Dynamic psychopathology covers psychoanalytic theory and its application to understanding mental disorders. This overlaps with both the psychological models section and descriptive psychopathology syllabus of Paper A. While psychoanalytic theory has declined in clinical dominance, its concepts remain embedded in psychiatric terminology and are regularly examined. The SPMM syllabus section 5.23 covers this material. Defence mechanisms, in particular, are a high-yield EMI topic.
Freud’s Structural Model of the Mind
Sigmund Freud (1856-1939) proposed that the mind is divided into three structures that develop over childhood:
The id: Present at birth. Operates on the pleasure principle (seeks immediate gratification of instinctual drives). Unconscious. Contains the life instincts (Eros, libido) and the death instinct (Thanatos, the drive toward aggression and self-destruction). The id has no awareness of reality or morality — its only goal is tension reduction.
The ego: Develops during the first year of life as the infant learns to negotiate reality. Operates on the reality principle (delays gratification until an appropriate object or situation is available). The ego mediates between the id’s demands, the superego’s prohibitions, and external reality. Functions include perception, memory, judgement, and reality testing. The ego uses defence mechanisms to manage conflicts between the id and superego.
The superego: Develops around age 3-5 (phallic stage), through resolution of the Oedipus complex and internalisation of parental and societal values. Comprises the conscience (what is forbidden, guilt) and the ego-ideal (what is aspired to, pride). The superego is the internal representative of moral standards and ideals.
Topographical model: Freud also described the mind in terms of consciousness: the conscious mind (current awareness), the preconscious (accessible memories and knowledge), and the unconscious (inaccessible material, drives, repressed memories, the contents of the id and superego). The goal of psychoanalysis is to make the unconscious conscious.
Freud’s Psychosexual Stages of Development
Freud proposed that psychological development proceeds through a fixed sequence of stages, each centred on a different erogenous zone. Fixation at any stage (due to excessive frustration or gratification) leads to characteristic adult personality traits.
- Oral stage (0-18 months): Pleasure centres on the mouth (sucking, biting). Weaning is the central conflict. Oral fixation: dependent, gullible, passive personality, or sarcastic/aggressive (oral aggressive). Disorders linked: depression, eating disorders, dependence.
- Anal stage (18-36 months): Pleasure centres on bowel and bladder control. Toilet training is the central conflict. Anal fixation: anal-retentive (orderly, stingy, obstinate) vs anal-expulsive (messy, disorganised, rebellious). Disorders linked: obsessive-compulsive traits.
- Phallic stage (3-6 years): Pleasure centres on the genitals. The central conflict is the Oedipus complex (boys: desire for the mother, fear of castration by the father, identification with father resolves the conflict) or Electra complex (girls: penis envy, desire for father, identification with mother resolves the conflict). Phallic fixation: vanity, recklessness, pride. Disorders linked: hysteria, sexual dysfunction.
- Latency stage (6-12 years): Sexual impulses are dormant. The child focuses on developing skills, social relationships, and intellectual pursuits. No new conflict.
- Genital stage (12+ years): Mature sexual interests emerge. The goal is healthy adult relationships combining love and work. The earlier stages have been successfully integrated.
Defence Mechanisms
Defence mechanisms are unconscious mental processes that protect the individual from anxiety by distorting or denying reality. Anna Freud (Sigmund’s daughter) systematised the list in The Ego and the Mechanisms of Defence (1936). The exam tests the definition and clinical recognition of each.
Mature defences (adaptive, higher-level): Sublimation (channelling unacceptable impulses into socially valued activities — e.g., aggression into competitive sport), humour (expressing feelings without discomfort), altruism (meeting needs through helping others), suppression (conscious, voluntary deferral of a feeling or impulse — the only conscious defence), anticipation (preparing for future discomfort), and asceticism (renouncing needs to rise above them).
Neurotic defences (intermediate): Repression (unconscious forgetting of unacceptable ideas or impulses — the most fundamental defence, from which others derive), displacement (redirecting an impulse to a safer target — e.g., angry at boss, takes it out on partner), intellectualisation (detached, analytical thinking about an emotionally charged issue, avoiding the feeling), rationalisation (constructing logical explanations for irrational behaviour), reaction formation (adopting attitudes and behaviours opposite to genuine impulses — e.g., being excessively kind to someone you dislike), isolation of affect (separating an idea from its associated emotion), undoing (ritualistic behaviour that symbolically reverses a previous action or thought).
Immature defences (primitive, lower-level): Projection (attributing one’s own unacceptable feelings to others — e.g., “I’m not angry, he is angry with me”), projective identification (projecting a feeling and unconsciously behaving in a way that induces that feeling in the other — closely associated with BPD), splitting (dividing objects into all-good or all-bad — the most characteristic defence in BPD), acting out (expressing unconscious impulses through action rather than words — self-harm is the classic example), denial (refusing to acknowledge a painful reality), regression (reverting to an earlier developmental stage), idealisation and devaluation (alternating between seeing the self or others as perfect and worthless), and schizoid fantasy (retreating into fantasy to avoid interpersonal conflict).
Jung’s Analytical Psychology
Carl Jung (1875-1961) broke with Freud in 1913 over the primacy of sexuality (Jung argued for a broader understanding of libido as general psychic energy). His key concepts: the collective unconscious (a universal, inherited layer of the unconscious shared by all humans, containing archetypes), archetypes (universal symbols and patterns — the Persona, Shadow, Anima/Animus, Self), individuation (the lifelong process of integrating the conscious and unconscious aspects of the self), psychological types (introversion/extraversion, and four functions — thinking, feeling, sensing, intuiting), word association test (a method of revealing unconscious complexes by measuring response times to stimulus words). The self (the archetype of wholeness, the goal of individuation) is distinct from the ego (the centre of consciousness). Mandala symbolism represents the self and appears in dreams and art during the individuation process.
Klein’s Object Relations Theory
Melanie Klein (1882-1960) extended psychoanalysis to children through play therapy (interpreting children’s play as equivalent to free association). She proposed that the infant’s inner world is populated by internal objects (mental representations of early relationships). Development proceeds through two positions (not stages, as they can be revisited throughout life):
- Paranoid-schizoid position (first 6 months):The infant experiences anxiety about the survival of the self. Objects are split into all-good and all-bad (the good breast vs the bad breast). Splitting and projective identification are the primary defences. The infant projects destructive impulses onto the bad object, which then feels persecutory (hence “paranoid”). This is a normal developmental phase but can be the basis for later paranoid or borderline pathology if not resolved.
- Depressive position (from around 6 months): The infant recognises that the good and bad objects are actually the same whole object (the mother, who is both gratifying and frustrating). This generates concern for the object and guilt for previous destructive fantasies (hence “depressive”). The infant develops the capacity for reparation (making amends) and concern for others. Successful resolution leads to gratitude, creativity, and the ability to tolerate ambivalence. Failure leads to depressive pathology, guilt, and difficulty maintaining relationships.
Wilfred Bion extended Klein’s work: the mother’s capacity for reverie (holding and processing the infant’s projected distress) and the container-contained model (the mother contains the infant’s unbearable feelings and returns them in a metabolised, manageable form). Donald Winnicott contributed the concepts of the transitional object (a comfort object that bridges the infant’s inner and outer reality — a teddy bear, blanket), the true self (spontaneous, authentic) vs the false self (compliant, defensive), and the good-enough mother (who meets the infant’s needs sufficiently for healthy development without being perfect).
Other Psychoanalytic Concepts Tested in the Exam
Transference: The patient unconsciously transfers feelings and attitudes from past relationships onto the therapist. The analysis of transference is a core component of psychoanalytic therapy. Positive transference: affectionate, idealising feelings. Negative transference: hostile, critical feelings. Erotic transference: sexualised feelings. The therapist uses their own emotional response (countertransference) as a source of information about the patient’s internal world.
Resistance: Any behaviour or mental process that interferes with the progress of treatment, particularly the uncovering of unconscious material. Resistance is not opposition to therapy but a manifestation of the patient’s defences. Examples: missing sessions, silence, intellectualisation, forgetting dreams, acting out.
The therapeutic alliance (working alliance): The collaborative, rational aspect of the therapeutic relationship, as distinct from the transference. A strong therapeutic alliance is the best predictor of therapeutic outcome across all psychotherapies.
High-Yield Exam Patterns
- Id/ego/superego and topographical model: Be able to identify which structure is operating in a given scenario
- Oedipus complex resolution: Identification with the same-sex parent. Age 3-5 (phallic stage).
- Most fundamental defence mechanism: Repression (from which others derive, per Freud)
- Defence most characteristic of BPD: Splitting (all-good/all-bad) AND acting out (ICD-11 emphasis)
- Sublimation: The most adaptive/mature defence (channelling into productive activity)
- Projective identification: Klein. Projecting then inducing the feeling in the other. Associated with BPD.
- Paranoid-schizoid vs depressive position (Klein): First 6 months = splitting/projection. From 6 months = concern, guilt, reparation.
- Transitional object: Winnicott. First “not-me” possession (teddy bear, blanket). Bridges inner and outer reality.
- False self: Winnicott. Compliant, defensive adaptation to inadequate early care.
- Collective unconscious: Jung. Archetypes (Persona, Shadow, Anima/Animus, Self).
- Individuation: Jung. Integration of conscious and unconscious. The goal of analytical psychology.
PsychStar’s Paper A question bank covers dynamic psychopathology with questions calibrated to the SPMM syllabus. Start with 5 free questions at psychstar.io/try.