Current Medical Diagnosis & Treatment in Psychiatry

Foundations of Psychoanalytic Theory

As a form of inquiry, psychoanalysis originated in Sigmund Freud’s modification of 19th-century medical consultations on what were then termed neurasthenias and other disabling psychological conditions, especially hysteria. The majority of all forms of psychiatry that claim a dynamic or cognitive orientation derive from Freud’s original work and from that of his students. Although psychoanalysis began primarily as a theory of neurotic functioning and character pathology, in the past 70 years it has changed dramatically to include severe psychopathology, addictions and eating disorders, sexual abuse, and other maladies.

Psychoanalytic Assessment & Diagnosis

Psychoanalysis, and dynamic psychiatry in general, face an ongoing task: How does the clinician distinguish the patient’s symptoms as products of purely psychological events (eg, a headache precipitated by overt and conscious rage) from products of a purely somatic event (eg, a headache caused by caffeine withdrawal), and how does he or she distinguish both of these from mixed cases (eg, a patient who, in order to punish himself for hostile wishes,"accidentally" forgets to drink his morning coffee, realizing vaguely that he will probably have a headache later in the day)? The latter case typifies Freud’s earliest discoveries regarding “parapraxes” or slips of the tongue: Sometimes careful examination of a person’s associations to his or her parapraxes, to loosely associated thoughts (dreams, daydreams, free associations) and symptoms reveals unexpected connections between these manifest behaviors and latent motivations (unconscious wishes). Discovering these linkages,"making the unconscious conscious,” has peculiar virtues for it can grant to patients a new measure of self-control. The precise pathways such discovery can take are documented in thousands of published case histories. Because these linkages are often mired in personal history and personal fantasy, the psychoanalytic clinician must necessarily work ex post facto and with highly subjective, often idiosyncratic meanings. Each of these aspects makes the validation of particular interventions, assessments, and evaluating theories of pathogenesis particularly difficult. Psychoanalytic theories abound, many of them based on thousands of patient contact hours; ways to validate those theories outside the narrow confines of the analytic pair of patient and therapist are fewer. Efforts to address this problem are now under way.

Psychodynamic interviews differ significantly from medical interviews (Table 4-1). An important characteristic of psychodynamic interviews is especially noteworthy: Sudden and apparently irrational feelings in the interviewer, so-called countertransference affects, often correlate with severe forms of character pathology in the patient. Because the interviewer uses his or her own affective responses to the patient as part of the assessment process, psychoanalytic theory and training focus special attention on the clinician as part of the diagnosing instrument. The requirement that all psychoanalysts undergo their own analytic treatment, a unique demand in the field of psychiatry, derives from this clinical axiom. This “training analysis” is mandatory and remains fundamental to all forms of psychoanalytic education and training. The potential for abuse of any such training is obvious: It might simply create zealots who blindly follow their leader. However, excluding such training, or indeed rejecting the concept of countertransference, is also dangerous. To deny validity to core analytic concepts, such as unconscious process, transference and countertransference, and “character” type makes sense only if one believes that people do not have internal lives and that their private (or secret or unconscious) beliefs have no effect on their behavior. Paradoxically, the decision to minimize psychodynamic categories in the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised (DSM-III-R) has energized psychoanalytic empirical research.

Psychoanalytic and psychodynamic assessment thus occurs after or in conjunction with regular medical and psychiatric assessments. In addition to knowing the patient’s current medical findings, relevant medical history, and mental status, the psychoanalyst (or psychodynamic clinician) wishes to assess three features: the patient’s highest and lowest personality functioning (ego strength and ego defense), the patient’s past and current relationships with others (object relationships), and the patient’s self state (characteristics of the self). Each of these features of the patient’s life pertains to key aspects of personality functioning. Not accidentally, each also pertains to major branches of investigation in contemporary psychoanalysis. Because assessing each of these features may require an extended history, 3–4 hours of interviews may be required to make a substantial assessment. If one fails to investigate a patient’s current character structure and pathology, the dangers of misdiagnosis increase dramatically. For example, narcissistic personality disorders may present with either very active or very passive forms of grandiosity. Among the criteria listed for this disorder are lack of empathy, sense of entitlement, and preoccupation with fantasies of unlimited success. Each of these concepts derives from the psychoanalysis of severe personality disorders.

Treatment planning and assessment should include a thorough and complete review of the patient’s medical, sexual, family, and personal histories. Squeamishness,"politeness," and other forms of avoidance on the therapist’s part (eg, the refusal to secure a complete sexual history or to ask about sexual abuse, drug or alcohol use, and other secrets the patient may wish to hide) hinder treatment from the beginning and may make it impossible in the end. To refuse to diagnose fully and properly is, in this sense, an instance of countertransference resistance, and in the absence of a proper diagnosis, it is impossible for the clinician to select the appropriate treatment.

General Considerations: Ego Strength & Levels of Defense

Ego strength refers to a classical Freudian notion that patients’ psychological functioning can be assessed according to how well or how poorly they handle the entire range of stressors that affect them. Ego defense refers to the range of behaviors and psychological mechanisms (eg, depressive affect, anxiety, panic) that patients use to avoid psychic pain. Because psychic pain varies according to mental states such as attention, altering one’s mental status through selective inattention, drug use, or dissociation decreases the severity of one’s immediate pain. Some defensive maneuvers and styles, such as humor and wit, keep the ego relatively intact; others, such as splitting and dissociation, disorganize the personality in major ways and give rise to severe character pathologies.

The classic notion of ego defense found expression in Anna Freud’s study in which she formalized her father’s implicit concepts. Fenichel outlined the classical theory, distinguishing between successful defenses (sublimation) and pathogenic defenses (denial, projection, introjection, repression, reaction formation, undoing, isolation, and regression). E. H. Erikson’s studies of personality development and character type conveyed psychoanalytic character theory to generations of educated persons even as they frustrated empirical laboratory researchers. More recently, Vaillant and his colleagues conducted extensive longitudinal and empirical studies of the concept “levels of defense” as it pertains to overall personality functioning and life-course: Subjects whom experts judged “successful” and free of major symptoms tended to manifest mature defenses, whereas those with significantly higher incidence of psychiatric illness and other measures of distress correlated with immature defenses (Table 4-2).

In addition to the theory of defense and character type, some contemporary researchers stress the value of observationally near descriptions of persons’ abilities. For example, Wallerstein noted the utility of using descriptive terms (which he called capacities) that are compatible with traditional psychoanalytic theory yet are more easily agreed upon by clinicians and researchers (Table 4-3). Wallerstein and his colleagues extended this tentative list to an implicit theory of psychopathology. Those persons who cannot manifest behavior within a putative normal range are, by definition, maladapted and dysfunctional. Hyper-or hypofunctioning on any one of these scales indicates psychopathology. For example, too much self-esteem we call narcissism; if it is persistent, it figures in DSM-IV as a narcissistic personality disorder. Too little self-esteem dominates the presentation of many depressive conditions and personality disorders, especially those in cluster C, the so-called anxious, fearful group (eg, avoidant and dependent personality disorders). Deficits along the lines of sense of self as agent and sense of effectiveness and mastery dominate presentations of the schizoid and schizotypal personality disorders.

Personality Development, Object Relations, & Classical Theory

Object relations refers to the patient’s current relationships to important persons, institutions, and spiritual persons, if the latter are part of the patient’s lived experience. Of most immediate concern to assessment is the clinical question: What are this person’s current emotional relationships to important persons? Often a patient exhibits psychiatric symptoms after a sudden change in an object relation. Object relations theory (ORT) refers to major European and American psychiatric and psychoanalytic groups that focus on the patient’s earliest forms of intense relationship with significant others. Like Freud and Erikson before them, contemporary ORT authors have dramatically influenced scholars and thinkers not affiliated with psychiatry proper. The next several sections compare ORT with classical theory to illustrate the range of contemporary analytic thought and how it differs from Freud.

Themes Shared by Classical Theory & Object Relations Theory

In both theories, the patient’s complaints about his or her life and about the therapist are authentic complaints. The patient is an unconscious supervisor. According to Langs, a patient’s disguised representations of the therapist ought to be respected as crucial elements in the process. Technique focuses upon the patient’s immediate experience, the “manifest material,” which reveals significant conflicts. These real conflicts are the only routes we have to reach into deeper levels of the patient’s experience. Longstanding conflicts from early childhood, often preverbal, are not remembered per se. Rather they are reenacted in the transference. Because patients fear recapitulating earlier traumatic or distressing relationships, they defend themselves against recognizing their repetitious behaviors with the analyst. The concept of defense can be applied to any psychological process used to avoid repetition of childhood stressors, especially separation anxiety and fear of bodily harm (eg, castration anxiety and other forms). All persons use projection as a part of normal life. For example, when we listen to a patient we may project our past experiences onto the patient’s material in order to grasp better the patient’s current experience. Empathy also involves many aspects of projection. A defense is any psychological mechanism or operation used to prevent further insight into the source and extent of a psychological conflict. Defense is always defense against painful feelings (eg, depression, anxiety, doubt, shame).

The clinician must be able to distinguish accurate from inaccurate perceptions in order to understand how these transference experiences (and the defenses against them) recapitulate developmental stages in which similar conflicts were resolved with similar neurotic consequences (or more severe ego impairments). The universal aim of psychoanalysis is to increase the patient’s freedom to speak and so discover what he or she actually feels and believes. Good technique is technique that increases the patient’s freedom to speak and decreases the patient’s anxiety about self-revelation. Both classical psychoanalysts and ORT analysts attempt to lay the groundwork for the “good hour.” In a good hour, we see a patient work at each level of conflict: with the patient’s current world of persons and struggles, with us in the transference, with us as real objects, and with us as self-objects (that is, as part of the patient’s internal mechanisms of self-governance and self-control).

Differences between Classical Theory & Object Relations Theory

ORT differs from classical analysis with regard to its concept of science, intrapsychic focus, attempted reconstructions, therapeutic goals, and technique and interventions.

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