Clinical Presentations

Some patients want only symptom relief and have no intrinsic interest in self-understanding. They are best treated with a straightforward psychopharmacologic approach that includes education to improve adherence. Others, aware that painful affects have important psychic determinants, can be engaged in psychotherapy but develop resistance to deepening the process, especially once symptoms are under control. Some enter psychotherapy or analysis already on medication for severe symptoms, and others develop problematic symptoms in the course of psychotherapy or analysis that require treatment. The following cases will illustrate some issues involved in each situation.

Case Example: Combined Psychotherapy and Medication Treatment as a Prelude to Psychoanalysis. Dr. R, a 33-year-old mathematician newly appointed to a university faculty, was referred to a medical analyst by a social worker he had consulted for treatment of a lifelong depression. He had been treated with a number of antidepressant medication regimens prescribed by internists and general psychiatrists over the previous 10 years, with widely varying success. He felt subject to uncontrollable changes in his mood that sometimes left him literally unable to function. Medications that seemed to work for a few months could suddenly have no effect, and he descended into a deep depression from which it took months to emerge. His superior intelligence and capacity for bursts of sustained effort had made it possible for him to finish his doctorate, and he had been married to a devoted and loving wife for 6 years. They were reluctant to have children because of his precarious emotional states. He had never engaged in intensive psychotherapy but had seen a number of social workers for brief supportive therapy.

Dr. R was the youngest of five children born to parents who accumulated considerable wealth through the father's ruthless business acumen. As a child Dr. R had been the object of much sadistic emotional and physical abuse not only at his father's hands, but also by his older brothers who were unsupervised by their alcoholic mother. He does not remember sexual improprieties, but is troubled by a recurrent dream of being penetrated from behind by an older man who means to trick him and ridicule him. Among his siblings only Dr. R was able to leave the family emotionally to a substantial extent. He had essentially ended contact with his father and had only brief, painful contacts with mother who was usually inebriated and always highly self-absorbed. Family visits left him in a depressed, overwhelmed state.

Over the course of several years of weekly and twice-weekly sessions, Dr R developed a strong alliance with his analyst who helped him begin tolerating more awareness of the impact of his childhood and the relevance of childhood patterns to current relationships. At one point the analyst raised discussion of converting the treatment to analysis, but Dr. R declined. The analyst felt Dr. R might be instinctively protecting himself from the awareness of negative transference, which he couldn't afford. He needed to maintain a positive transference to the good maternal figure he had found in the analyst but also began bringing in dreams and attempting to make connections between childhood events and reactions in his current life.

After several more mood cycles that seemed unresponsive to the effects of psy-chotropic medications, Dr. R and the analyst came to understand his bursts of high energy as the equivalent of a manic phase of manic-depressive illness, a condition likely affecting other family members. With the addition of valproate and olanzapine to an SSRI and a stimulant, Dr. R had a brief period of stability that was interrupted by the development of an inability to finish a paper that threatened his chances for promotion. This inhibition was clearly related to earlier conflicts about success and competition. At this point Dr. R understood fully the limits of medication treatment and the risk of losing his job due to unresolved psychological conflicts; he asked about entering psychoanalysis. It was agreed that the long history of supportive treatment with the prescribing analyst would make it difficult to switch to an analytic format. He was given a referral to another analyst for analytic treatment so that the prescribing analyst could maintain the medication treatment.

This case illustrates the common presentation of depression complicating underlying neurotic conflict and the sequelae of childhood trauma. Dr. R was quite fragile and initially resistant to pursuing psychotherapy. He had hoped to gain control of his symptoms with medication. He had no history of euphoria or overtly manic behavior, but as a result of regular contact with his analyst, it became apparent that he cycled between depression, mild hypomania, and mixtures of the two that may have been made worse by antidepressant and stimulant treatment. (A common but frequently unrecognized point is that one or both of Dr. R's parents may also have bipolar mood instability, with concomitant negative influences on their capacity to parent. Thus, both nature and nurture factors play a role.) With time, he came to feel safe enough with the analyst to touch on painful memories he had long avoided and became convinced of the power of these memories as his dreams kept pace in illustrating the issues discussed in sessions.

In the analyst's opinion, Dr. R was not initially prepared to deal with the full force of transference given the nature of his childhood experience and the bipolar mood disorder that was difficult to control. The combination of medication and psychoanalytic psychotherapy gave him both the necessary mood stability and the conviction that it would be safe for him to investigate his mental life more fully in analysis.

The effectiveness of medication is always a function of the context of the patient's emotional life. The same medication that maintains euthymia under ordinary life circumstances may no longer work when the patient is under extreme stress. There is also the issue of setting realistic goals for medication: maintaining adequate sleep, energy, concentration, and appetite are reasonable expectations, but medication does not teach individuals how to recognize what they are feeling or how to modulate their emotional responses to the world. In the case of Dr. R, he had looked to medication to keep his mood stable and his energy level high while avoiding awareness of the impact of childhood trauma (and ongoing derivatives in adult transference relationships) that pervaded his life. His reactions to hostilities from a senior faculty member attempting to block his promotion made clear the childhood roots of his "escaping into depression" as a response to his father's vicious emotional abuse and his mother's alcoholic incapacity to protect him. Previous psychiatrists had overlooked the impact of childhood history and its effects on his adult functioning. Closer contact with the analyst raised the possibility of bipolar mood fluctuation and led to improvement in the pharmacologic treatment approach, while also creating the opportunity for Dr. R to investigate the past that haunted him.

Case Example: Beginning Medication after Starting Psychoanalysis.

Ms. M, a middle-aged married woman with two teenagers, sought treatment for lifelong depression that interfered with her capacity for pleasure and intimacy. She was evaluated by a biologic psychiatrist who found that she did not meet criteria for any Diagnostic and Statistical Manual (DSM) disorders and referred her to an analyst for psychotherapy. The analyst found that Ms. M had serious impairment in relations with her husband and children and that her narcissistic vulnerability had tragically limited her capacity to realize her considerable potential. She was subject to bouts of gastrointestinal distress and felt miserable much of the time but denied problems with sleep, appetite, or energy level.

Ms. M entered analysis with only vague awareness of the impact of her considerable history of neglect and abuse in childhood. The opening phase was marked by a struggle to free associate (say whatever was on her mind) and the bringing in of photographs and scrapbooks as a means of telling the analyst the story of her painful history. As memories of sexual abuse by her grandfather came into focus, she developed severe abdominal pain, suicidal preoccupation, and hopelessness that all served to enrage her. Just as she had felt toward the mother who neglected her, Ms. M felt the analyst was sadistically subjecting her to these humiliating feelings that interfered with her ability to maintain the little bit of equilibrium she had gained in life. Efforts by the analyst to work interpretively with the intense negative transference did not quiet the symptoms that threatened to end the therapy, and antidepressant treatment was offered. This led to enough mood stability that Ms. M could continue the analysis, which was eventually quite helpful to her.

Like Dr. R, significant childhood trauma leading to symptoms of depression and complex posttraumatic stress disorder, contributed to Ms. M's presentation, and led her to consultation with a biologic psychiatrist in an effort to remain unaware of the full force of childhood history. Although Ms. M would be considered analyzable by most standards, the effects of childhood trauma limited her capacity to use traditional analytic treatment. Traumatized patients have difficulty maintaining the "as-if" quality of the treatment relationship and may need pharmacologic help in managing the negative aspects of the transference. This is essentially a parameter, used to help the patient regain effective ego strength. Ostow (1990) has noted the "surprising rigidity" shown by patients who require medication, but feels that nonetheless, the procedure often has benefits.

Many reviewers have concluded that even if a patient is judged analyzable, the outcome is unpredictable (Wallerstein, 1996). Some "good neurotics" like Ms. M cannot tolerate the rigors of traditional analytic treatment, while many severely ill patients have benefited greatly from psychoanalytic psychotherapy. Considerable differences exist in analysts' beliefs regarding which symptoms can be addressed with psychother-apeutic means and which require medication. Medication treatment does not confer the capacity for emotional modulation, though by eliminating overwhelming depression and anxiety it might make it possible for an individual to enter the therapy that would lead to the development of this capacity.

Case Example: Starting Psychoanalysis with a Patient Already on Medication. Mr. J, a 50-year-old married computer scientist, came for treatment of depression and insomnia that developed after the death of his mother. Despite lifelong alcohol dependence, he had had a successful career, but his marriage and other relationships were impaired by sadistic impulses that he made little attempt to disguise. He was now in a major depressive episode, with suicidal thoughts, sadness, poor concentration, loss of appetite, and intense dysphoria exacerbated by the drinking that once soothed him. Treatment with nefazodone, a sedating antidepressant, helped a little, and he was able to abstain from alcohol, but eventually venlafaxine, a more stimulating antidepressant, was added, leading to distinct improvement and cessation of the suicidal preoccupation. Mr. J entered analysis after 15 weekly sessions spent adjusting medication and investigating his history and current problems.

Mr. J worked well with dreams, which evolved over the course of the analysis from essentially mechanical landscapes devoid of people to interactions among people. For the first time in his life he could begin to identify feeling states in others. The analysis enabled him to successfully deal with hostilities in his work environment and enabled him to accept the limitations of his marriage and his part in creating them. He was able to deal straightforwardly with his father's death some years later. He has remained on antidepressant medication, prescribed now by his internist.

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