BASIC FEATURES IN DYNAMIC PSYCHIATRIC DIA GNOSTICS

The authors describe the basic structures of the dynamic-psychiatric c onception of personality and its implicit image of man. They illustrat e how this conception is diagnostically employed in the case conferenc es of the Dynamic-Psychiatric Hospital. The following can be considere d 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 a nd groups and by the quality of the interpersonal contacts; - the inhe rent striving for identity and autonomy. Identity is rooted in the unc onscious and determined by social energy. The unconscious is the reser voir of human possibilities and their developmental potentials; - man as a constantly developing being. Clinical diagnosis must lead to a co mprehensive image of the patient, containing his healthy as well as hi s pathological aspects. Thereby, the group dynamics and their reflecti on in the therapeutic team participating in the case conference serves as an important diagnostic instrument. Ammon's model of human structu re allows a structural diagnosis of the whole personality, assessing t he central unconscious structure as well as the primary somatic and th e secondary behavioural structure. Moreover, the degree of differentia tion and integration of the personality, including symptoms and defens e mechanisms, should be estimated. The central unconscious personality structure fulfills an integrating and coordinating function for the w hole personality. The therapy of patients suffering from early disturb ances (patients with a borderline structure, schizophrenic structure o r psychosomatic patients) must aim at a structural change in the uncon scious core of the personality in order to avoid mere symptomatic impr ovement of their conditions. The clinical setting offers the condition s for the development of constructive identity by allowing the retriev al of ego-developmental steps. The diagnosis of human structure is sub ject to change during the therapeutic process, in the sense described by Ammon (1959) as >>diagnosing process<<. Thus, diagnosis <<has the v alue of a rough orientation allowing communication<< (Ammon 1986). Fig . 2 illustrates the data assessment in preparation of the case confere nce. In the Dynamic-Psychiatric Hospital Menterschwaige, the patient c an be diagnosed and observed in his unconscious expression and his beh aviour by therapists and diagnosticians in a therapeutic field. Beside s the direct observation of his group dynamics, the life history, the development of the illness and its symptoms and the psychiatric diagno sis can be assessed in the case conference. Additionally, the results yielded by the psychological exploration and test diagnosis, as well a s by the sleep-EEG and the autokinetic light test are included. The so cial anamnesis conveys the results of interviews with relatives, inclu ding data on the development of the patient in school and profession. In order to gain a comprehensive and integrated picture, the reports f rom the therepeutic milieu and from the nonverbal therapies such as da nce therapy, art therapy, music therapy, theatre therapy and horseridi ng therapy are considered. This enables the therapists to conceive an individual therapeutic programme and a therapeutic prognosis anticipat ing the future developmental perspectives. All these results, analysed in the course of the case conference lasting often more than three ho urs, are communicated too, and discussed with, the patient himself and his accompanying co-patients. The authors illustrate the essential ch aracteristicts of dynamic-psychiatric diagnosis and of the process tak ing place during the case conference by a case history. Ms. A., a 23-y ear-old patient, had been pharmacologically treated in various hospita ls with the diagnosis of >>hebephrenia<<. At admission, she was suffer ing from severe depression and feelings of loneliness, accompanied by psychosomatic complaints such as obesity, spastic bronchitis and enure sis nocturna. The analysis of the patient's group dynamics showed an i solated, inwardly symbiotic family, characterized by severe psychosoma tic 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 sti ll 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. Cons idering the reflection phenomena within the therapeutic team group, th e 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 ca se of the patient, this was evident by the fragility of her personalit y facade and the versatility of her symptoms. Further, the authors des cribe the human functions of the patient, showing their primarily dest ructive and deficient character. They make it clear, that the patient was not permitted to express her anxiety in the primary group and, the refore, this human function is so deficient, that it only could be inf erred from the test results. Thus, she had avoided filling out the anx iety items of ISTA. The pictures she painted in the art therapy gave u nconscious expression to her anxiety. The psychological tests MMPI and ISTA yielded primarily a >>defense profile<<. Structurally, the distu rbances in the human functions of aggression, anxiety and narcissism f orm 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 d esintegrated, containing unintegrated identity aspects. Constructive a spects of her identity are represented by her artistic abilities and h er spiritual and religous values. The case conference came to the conc lusion, that the healthy identity aspects should be reinforced by nonv erbal therapies as therapeutic allies in the further treatme