Psychoanalytic Diagnosis

Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV)

DSM-IV is a handbook that provides a diagnostic framework of mental disorders for both adults and children. It explains the personality of an individual not only in depth but also at surface levels. It also provides the emotional and social functioning, causes, various symptom patterns, prognosis and potential treatment options. This guide is usually used by the mental health professionals while dealing with patients to better understand their disorder and to find out the best treatment options. It requires a proper clinical training to avoid the inappropriate use of the contents. It uses a multidimensional approach to psychoanalytic diagnosis as discussed below (American Psychiatric Association, 2012):

1. Clinical syndromes: Mental disorders like schizophrenia, depression, anxiety, and social phobia
2. Developmental/intellectual and personality disorders: Autism and mental retardation (first observed in childhood) and clinical syndromes such as paranoid, borderline personality disorders, and antisocialism
3. Physical conditions: Brain injury or HIV/AIDS can result in some symptoms of mental illness
4. Severity of psychosocial/environmental stressors: Death of a dear one, unemployment, sometimes even marriage, and joining a new college or job
5. Highest level of functioning: An individual’s level of functioning is rated based on the above-mentioned conditions

Diagnostic and Statistical Manual-V (DSM-V): A future guide

Diagnostic and Statistical Manual is under revision so that the medical basis of the psychoanalytic diagnosis and classification can be expanded. This time American Psychiatric Association and National Institute of Mental Health are working together to provide us a better and improved DSM. Leaders of American Psychiatric Association, the World Health Organization, and World Psychiatric Association considered it important to include the specific diagnostic areas. Several conferences are being held to discuss various relevant research areas so that the evidence can support the revisions in the DSM. The whole process involves the formation of work groups constituted by experts from various organisations. They meet regularly, discuss the pros and cons of DSM-IV, and develop some hypotheses. Then they investigate the existing literature and data to support their hypotheses. They do research planning too, which can be tested in trials. Based on the results and findings of these trials, they make a draft distribute it among other work groups. The draft is reviewed and critically analysed by the work groups, and submit their comments. If everything is fine, the draft will be submitted to the American Psychiatric Association and the trustees. On approval, the final DSM-V is expected to be released on May 2013.

A new method for psychoanalytic diagnosis

A new method to study psychoanalytic diagnosis was presented by Shedler (2002) and hence named the Shedler-Westen Assessment Procedure (SWAP). In fact, it has been believed that the whole process is too complicated but this method captures the richness and complexity of psychoanalytic constructs. In addition, it also provides reliable data for research. The method is considered a measure of the structural change in the whole psychoanalytic process. It is also being used to develop a more accurate system that is psychoanalytically relevant. It also plays a role in psychoanalytic training (Shedler, 2002).

Case Studies

There are a number of mental health conditions such as schizophrenia, bipolar disorder, anxiety, depression, post-traumatic stress disorder, eating disorders like anorexia nervosa, and personality disorders, comprising the poorly understood conditions. The impact of these mental conditions varies significantly and symptoms may range from mild to severe.

Schizophrenia

Schizophrenia is a severe psychiatric disorder with the symptoms of hallucinations, delusions, and disorganised speech and behaviour. Schizophrenia will be appropriate for the case study as it best describes a psychiatric disorder.

Case Study 1: John P, a 25-year-old man, was diagnosed of schizophrenia. Although he was a healthy child, his parents reported that his growth was slow compared to his brothers and sisters. His maternal uncle too had schizophrenia. He was also hospitalised in his late teens and was treated with haloperidol and then with olanzapine. As a result, he gained 20 pounds and developed diabetes mellitus too. He used to smoke and drink to calm himself. Although his parents supported him financially, his brothers and sisters didn’t show much of a concern as they are frightened and upset with him. John visits a psychiatrist but irregularly and does not have a primary care physician. So, his psychiatrist wants him to take a long-acting injectable treatment, but he is scared to injections and not sure if he needs any kind of medication (Frankenburg, 2012).

Case Study 2: Carol is a 26-year-old woman. She is single and has graduated. She was a hard-working student. She was raised in such a family where academic and career excellence was important. She had many friends, though she was shy and introvert. She went out to college after graduating from high school. In her first year, she started experiencing hallucinations and delusions and got only passing grades. She isolated herself from people. She was hospitalised for 1 month at the age of 18 years and had to drop out of college. Due to frequent hospitalizations, she was unable to work. Her family supported her financially and there was no history of any mental illness in the family.

Carol was given an inpatient treatment for 2 months and then she was discharged from the hospital. She was diagnosed of undifferentiated chronic schizophrenia. She continued staying with her parents but was kept under medication. Her negative symptoms were dominant and hence she was inactive, socially isolated, and was unable to live independently.

After taking proper medication and counseling sessions, Carol showed an impressive progress in many areas of her life. Follow-up data indicated that Carol is showing an improvement in psychiatric symptoms, number of hospitalizations, and psychosocial functioning (Bradshaw, 1998).

Case Study 2: Carol is a 26-year-old woman. She is single and has graduated. She was a hard-working student. She was raised in such a family where academic and career excellence was important. She had many friends, though she was shy and introvert. She went out to college after graduating from high school. In her first year, she started experiencing hallucinations and delusions and got only passing grades. She isolated herself from people. She was hospitalised for 1 month at the age of 18 years and had to drop out of college. Due to frequent hospitalizations, she was unable to work. Her family supported her financially and there was no history of any mental illness in the family.

Carol was given an inpatient treatment for 2 months and then she was discharged from the hospital. She was diagnosed of undifferentiated chronic schizophrenia. She continued staying with her parents but was kept under medication. Her negative symptoms were dominant and hence she was inactive, socially isolated, and was unable to live independently.

After taking proper medication and counseling sessions, Carol showed an impressive progress in many areas of her life. Follow-up data indicated that Carol is showing an improvement in psychiatric symptoms, number of hospitalizations, and psychosocial functioning (Bradshaw, 1998).

Case Study 3: Mike is a 33-year-old divorced man. He has got two children (8 and 10 years of age) whom he hardly ever sees. He has never seen a psychiatrist. Though his family physician has tried a lot to make him see a psychiatrist, Mike always refuses to go. He believes that his brain has been replaced with someone else’s. He thinks that as somebody else’s brain is controlling him, he is not responsible for what he does.

He has been on a job for 15 years. He says that he has many friends but he thinks that its one of them who has done the replacement of the brain. He is a well-educated person and has a degree in computer science. His family physician advised a magnetic resonance imaging (MRI), which was found to be negative. He also had an electroencephalography (EEG) test, which was normal (PsyWeb.com).

Case Study 4: Haresh, a graduate, was diagnosed with schizophrenia. After living with schizophrenia for 4 years, he was taken to a hospital for treatment. Two months of hospital treatment stabilised him a lot. His father was explained the nature of both the disease and the treatment. He got a part-time job of a helper with his father’s reference. Without his knowledge, his entire pay was reimbursed by his father to the employer. After 3 months, Haresh was more positive towards life. Haresh switched on to a new job again with his father’s reference. In 6 months, he gained the confidence and becomes his original self. Now he was ready to go out into the outer world. He gets a job of his choice with a higher pay and designation and that too without his father’s recommendation. He has shown a good progress in 6 months and has proved himself an honest and hard-working employee (aarogya.com, 2011).

Case Study 5: Mary is a 23-year-old, married woman. She has two children of 5 and 8 years of age. She was referred to a psychiatrist by her family physician as she would wake up early in the morning and would feel that she had insomnia. After 1 or 2 hours, she would feel that she has taken some drug. She was reported to have visual hallucinations. She also had complaints of depression, anxiety, and distraction. She was also unable to express her feelings. The psychiatrist discovered that she had been hospitalised many times for panic attacks of schizophrenia. The psychiatrist recommended her MRI, which was negative, and an EEG, which was normal (PsyWeb.com, 2011).

Kleinian Psychoanalytic Diagnostic Scale

A psychodiagnostic instrument has been introduced in the year of 2007, known as the Kleinian Psychoanalytic Diagnostic Scale (KPDS). The assessment of the psychoanalytic diagnoses is based on the theory of object relations. The purpose of creating this instrument is to introduce a relational dimension to the clinical research and epidemiology of psychiatric diagnoses. It includes 15 subscales categorised into the following four dimensions, i.e., (a) ego abilities, (b) projective identification, (c) paranoid-schizoid, and (d) depressive. These four dimensions comprise various relatively stable aspects of the mental health of the patient/individual. When following various unstructured interview sessions, the scale is assessed based on the information provided by the subject and on what the rater detects in the relationship. However, this scale follows a structured process of assessment and hence ensures the reliability and validity of the diagnoses. Also, various parameters of assessment such as reliability, stability, as well as internal consistency of the scale have all been found to be high (Anguilar, Mauri, Salamero, Amadei, & Ballo, 2007).