COMMENTARY

Agitated Patients? They May Be Taking Their Cue From You

Derick E. Vergne, MD; Sivan Mauer, MD, MS; Kristina Gaud, MD

Disclosures

August 24, 2016

In This Article

Influence of Trauma, Neglect, and Affective Dysregulation

Illnesses do not develop in a vacuum. Symptoms have context, quality, and timing, and are often interrelated (syndromes). In our case, further inquiry into the patient's history revealed that she had been molested from age 8-10 years by an older cousin, and had been dismissed by her parents as a "manipulative little brat" who used to "come up with stories out of boredom." This patient therefore internalized an image or representation of her parents as aloof, neglectful, and uncaring entities.[4] As an adult, the patient's response to perceived slights or rejections is accompanied by strong emotional reactions, often anger or rage leading to guilt, with the end result being depression (affective dysregulation). The cycle of anger-guilt-depression characterizes the spectrum of severe personality disorders.[5,6]

In many cases, a patient's unexpected intense emotional reaction while in the presence of a clinician tends to point to the activation of internal object representations (eg, key primary caregivers). In other words, what the patient initially internalized from her relationship with the caregiver early on in life is then activated by the present-day interaction. Our psychiatry resident's condescension is an unconscious reminder of the neglect, abuse, and rejection the patient experienced in childhood.

The activation of this early-life neglect in connection to the present day psychiatric interview is what is called an "object relations dyad."[7] The activation of object-relational representations in cases where severe personality disorders are present comes with an accompanying affective response that is representative of the early-life internalization of negative or traumatic experiences.

Such strong, and at times uncontrollable, affective response can be debilitating to patients and interfere with multiple aspects of their lives. This is even truer when mixed with substances, such as alcohol, whereby negative affective responses can lead to impulsive aggressive reactions to challenging life situations. As in our case, this combination of unfortunate circumstances can often lead these patients to psychiatric inpatient units.[8] A closer look at such reactive patterns in clinical situations can readily be observed through attention to physician/patient or therapist/patient transference dynamics.

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