Basic Features in Dynamic Psychiatric Diagnostics

Author(s): Dworschak, M., Schmolke, M.

Journal/Book: Dynam Psych. 1994; 27: Kantstrasse 120/121, D-1000 Berlin 12, Germany. Pinel-Verlag Fur Humanistische Psych Philos. 187-201.

Abstract: The authors describe the basic structures of the dynamic-psychiatric conception of personality and its implicit image of man. They illustrate how this conception is diagnostically employed in the case conferences of the Dynamic-Psychiatric Hospital. The following can be considered as essential aspects of the image of man: - Man as a holistic being in health and illness; - man as a being defined by his relationships and groups and by the quality of the interpersonal contacts; - the inherent striving for identity and autonomy. Identity is rooted in the unconscious and determined by social energy. The unconscious is the reservoir of human possibilities and their developmental potentials; - man as a constantly developing being. Clinical diagnosis must lead to a comprehensive image of the patient, containing his healthy as well as his pathological aspects. Thereby, the group dynamics and their reflection in the therapeutic team participating in the case conference serves as an important diagnostic instrument. Ammon's model of human structure allows a structural diagnosis of the whole personality, assessing the central unconscious structure as well as the primary somatic and the secondary behavioural structure. Moreover, the degree of differentiation and integration of the personality, including symptoms and defense mechanisms, should be estimated. The central unconscious personality structure fulfills an integrating and coordinating function for the whole personality. The therapy of patients suffering from early disturbances (patients with a borderline structure, schizophrenic structure or psychosomatic patients) must aim at a structural change in the unconscious core of the personality in order to avoid mere symptomatic improvement of their conditions. The clinical setting offers the conditions for the development of constructive identity by allowing the retrieval of ego-developmental steps. The diagnosis of human structure is subject to change during the therapeutic process, in the sense described by Ammon (1959) as > > diagnosing process<<. Thus, diagnosis <<has the value of a rough orientation allowing communication<< (Ammon 1986). Fig. 2 illustrates the data assessment in preparation of the case conference. In the Dynamic-Psychiatric Hospital Menterschwaige, the patient can be diagnosed and observed in his unconscious expression and his behaviour by therapists and diagnosticians in a therapeutic field. Besides the direct observation of his group dynamics, the life history, the development of the illness and its symptoms and the psychiatric diagnosis can be assessed in the case conference. Additionally, the results yielded by the psychological exploration and test diagnosis, as well as by the sleep-EEG and the autokinetic light test are included. The social anamnesis conveys the results of interviews with relatives, including data on the development of the patient in school and profession. In order to gain a comprehensive and integrated picture, the reports from the therepeutic milieu and from the nonverbal therapies such as dance therapy, art therapy, music therapy, theatre therapy and horseriding therapy are considered. This enables the therapists to conceive an individual therapeutic programme and a therapeutic prognosis anticipating the future developmental perspectives. All these results, analysed in the course of the case conference lasting often more than three hours, are communicated too, and discussed with, the patient himself and his accompanying co-patients. The authors illustrate the essential characteristicts of dynamic-psychiatric diagnosis and of the process taking place during the case conference by a case history. Ms. A., a 23-year-old patient, had been pharmacologically treated in various hospitals with the diagnosis of > > hebephrenia<<. At admission, she was suffering from severe depression and feelings of loneliness, accompanied by psychosomatic complaints such as obesity, spastic bronchitis and enuresis nocturna. The analysis of the patient's group dynamics showed an isolated, inwardly symbiotic family, characterized by severe psychosomatic illnesses of the father, the only member of the family to whom the patient entertained emotional contact. The father died, aged seventy, as the patient was ten years old. Following his death, the symbiotic demands of the mother became so excessive, that the patient was unable to free herself from her ambivalently destructive embracement and still lives together with her in a small appartment. In the course of the case conference it became clear, that the patient unconsciously took over the destructive aspects of her family as a > > symtom carrier<< (e.g. the developmental arrest and the fragility of its identity), while her brother was able to accomodate to its norms and expectations. Considering the reflection phenomena within the therapeutic team group, the group dynamics of the primary group could be described as that of a typical borderline family. According to Ammon, the most characteristic property of the borderline disease is the lack of identity. In the case of the patient, this was evident by the fragility of her personality facade and the versatility of her symptoms. Further, the authors describe the human functions of the patient, showing their primarily destructive and deficient character. They make it clear, that the patient was not permitted to express her anxiety in the primary group and, therefore, this human function is so deficient, that it only could be inferred from the test results. Thus, she had avoided filling out the anxiety items of ISTA. The pictures she painted in the art therapy gave unconscious expression to her anxiety. The psychological tests MMPI and ISTA yielded primarily a > > defense profile<<. Structurally, the disturbances in the human functions of aggression, anxiety and narcissism form the > > resistance triangle<< described by Ammon (Ammon 1982), which makes it difficult to achieve structural changes by identiy therapy. The patient experiences friendly contact and demands as menacing. Her personality structure and identity can be described as deficient and desintegrated, containing unintegrated identity aspects. Constructive aspects of her identity are represented by her artistic abilities and her spiritual and religous values. The case conference came to the conclusion, that the healthy identity aspects should be reinforced by nonverbal therapies as therapeutic allies in the further treatment. Her interest should be supported and enhanced in groups, thus making the working through of her feelings of abandonment and aggression possible. The therapeutic prognosis was estimated favourable with the condition of a longer continous out-patient treatment and the creation of a life situation independently from the family. The authors conclude that a holistic and integrative diagnosis must take into consideration the unconscious structural aspects as well as the healthy, creative aspects of the patient. In the mentioned case history, the psychiatric diagnosis could be corrected, thus freeing the patient from the stigma of schizophrenia and allowing far-reaching consequences for her further treatment and life perspectives.

Note: Article I Burbiel, Dynam Psychiat Klin Menterschwaige, Psychol Diagnost ABT, Geiselgasteigstr 203, D-81545 Munich, Germany

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