypothalamus) and resisted attempts to modify it psychosocially.

 This case illustrates the response of female peers to a girl with extremely boy-like gender-role behavior. Many other instances of prenatal androgenization of girls have been discussed in which complex nature-nurture interactions have been described.

Peers are not the only source of difficulties for boys, however. Often older males-even fathers and other relatives-are also intolerant of atypical gender-role behavior. An important reason for difficulties between boys on a homosexual developmental track and their fathers is temperamental incompatibility in gender-role behavior. The son's innate temperamental proclivity toward nonstereotypical gender-role activities provokes anxiety and defensive responses in the father whose attitudes and values about masculinity are likely to be influenced by his own sex-stereotypical gender-role temperament.

Childhood difficulties with same-sex peers and with his father may have additive effects in diminishing a child's self-regard and contributing to his sense of being "different."

 The feeling of not belonging to the mainstream may also be influenced by awareness of romantic and sexual feelings toward those of the same sex.

The term "homophobia" was introduced almost half a century ago to indicate irrational aversion to nonheterosexual persons and has now become part of everyday parlance.

 Arguably, its most distressing manifestation is violence, almost always perpetrated by males, and directed against males more frequently than females.

Homophobic violence is perhaps best understood as being a special type of male aggression. Worldwide, some men and boys have a tendency to be violent, and their victims include other men, women, and children.

 This tendency, however, is not simply due to the effects of testosterone, either prenatal or postnatal. Most men are not violent, and androgenized females are not any more prone to violence than ordinary ones. We speculate that the antecedent history of childhood neglect/abuse with disruption of secure bonding increases the likelihood of male violence later in life. We do view the tendency of some males toward violence, however, as a pathological distortion of the tendency of most to engage in a certain type of male-bonding behavior whose earliest manifestation is rough-and-tumble play.

 Prenatal testosterone effects most likely interact with postnatal psychosocial influences to shape behavior, either in a prosocial or antisocial direction.

Many clinicians and investigators have documented an increased prevalence of psychopathology among homosexual  men and women compared with heterosexual individuals and have generally attributed this to minority stress and stigmatization.

Psychodynamic psychiatry offers an additional conceptual model for understanding the phenomenon of internalized homophobia. Children internalize the attitudes, values, and moral precepts of significant others. These internalizations all influence the conscience structure of the child. Violation of internal taboos triggers guilt, and failure to live up to internal standards leads to shame. Guilt and shame are the affects associated with "internalized homophobia"-a term introduced in the 1980s.

Clinical experience indicates that negative internalizations from different phases of development and including different significant others can become condensed into a unitary negative self-label. Internalized homophobia is not a specific psychopathological syndrome. Rather, it is a psychological dynamic found across all syndromes and may influence severity and treatment outcome in varying degrees, depending on clinical context.

There are many influences on internalized homophobia; in this article only those commonly associated with gender-role difficulties-due to innate temperamental incompatibilities between a boy, his family members, and peers, are addressed.

Bill W., a homosexual man, sought treatment for depression. Although most of his symptoms rapidly improved with appropriate pharmacological intervention, he had persistent low self-esteem that required psychotherapy. Painful experiences at varying stages of development influenced a negative self-image about being homosexual. This self-condemnatory stance had persisted, despite the fact that he was a highly regarded member of the homosexual community-openly homosexual at work and with all significant others.

As a child, Bill avoided team sports, preferred girl to boy playmates, and was drawn to art and drama. His father, an enthusiastic weekend athlete, withdrew from him in favor of his older brother-a star hockey player. In middle school, Bill had been bullied and ostracized by male peers. During adolescence he had been menaced and beaten on more than one occasion and called "fag." For years-until late adolescence, when he went to college-he felt so anxious around groups of men that he became nauseated. As an adult, much of his low self-esteem was related to self-destructive behavior motivated by the mental mechanism of identification with the aggressor.

This negative self-label was based on childhood internalizations, primarily of his father and peers. In psychotherapy, significant attention was devoted to the influence of his temperament on the development of his personality-particularly in the area of gender-role behavior. The ongoing therapeutic effort was directed to reframing the interests determined by his innate temperament so that they could be positively valued by him. As the work progressed, his chronic feelings of shame, present since childhood, diminished.

Although many patients who experience internalized homophobia respond positively to an affirmative supportive stance about being homosexual, others require psychotherapy. In psychotherapy, improvement is not only associated with efforts to help the patient overcome present life stress but also to better understand childhood determinants of negative self-esteem.

The factors contributing to the genesis of internalized homophobia must be assessed on a case-by-case basis. In addition, the same types of variables that influence treatment outcome in psychotherapy generally are relevant here. These include the presence of psychiatric disorder(s), a past history of trauma, the genetically influenced tendency toward psychopathology versus adaptive coping, and the quality of the therapeutic relationship.

 2nd ed. Sunderland, Mass; Sinauer Assoc: 2006.


 McEwen BS. Gonadal steroid influences on brain development and sexual differentiation. In: Greep RO, ed. 

Reproductive Physiology IV. International Review of Physiology.

 Vol. 27. Baltimore: University Park Press; 1983: 99-145.


 Breedlove SM. Sexual differentiation of the human nervous system. 

 Gorski R. Sexual differentiation of the endocrine brain and its control. In: Motta M, ed. 

 Collaer ML, Hines M. Human behavioral sex differences: a role for gonadal hormones during early development. 

 Phoenix CH, Goy RW, Gerall AA, Young WC. Organizing action of prenatally administered testosterone propionate on the tissues mediating mating behavior in the female guinea pig.

Dittmann RW, Kappes ME, Kappes MH. Sexual behavior in adolescent and adult females with congenital adrenal hyperplasia. 

 Berenbaum SA, Snyder E. Early hormonal influences on childhood sex-typed activity and playmate preferences: Implications for the development of sexual orientation. 

 Hines M, Brook C, Conway GS. Androgen and psychosexual development: core gender identity, sexual orientation and recalled childhood gender role behavior in women and men with congenital adrenal hyperplasia (CAH). 

 LeVay S. A difference in hypothalamic structure between heterosexual and homosexual men. 

Byne W, Tobet S, Mattiace LA, et al. The interstitial nuclei of the human anterior hypothalamus: An investigation of variation with sex, sexual orientation, and HIV status. 

 Roselli CE, Larkin K, Resko JA, et al. The volume of a sexually dimorphic nucleus in the ovine medial preoptic area/anterior hypothalamus varies with sexual partner preference. 

 Morris A, Gobrogge KL, Jordan CL, Breedlove SM. Brain aromatase: dyed in the wool homosexuality. 

Cohen-Bendahan CC, van de Beek C, Berenbaum SA. Prenatal sex hormone effects on child and adult sex-typed behavior: methods and findings. 

Author | Richard C. Friedman, MD

Articles

Issues in Psychodynamic Psychiatry

Sexual Orientation: Neuroendocrine and Psychodynamic Influences