The application of Kohutian self psychology to consultation--liaison psychiatry

Explanations of emotional and behavioral response to illness seen by consultation--liaison psychiatrists include crisis theory, stress theory, classical Freudian theory, grief, and alexithymia. Recent developments in self psychology are also useful. Kohut identifies empathy as central to the establishment and maintenance of a sense of personal integrity, self-esteem, tolerance, and administration of others; deficits may cause feelings of shame, humiliation, rage, emptiness, and hypochondriasis. Persons who experience insufficient empathy during development are particularly vulnerable to these findings at the slightest hint of decreased concern, support, or empathy from parent surrogates. They attempt to compensate with a grandiose self-image, or by attachment to an idealized other. Prior formulations have considered illness a real or threatened object loss, with the lost object assuming symbolic significance in the individual's emotional or behavioural experience. However, illness may also be understood as a threat to the integrity of the self. This helps explain the range of emotional reactions observed and the disturbances in the doctor-patient relationship. Intervention is directed toward reconstitution of the self. Cases are presented to illustrate the application of this theory to formulation and treatment.