The psychodynamics of abnormal illness behaviour

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The psychodynamics of abnormal illness behaviour

• Dr C S Mizen MBBS MRCPsych.
• Consultant Psychiatrist in Psychotherapy

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Medically unexplained symptoms

• Somatization disorder
• Hypochondriacal disorder
• Persistent pain disorder
• Conversion disorder
• Chronic fatigue syndrome
• Neurasthenia
• Dysmorphophobia
• Factitious disorder and malingering

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Illness behaviour and personality disorder

• Somatization disorder
• Dramatic emotional type
• Paranoid Hostile type
• Passive aggressive dependant type
• Hypochondriacal disorder
• High neuroticism and negative affectivity,
• 2/3 above PD caseness Obsessionality and
  Narcissism
• Persistent pain disorder
• Histrionic, narcissistic, avoidant and dependent

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Illness behaviour and Personality Disorder

• Conversion disorder
• Neurotic/borderline/hysterical
• Chronic fatigue syndrome
• Perfectionist obsessive compulsive
• Dysmorphophobia
• Obsessive compulsive
• Factitious disorder and malingering
• Most meet the criteria for personality disorder

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Borderline Psychoanalytic definition (Kernberg)

• Symptoms
• Multiple phobias
• Obsessive compulsive symptoms
• Multiple/ bizarre conversion symptoms
• Dissociative reactions
• Hypochondriasis
• Polymorphous perverse sexual trends
• Classical pre-psychotic personality structures
  Paranoid, Schizoid and hypo-manic

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Borderline Psychoanalytic definition (Kernberg)

• Structural analysis
• Non specific manifestations of ego weakness e.g.
  lack of anxiety tolerance, impulse control and
  sublimatory channels
• Shift towards primary process thinking
• Specific defensive operations
• Persistence of splitting
• Regressive refusion of self and objects
• Lack of apparatus for autonomy
• Lack of anxiety tolerance (Constitutional)
• Excessive frustration in reality
• Consequent excess of aggression

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Formulation

• Thinking about management of patients in
  psychiatric practice on a day to day basis.
• Thinking about the needs of patients who present
  with abnormal illness behaviour who served poorly
  by mental health services at great financial
  cost.
• As an example of how such a formulation can be
  applied to service design.

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Patient B

• 25 year old single woman
• Current circumstances
• History of current complaint
• Personal History
• Counter transference

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Formulation Depressive position

• A beginning requires coming to terms with an
  ending. Each greeting implies a parting.
• A mixture of sadness and pleasure in both being
  with and being apart.
• Reconciliation of impotence and omnipotence
  towards recognition of limitations, external
  realities and tolerance of loss.

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Formulation Splitting
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The Borderline Solution
Sit on the fence
Oscillation
One foot in each camp
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Patient B

• Prior to injury
• Post injury
• Relation to history
• Implications for management.
• Whole team/system approach
• Integration of splitting in team
• A therapeutic model which can work across
  agencies
• Overarching philosophy

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Implications for service development

• Personality Disorder as a Mental Illness.
• Responsibility splits in professional views.
• Neuroscientific perspective
• Rationale for inclusion within secondary mental
  health services.
• Treatability
• De-escalation of Risk to Self and others
• Management of chronic disability/suffering/social
  consequences.
• Not doing harm.

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Implications

• Boundary issues
• Access to secondary mental health services
• Above
• Access to inpatient beds
• Assessment
• Risk management
• Containment in the service of therapeutic goals
• Medication management
• Rare
• Brief
• Proactive/planned
• Psychotherapeutically informed.

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Aims

• Therapy
• Provide adequate access to evidence based
  therapies.
• Whole team approach fostering adult
  functioning.
• Service design which does not replicate the
  claustrum.
• Consultation
• Provide psychotherapeutically informed risk
  assessment.
• Provide psychotherapeutically informed
  management.
• Training
• Well informed and trained care coordination and
  primary care input.
• Cohesive interagency working
• Appropriate models
• Organisational structures which facilitate and
  incentivize co-operation