The psychodynamics of abnormal illness behaviour :The psychodynamics of abnormal illness behaviour Dr C S Mizen MBBS MRCPsych. Consultant Psychiatrist in Psychotherapy


Medically unexplained symptoms :Medically unexplained symptoms Somatization disorder Hypochondriacal disorder Persistent pain disorder Conversion disorder Chronic fatigue syndrome Neurasthenia Dysmorphophobia Factitious disorder and malingering


Illness behaviour and personality disorder :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


Illness behaviour and Personality Disorder :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


Borderline – Psychoanalytic definition (Kernberg) :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


Borderline – Psychoanalytic definition (Kernberg) :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


Formulation :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.


Patient B :Patient B 25 year old single woman Current circumstances History of current complaint Personal History Counter transference


Formulation: Depressive position :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.


Formulation: Splitting :Formulation: Splitting


The Borderline Solution :The Borderline Solution Sit on the fence Oscillation One foot in each camp


Patient B :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


Implications for service development :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.


Implications :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.


Aims: :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