Journal of Internal Medicie and Patient Care

The Command Auditory Pseudohallucination as Ego Defense Mechanism in a Patient with Pathological Grief; a Diagnostic Psychodynamic approach

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Published Date: September 28, 2018

The Command Auditory Pseudohallucination as Ego Defense Mechanism in a Patient with Pathological Grief; a Diagnostic Psychodynamic approach

Reza Bidaki1,2, Seyed M. Yassini3, Afsaneh Hassanbeigi4*, and Jafar Askari5

1Department of Psychiatry, Research center of Addiction and Behavioral Sciences, ShahidSadoughi University of Medical Sciences, Yazd, Iran

2Diabetes Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

3Department of Psychiatry, Research center of Addiction and Behavioral Sciences, ShahidSadoughi University of Medical Sciences, Yazd, Iran

4Mental Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

5Department of Clinical Psychology, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

 

*Corresponding author: Afsaneh Hassanbeigi, Mental Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran, E-mail: Af1672@yahoo.com

Citation: Bidaki R, Yassini SM, Hassanbeigi A, Askari J (2018) The Command Auditory Pseudohallucination as Ego Defense Mechanism in a Patient with Pathological Grief; a Diagnostic Psychodynamic approach. J Int Med Pat Care 1(1):103.

 

Abstract

 

The differentiation between true and pseudohallucination is very important, hard and vital in the psychiatry field. It can recognize the distinction between neurosis and psychosis. It can be important for diagnosis, treatment, prognosis and forensic psychiatry. The case reports about this subject are rare. The psychodynamic approach is less considered for psychiatry case reports, too. Therefore, we decided to introduce a woman with a misdiagnosis of hallucination. Finally, she treated partially by a psychoanalytical approach. The patients with this symptom may don’t a response to pharmacotherapy, only. Therefore, the integration and combination of psychoanalytical psychotherapy to psychopharmacotherapy may accelerate response to therapy, dramatically.

Keywords: Hallucination; Pseudohallucination; Psychosis; Ego defense mechanism

 

Introduction

 

As Vaillant’s definition, the defense mechanisms are a series of autonomic regulatory process that modulates and decline cognitive distortions and effect on how the perception of threatening events in order to minimize sudden changes in internal and external realities [1]. It is suggested that the ego is unchangeable, but in fact, the development of ego is possible. The higher level of ego causes better control of impulses [2]. The hallucinations have been shown to detect in the general population and may be the created of some of the psychic mechanisms [3–5].

As our search about psychiatry or psychology articles, it is less paid by psychodynamic approach for explanation or discussion of it. We use a psychodynamic view for evaluation and treatment of this hard case and understanding of nature of misperception. Really, pharmacotherapy was insufficient for help to her and it seems that we must change and justify the methods of therapy.

 

Case Presentation

 

A 51-year-old married woman from the south area of Iran was admitted in the psychiatry ward. The chief complaint was a psychotic-like experience as formed, sustained, persistent auditory command pseudo hallucination. She mentioned that pseudohallucinations have created considerable suffering her. She had insight into her problem. But in an interview and during taking a history about this misperception she didn’t show worry and suffering in non-verbal communication. She said any about hallucinations in other modalities or delusion. The other symptoms included insomnia, depressed mood, poor concentration, sexual dysfunction, a decrease of energy, fatigue, suitable grooming and self-care, death idea. She expressed major and minor life stressors such as no suitable relationship with her husband and boys (a brief naturalistic and chronic stressor), the loss of her father 7 years ago. She didn’t accept the death of him, therefore decided to study about the presence of spirit. But she wasn’t success and onset of hallucination formation was here. She was depressed and her diagnosis was major depressive disorder and low self-esteem in past years ago. After treatment of depression, she was resolved but she was ill again with auditory hallucination presentation. We believed that this isn’t a true hallucination and it is an echo of thought of her. She had ambivalence between good and bad, hate and love which displaced or altered own of voice because of separation of guilt, suffering, and poor goals. The loss of job success was cause for change of it. She reported a history of substance use. The histrionic personality traits and suggestibility were detected. She had an extramarital relationship (a distant stressor) and guilt feeling follow it. We believed that she didn’t interest the resolve of hallucination and was resistance to it. She didn’t mention legal problems. She created a fantastic husband for self. But she believed that this relationship is an infidelity.

 

Paraclinical findings

 

The paraclinical examinations and imaging were intact. Electro-Encephalography (EEG) and Brain magnetic resonance imaging (MRI) findings were normal. The organic problems were assessed and ruled out.

Pharmacotherapy

She used Clomipramine 150 mg/daily, Lithium carbonate 900 mg/ daily and Clonazepam 1 mg/Hs.

 

Discussion

 

We were confused about this patient and her complaint and some questions were been formed:

  1. Is it a true or pseudohallucination?
  2. What we can distinguish hallucination from pseudohallucination?
  3. Is it a psychosis or neurosis?
  4. Why this type of misperception is formed?
  5. Why she is resistant to treatment?
  6. Is it an ego-dystonic or ego-syntonic state for her?

Assessment of the Client’s Problems

The psychologist tries the use of projective tests like TAT for better diagnosis.

The diagnosis and treatment process last 2 weeks.

A Psychodynamic Perspective

The psychological findings included:

Needs

To be known, brilliant, famous, demanded, love and intimacy, gloominess.

Pressures

She had a punisher superego. The sexual, domination and deprivation pressure was noticeable.

Pseudohallucination is in context of non-psychotic perceptual disturbances.

Defense mechanisms

Displacement, Fantasy, suppression, Primary process

Tension release by:

1. Reflex action

2. Primary process: Resort to the imagination and thought to be like a hungry person food deficit reduced by visualizing or dreaming of some of the requirements is satisfied paced [5]. The Id displaces needs for tension release. She help of primary process for satisfaction with lonely need and assurance via others. Finally, The pseudohallucination is an altar for her husband and family. Her husband hadn’t an authoritarian person, therefore this voice decides her. The voice is altered for a fantastic, nice, strength and commanding man.

Findings

  1. Escape mechanism to elude fear/anxiety or from intolerable reality.
  2. Wish-fulfilling mechanism to achieve satisfaction denied in real life.
  3. Expression of intolerable hostile feelings/wishes.
  4. Expression of feelings of guilt or fear of punishment.
  5. The neurotic reliving of a traumatic event.

The lack of defense strategies or the insufficiency to use them effectively can often create life events. Also, the implication of the defense mechanisms at the unsuitable time or overuse them, which can be destructive. We concluded this patient implicated some defense mechanisms overuse. If defenses mechanisms are maladaptive, therefore they create greater symptoms. Also, the severity of symptoms destroys to these mechanisms [7]. Therefore, they didn’t help her, but also were harmful and produced a misperception as pseudohallucination that created her a noticeable suffering and distress. Even some psychiatrist was confused for diagnosis and treatment. Although it seems hallucination, in fact, it was pseudohallucination. She didn’t show a suitable response to antipsychotic drugs but a psychoanalytical approach opened some lucks in the treatment of this hard patient. She had hypermnesia or fixation on memory about some remembers in adolescence. Therefore, it explained a psychic trauma.

 

Conclusion

 

The distinction between true and pseudo hallucination in some patients is a problem. The patients with this symptom may don’t a response to pharmacotherapy, only. But also, a combination of psychoanalytical psychotherapy to psychopharmacotherapy may accelerate response to therapy dramatically.

 

Acknowledgments: We grateful to the patient because of suitable cooperation

Financial Disclosure: None

Funding/Support: No

Conflict of interest: None

Consent patient: Achieved

Authors’ contribution: SMY, AHB, and JA designed the study. RB prepared and participated in drafting, revise, design and submission of the manuscript.

 

References

 

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  4. Lawrence C, Jones J, Cooper M. Hearing voices in a non-psychiatric population. Behav Cogn Psychother. 2010;38(3):363-73. doi: 10.1017/S1352465810000172.
  5. McKegney FP. Auditory hallucination as a conversion symptom: a theoretical proposal with two case illustrations. Comprehensive Psychiatry. 1967;8(2):80-89.
  6. Marnat GG. Handbook of psychological assessment. 5th ed. Wiley. 2009.
  7. Albucher RC, Abelson JL, Nesse RM. Defense mechanisms changes in successfully treated patients with Obsessive-Compulsive Disorder. Am J Psychiatry. 1998;155(4):558-9. 

 

Copyright: © 2018 Bidaki R, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.