The Psychodynamic Formulation in the Pediatric Medical Consultation: Purpose, Approach, and Clinical Application

Introduction

In the past, the writing of a psychodynamic formulation in the medical consultation was widely accepted as a desirable means of seeing into the deeper psychological “life” of the patient. This is no longer the case; the role of the dynamic formulation in the care of medical patients and the appropriate elements to be included in this formulation, are rarely taught. Accompanying a waning familiarity on the part of psychiatric trainees with the basic psychodynamic principles, which inform a psychodynamic formulation, is the often-asked question, “What, if anything, does this knowledge set add to the understanding of the pediatric patient for whom a psychiatric consultation is sought?” The clinician who requests a consultation in this highly medicalized setting is often wholly unaware of the power of psychodynamic concepts, the effect of transference behaviors in treatment relationships, and the capacity of it to enhance therapeutic effectiveness the clinician can derive from understanding the unconscious forces of fantasy and resistance. The psychiatric consultant is confronted with the belief on the part of the referring physician that the stress of a pediatric illness is the major and sufficient explanation for symptoms presenting or that, alternatively, the identification and treatment of a comorbid psychiatric disorder will suffice to remove psychological barriers to the patient’s medical treatment. This paper will address the question of what application a knowledge of psychodynamic principles has in the pediatric consultation and propose a form for its incorporation into the consultative process which is easy to understand, teach and utilize therapeutically.

What Makes Consultation to the Pediatric Team Different from Working in the Mental Health Setting?

There are a number of important factors specific to work with the pediatric team that result in barriers to communication and effective collaboration with the psychiatric consultant. The request for a consultation with child psychiatry often comes at a moment of acute crisis, sometimes following a subacute phase of intensifying psychiatric symptomatology. Thus, the time constraints and clinical pressures typically encountered in the pediatric setting are compounded. In spite of shared medical training background, pediatricians and child psychiatrists do not share the same clinical language, graduate medical training, and paradigms. Child psychiatrists have not received the depth of training in normal development received by pediatricians. Pediatricians are not adequately trained in the psychiatric and psychological assessment of the child and have rarely had extensive, longitudinal exposure to children with serious mental illness. The basic skill of performing the mental status examination is rarely well developed in pediatric training. Therefore, in the initial discussion of the reasons for concern that lead to a request for consultation by child psychiatry, much is missing.

Though pediatricians are familiar with the basic elements of the Diagnostic and Statistical Manual of Mental Disorders system of diagnosis, most particularly the compendium of Axis I disorders, they are often unfamiliar with the more complex world of personality/character disorders and the underlying issues which contribute to their presentation, such as object relations, ego development, the role of unconscious fantasy, defensive operations and family psychopathology. And yet these are often precisely the issues that result in pathological illness behavior, poor compliance and puzzling somatic presentations. This gulf results in a narrow overlap in the understanding of the presentation of the patient.

Finally, though physicians trained in child psychiatry also complete a residency in adult psychiatry—if for no other purpose than to acquire the skills and understanding necessary to assess and work with the parents of their child patients—pediatricians do not undergo similar training, and may be limited in the skills necessary for work with adults.

Interaction of Developmental Level, Resiliency and Medical Illness

Children can develop and change very rapidly, either with regression and loss of previously acquired skills or acquisition of new skills under stress. Children are also resilient, and an assessment of resiliency, this dynamic process of positive adaptation in the face of significant adversity, is crucial to the full understanding of the patient. Twin studies have demonstrated that genetic processes, temperament and parenting quality, specifically maternal warmth and support, are the most important factors promoting resiliency (McGoran, 2012). There is an extensive literature on the association between quality of caretaking and security of attachment. A secure attachment to a consistent caregiver is one of the most robust predictors of resilient functioning. (McGoran, 2012)

The assessment must also take into account the developmental level of the child. Behaviors, fantasies, and thought processes that are normal in one phase of development can be harbingers of serious psychopathology at another developmental stage. For example, the vivid imaginary friends experienced in middle childhood are developmentally normal and useful, whereas such experiences in adolescence and adulthood portend serious psychopathology. Furthermore, developmental timing of exposure yields important additional information regarding the vulnerability of the child to stress.

Finally, the defenses utilized by the child and their robustness must be understood to accurately assess the response the child will have to the significant stress of a medical illness, as the child’s defensive structure and medical illness mutually effect one another.

Psychodynamic Assessment in the Pediatric Setting

The basic tenets of a psychodynamic approach to the assessment are simple: the patient has unconscious mental processes that contribute to the clinical picture; symptoms have meaning to the patient (and these can be understood by the assessing psychiatrist); these symptoms and underlying conflicts can significantly contribute to the patients functioning, including interaction with the medical team, compliance with treatment, and expression of psychological conflict through somatic symptoms. Unconscious developmental issues may alter the child’s perception of his illness and treatment process despite the presence of normal cognitive function. These conflicts may be manifested in anxiety, misunderstanding, distorted perceptions or forgetting, behavioral problems and psychosomatic symptoms, all of which occur commonly in children (Van Ravesteijn, 2009).

In the curriculum for teaching trainees in pediatric psychosomatic medicine the proper process of psychodynamic formulation, two phases are presented. In the first, the student is encouraged to create a grid in which important factor are identified in the case being considered (Table 1):

In this initial phase, important biological, psychological and social elements are identified over time (past: predisposing/precipitating/protective; present: perpetuating/protective). Examples of each category are presented to trainees. Examples of biological factors can include presence of medical illness or genetic disorders; psychological factors include cognitive and educational functioning; social factors would encompass such elements as socio-economic status, educational level of child/family; cultural background.

In the second phase, the information gathered in grid form is incorporated into a four-part case summary, the format based on Shapiro’s (1989) recommendations for the psychodynamic formulation in child and adolescent psychiatry. This format culminates in a prediction concerning the effectiveness of the initial therapeutic intervention being recommended.

CAP Dynamic Formulation

Cases

I will now present three cases recently seen at our children’s hospital by the pediatric psychosomatic consultation liaison team.

Case 1: The Substitute

I. Case Summary

J.A. was an 18-year-old recent high school graduate who was referred for psychiatric evaluation by the pediatric gastroenterology service after medical workup could find no explanation for six months of complaints of nausea, vomiting, epigastric pain, and a five-pound weight loss.

The patient had noted a severe change in personality, which began four years earlier, after witnessing his cousin’s murder. The murder occurred in J.A.’s home and was carried out by J.A.’s sister’s boyfriend …J.A. recounted that when he returned home from school with his girlfriend on the fateful day, his cousin was asleep in J.A.’s bedroom. J.A. asked his cousin to leave the room so the couple could have privacy. The cousin then moved to J.A.’s sister’s room, fell asleep, and shortly thereafter was discovered by the sister’s boyfriend asleep in her room. The sister’s boyfriend flew into a jealous rage and shot J.A.’s cousin in the head. Although J.A. had no memory of the first few hours after the murder (other than an intense image of his murdered cousin’s bloodied head), relatives described J.A. as screaming and agitated to the point that police on the scene had to physically restrain him. Since that event, the patient describes a gradually increasing “numb” mood and difficulty in forming new relationships and feeling connected to his family or close friends. He has found it difficult to enjoy things as he had, “I go to parties, but I’m not that fun guy, I sit on the couch, just watching.” His energy was low due, in part, to his chronically disturbed sleep. He reported waking up many times during the night, always with the sensation that someone else was in the room; he then must turn on the lights to reassure himself that he was, in fact, alone.

J.A. did not indicate psychotic symptoms, but described a sensation of being followed when he was outdoors and walking in unfamiliar places, and that “someone may be behind me. I check a lot.” He often was surprised by the image of his cousin’s “shot up face,” appearing before him without warning. When he experienced this image, a daily occurrence, he described a sensation of “losing time and going into a daydream.” This experience could last for several minutes.

J.A. has been a heavy marijuana user for the past 18 months, smoking three joints per day. He derived a feeling of “calm and wellbeing” from the marijuana. He denied all other substance or alcohol use.

II. Non-Dynamic Factors

J.A. had lived with his mother and older sister since birth until the time of the cousin’s murder. His father had been absent from his life since J.A.’s infancy. His mother stated after her nephew’s murder she suffered from severe gastrointestinal symptoms and episodes of panic, which were eventually diagnosed as an anxiety disorder. She stated that she shared this realization openly with J.A. His sister (whose boyfriend, the murderer, was subsequently incarcerated) also suffered from severe anxiety after the murder, and was briefly in psychotherapy. Prior to the murder, J.A. was described as a happy child with an exuberant outgoing personality, he did well in school and had no previous psychiatric history. JA has had asthma since infancy. He has not required medications for this for a number of years and was otherwise in good health. At the time of evaluation he was prescribed omeprazole for his gastrointestinal complaints. Shortly before the consultation was initiated, J.A. had completed high school and was looking for employment, requiring that he travel around the city extensively.

III. Dynamic Factors

After the murder of his cousin, J.A.’s family could no longer bear to live in the home where the incident took place and moved to another borough. Under significant family pressure, J.A. remained in the neighborhood and moved in with his aunt and uncle, the parents of the murdered boy. He lived with them for several years, remaining in his school and close to his network of friends and his girlfriend. J.A. and his mother both report that the aunt and uncle were “trying to replace their son” with J.A. J.A. described the difficulty he had in expressing or even experiencing his own grief and suffering after the event in an attempt to protect these more vulnerable family members from his feelings and memories.

J.A. expressed being able to “count on” his mother for support in serious matters but also experienced disappointment that she had allowed him to be removed from her care and day–to–day awareness. He did not seem to be aware of his mother’s severe gastrointestinal and anxiety problems after the murder, though his mother reported he was very aware time of these problems at the time and that she had carefully explained to him that her GI symptoms were thought to be anxiety resulting from his cousin’s murder. At the time of our evaluation, J.A. had little insight or ability for self–observation in understanding the psychological aspects of his medical symptoms and their connection to his mother’s presentation with similar symptoms years e.

J.A. maintained a relationship with his girlfriend for the past five years. She had remained an important source of comfort for him and was the only individual he had been able to be open with emotionally. The couple had a satisfying sexual relationship. His other relationships were described as remote, mild, and unsafe. It was notable that as the interview progressed, J.A. became relaxed and warmed to the interviewer, expressing hope that talking to someone about these matters could be helpful.

Dynamically, J.A.’s symptoms of anxiety and gastrointestinal distress can be seen as an unconscious identification with his mother as well as a vehicle for re-involving her closely in his life.

The murder resulted in the destruction of J.A.’s home and secure extended family support. J.A. also experienced the withdrawal of his mother’s love due to her precipitous move and subsequent unavailability. He then succumbed to the pressure to remain as a substitute son for the parents of his murdered cousin. This role as substitute also was accompanied by significant systemic pressure for him to “swallow” or “bury” his own emotional experiences of grief, anger, fear and presumably guilt over his cousin’s death.

Defenses seen in the initial assessment include somatization/displacement, repression, and isolation of affect, withdrawal.

IV. Initial Predictive Responses and Initial Interventions

Therapeutically, J.A.’s gastrointestinal complaints and chronic post traumatic symptoms worsened, and he came to medical attention in the setting of high school completion and the increased pressure for him to search for employment, thereby encountering unknown places and people. The worsening symptoms caused his mother to become closely re-engaged with him, and in this setting a link between J.A.’s and his mother’s somatized symptoms of anxiety could be identified and explored. Initial therapeutic intervention aimed at identifying the social factors in the presence of a psychotherapist (with whom J.A. was able to make a successful initial alliance), gathering details of the trauma and his worsening physical and emotional symptoms, and offering guidance for how he can tolerate these emotions as he attempts to involve himself in new life experiences and attachment’s. J.A.’s comfort with the evaluation and his willingness to open up during the initial assessment is a positive prognostic sign regarding his engagement in psychotherapy.

Case 2: The Healthy Twin

I. Case Summary

N.J. is a 17–year–old high school senior who was referred by the pediatric cardiology service for evaluation of possible depression. The patient had become known to pediatric cardiology when her identical twin sister, who was not previously known to our pediatrics department, was admitted to the Children’s Hospital ICU from the pediatric emergency room of a local community hospital in acute heart failure. N.J.’s twin was diagnosed with a musculoskeletal disease of unknown etiology and rapidly received a heart transplant. Soon thereafter N.J. was evaluated by pediatric cardiology and found to have mild signs and symptoms of heart failure, including exercise intolerance, chest pain, dizziness and fatigue.

N.J.’s twin had a complicated postoperative course: She remained unconscious after surgery and was not successfully weaned from ventilator assistance, a very rare postoperative course in pediatric heart transplant. She was eventually transferred to an inpatient pediatric rehabilitation facility and her long–term prognosis was revised to very grave when the cause of her heart failure, a rare genetic abnormality, was finally diagnosed. N.J. was identified as carrying the same genetic abnormality, and her prospect as a potential heart transplant recipient was questioned because the long–term prognosis for the twins was poor. During her sister’s postoperative struggles and N.J.’s medical workup, N.J.’s maternal grandmother suffered a stroke. The grandmother was transferred to a skilled nursing facility with severe deficits, unable to speak or ambulate. During this period, N.J. developed signs of depression, including sense of hopelessness, a sad mood. and irritable affect. When the pediatric psychiatrist evaluated N.J., she stated, “I am living to die.”

II. Non-Dynamic Factors

N.J. has lived with her mother, maternal grandmother, and twin sister since birth. Her biological father has never been involved in her life, and her mother refused to disclose any information pertaining to the biological father. N.J.’s mother identifies herself as a lesbian and her long–term partner has lived with the family for the past 10 years. N.J.’s mother denied any psychiatric history in the family. However, it was noted by the team during the pretransplant evaluation of N.J.’s twin that the mother was guarded, inconsistent in her history, and refused to give permission for access to any medical records from prior medical evaluations. The medical team frequently described the mother’s response to routine medical interviews and requests as “suspicious” and “paranoid.” It subsequently became clear that the maternal grandmother had been the principal caregiver for the twins during their childhood.

During the initial evaluation, N.J. denied any history of abuse or neglect. However, after a second admission for worsening heart failure, and coincident with an improvement in medical status of her twin possibly leading to discharge home, N.J. began to disclose to the medical team a long history of severe neglect of both twins. This included consistent failure to bring N.J.’s twin for medical evaluations over the course of several years in spite of worsening medical status and persistent pleas from both N.J. and her grandmother. N.J. refused to return home to her mother’s care, and the medical team helped her to arrange living with a maternal cousin. Because N.J. had recently turned 18, this could be done without her mother’s permission.

III. Dynamic Factors

Two major issues for N.J. were identified. The first was the difficult, insecure attachment to her psychiatrically disturbed, intermittently abusive mother. The maternal grandmother, a consistent, protective attachment had provided a lifelong anchor, resulting in warm attachments in her life. In addition, N.J.’s caretaking bond to her medically fragile twin sister sustained her and provided her with a major role as her sister’s protector and caretaker. When, over a very short period of time, both of these beloved relations became mortally ill, N.J.’s functioning declined precipitously. She had always identified herself as the “healthy twin,” a self–image that was shattered when it was found that the illness her sister had was caused by a genetic abnormality that both shared, and N.J. began to develop mild symptoms of the same disorder. All these blows overwhelmed N.J.’s defenses, leading to the dramatic presentation “I AM LIVING TO DIE.” This statement can be seen as both an indirect, unexamined suicidal wish as well as identification with her sister: We are one; if she is sick, I am sick.

IV. Initial Predictive Response and Initial Intervention

N.J. began treatment with a psychologist on the pediatric psychosomatic team. She initially was unresponsive and noncompliant. This resistance softened dramatically when N.J. turned 18 and elected to move in with her cousin and sever all communication with her mother. Her initial engagements with the therapist were promising. She regularly visits her twin and grandmother, both of whom remain in rehabilitation facilities. (They have gradually improved.) The therapist identified the most pressing initial concerns in treatment to be N.J.’s adjustment to separation and individuation from her chronically ill sister, her assumption of an independent, adult role, and her adjustment to her medical diagnosis.

Case 3: The Smallest Loser

I. Case Summary

T.H. is a 12-year-old African American girl who was referred by the pediatric obesity program for failure to lose weight following six months of this intensive intervention. The pediatric team wondered if secret binge eating, which the patient, mother, and maternal grandmother vigorously denied, was the cause of her treatment–refractory outcome.

Two years prior to the presentation, at the time when her father moved to a distant city, T.H. began to steal petty amounts of money from her mother and grandmother, which she used to buy food and other small trinkets. T.H. admitted to these symptoms, recounted by her mother, with little affect.

II. Non–Dynamic Factors

T.H. is the only child of her mother and father, who separated when she was an infant. She currently lives with her mother, a surgical nurse, and maternal grandmother, a Jamaican–born homemaker. After her parent’s separation, T.H. remained close to her father until two years earlier, when he moved to a distant city with his pregnant wife. T.H. continues to maintain frequent telephone contact with her father (who now has a two–year–old son) but rarely sees him.

T.H.’s mother and maternal grandmother are both morbidly obese. T.H.’s mother works on the evening shift, while maternal grandmother is the main caretaker for T.H. The grandmother is the family cook, making typical Jamaican fare of high-calorie fried foods, and she refuses to follow the nutritional guidelines when preparing meals. T.H.’s mother stated that she felt uncomfortable challenging her mother on these dietary issues.

T.H. is a sixth grader in a regular education class in her local public school. She is an average student and has a few friends. T.H. presents as a bland, passive girl who is morbidly obese. Her overall affect is blunted. She was cooperative with the examination but made only intermittent eye contact. She denied any concerns about her bodily appearance but said she wanted to lose weight “because it isn’t healthy.” She described herself as a “good student” but was unable to state what she particularly enjoyed at school.

III. Dynamic Factors

This case presents a young girl in early puberty with symptoms over a two–year period of excessive eating leading to morbid obesity, hoarding of food and small trinkets, and petty theft. Significant stressors are the loss of her father, who had been a close and attached figure, and the controlling parenting of a morbidly obese grandmother, with her morbidly obese mother acting as accomplice.

There was a notable repression of normal affect, a notable isolation of affect, and lack of concern regarding her body image issues, which are far from what one would expect in this developmental phase. The issue of disruption of object relations was central to understanding this case. At precisely the time (late latency/approaching puberty) when T.H. would have expected to move closer to her father, she lost him when he moved to a distant city. This loss resulted in a regression for T.H., an attempt to “stop the clock” from a developmental point of view. Symptoms of excessive eating, hoarding, and petty thievery emerged. Her increasing identification with her morbidly obese mother and grandmother led to the emergence of T.H. as “the smallest loser” in the triad.

IV. Initial Predictive Response and Initial Intervention

T.H. presents with significant symptoms of regression, impaired relatedness and minimal ability for self–observation and emotional insight. Her body image is distorted and her motivation to address her symptoms is minimal. In light of her presentation, the team made a recommendation for family intervention, which would include the mother and grandmother as well as outreach to T.H.’s father. Initial prognosis was guarded. Several weeks after this recommendation, the family had failed to keep a series of follow–up appointments and the social work service was engaged in outreach to the family.

Conclusions

Our current psychiatric diagnostic schema does not encompass some of the most important material necessary to fully understand and help our patients. Psychosomatic symptoms are a story that the patient is retelling, a story about unconscious conflicts, the anxiety they cause, and the partially successful solution the patient has come to. The psychodynamic formulation is useful in gathering diverse and discordant information which, when integrated, can help unravel the complex dynamics seen in our suffering patients and their families. The understanding that results can strengthen the alliance between doctor and patient. The preceding approach adds important data to the assessment of the patient on the pediatrics unit, informs initial therapeutic recommendations, and aids in the predictions of how the patient is likely to respond to our interventions. This method has been presented in a format that is simple and can be taught to trainees at all levels who are involved in consultation to children and their families on the pediatric unit.