Family Conflict in Dysthymia and preoccupation with unusual bodily sensations: A case study with the help of Somatic Inkblot Test and Sack’s Sentence Completion Test

Swati Agarwal & Satyadhar Dwivedi

(SIS Journal of Projective Psychology & Mental Health, (2024):31: 2, 119-122).

Abstract: 

Dysthymia, a persistent depressive disorder, manifests as a chronic state of depressed mood. Its prevalence in the general population is estimated to be around 1% to 2%, with a higher incidence in women compared to men. The utilisation of innovative psychological assessment tools like the Sentence Completion Test and Somatic Inkblot Test provides a nuanced understanding of an individual's perceptual and cognitive processes related to bodily sensations and emotional experiences. By integrating familial lens into the exploration of dysthymia and heightened fixation on unusual bodily sensations, this study endeavours to unravel the potential role and impact of family dynamics in shaping the experiences of individuals grappling with this intricate intersection. Mr. Y.C. is a 33 year old male, Hindu, from upper middle socio economic status, hailing from urban background, Graduate Engineer (B.tech) and currently unemployed. His chief complaints were of sad mood, feelings of loneliness, lack of concentration, loss of pleasure in things he previously enjoyed, indecisiveness and uncomfortable body sensations such as stiffness in body and sensation of heat in certain parts of body. He reported having sexual relationships with several partners but not able to build an emotional attachment with anyone. The findings on assessments reveal parental conflict that contributes to his symptoms of dysthymia and heightened preoccupation with bodily sensations. Furthermore, his conflicted relationship with mother also reflects internalised aggression and frustration, which impacts his ability to maintain a healthy romantic relationship with any woman. The weekly therapy sessions spread over a period of 4 months have led to improvement in socio-occupational functioning as the patient is now working as an IIT coach in a coaching centre. Future interventions will focus on developing conflict resolution strategies and promote constructive ways to address and resolve family conflicts. 

Introduction: 

Dysthymia, a persistent depressive disorder, manifests as a chronic state of depressed mood. Its prevalence in the general population is estimated to be around 1% to 2%, with a higher incidence in women compared to men. Epidemiologically, it often begins in adolescence or early adulthood, potentially lasting for years if left untreated. Family conflicts can significantly contribute to the development and perpetuation of dysthymia. Constant tension, unresolved issues, or dysfunctional communication patterns within the family unit can create a stressful environment that exacerbates or triggers symptoms. The chronic nature of dysthymia often intertwines with familial dynamics, with conflicts amplifying the ongoing depressive symptoms, leading to a challenging cycle that can be tough to break without intervention and support.

The utilisation of innovative psychological assessment tools like the Sentence Completion Test and Somatic Inkblot Test provides a nuanced understanding of an individual's perceptual and cognitive processes related to bodily sensations and emotional experiences. By integrating these assessments with clinical observations and psychosocial histories, this paper aims to illuminate the family dynamics in a detailed case study of a patient with dysthymia and an increased fixation on unusual bodily sensations. Moreover, family conflict has emerged as a crucial factor in the manifestation and perpetuation of various mental health conditions, including dysthymia. 

The complex interactions within familial relationships can significantly influence the development and maintenance of psychological distress and somatic preoccupations in individuals (Chen et al., 2017). By integrating this familial lens into the exploration of dysthymia and heightened fixation on unusual bodily sensations, this study endeavours to unravel the potential role and impact of family dynamics in shaping the experiences of individuals grappling with this intricate intersection.

Case History:

Mr. Y.C. is a 33 year old male, Hindu, from upper middle socio economic status, hailing from urban background, Graduate Engineer (B.tech) and currently unemployed. His chief complaints were of sad mood, feelings of loneliness, lack of concentration, loss of pleasure in things he previously enjoyed, indecisiveness and uncomfortable body sensations such as stiffness in body and sensation of heat in certain parts of body. The family history of anxiety and insomnia in father was reported. Premorbidly, the patient appears to have anankastic traits along with perfectionist beliefs. 

The patient reported experiencing a depressed mood for eight years. He reported that there was a lack of initiative in anything on his part. After B.Tech he worked as a teacher in several coaching institutes but he kept leaving the jobs after losing concentration on work. He reported that he would feel uneasy while working, would experience hot flashes in the body and mental fogginess. He reported being unable to form a long-term relationship with anyone because of his depressed mood and preoccupation with uneasiness from bodily sensations. He reported having sexual relationships with several partners but not able to build an emotional attachment with anyone. His first sexual contact was at the age of 16 years with a woman who was 10 years older than him. He mentioned not being able to have a conversation with anyone for more than 10 minutes as he would feel uncomfortable talking about himself. Currently, he keeps searching for a female partner online. He keeps searching until he loses interest. Currently, he is bothered that he is unable to motivate himself to do anything and is worried about his future career prospects as he has been inactive for a long time. He is unable to read books due to lack of focus and feels everything is blurry along with stiffness in body. The patient has reported going to Vipassana centres and completed 10 days courses multiple times in the past 2 years. He reports feeling better after the completion of each course, but after 15-20 days again starts experiencing low mood. Now he has come to Institute of Mental Health and Hospital Agra for the treatment of above symptoms.

Family History:

The patient reported that his father has suffered from anxiety and insomnia since his childhood. He has never experienced any closeness with his father since childhood as he remains aloof. He feels closer to his mother, but he feels that she did not treat him and his siblings equally. He has seen his father being physically violent towards his mother many times. Due to his unemployment, often he gets critical comments from his father which makes him sad. He is not on talking terms with his father currently. When asked about his relationship with his mother, he feels upset when she compares him with his siblings and keeps nagging him. 

Methodology: 

Somatic Inkblot Test Booklet version was administered on the patient following standard procedure (Cassell & Dubey, 2009,2003 and Dubey et al, 2019). The patient’s responses and the rejected images were analysed using content analysis and psychoanalytic interpretation. In addition, Sacks Sentence Completion Test was administered to further explore the inner conflicts of the patient.

Test Findings and Discussions:

Somatic Inkblot Test:

A few Clinically significant responses on SIS are interpreted ahead following content analysis and psychoanalytic interpretation:

Three Best liked pictures:

A5 (Image 3 of SIT): “Heart and Smile.” These are normal responses. It reflects his desire to have a happy life which he was deprived of in childhood. 

A6 (Image 4 of SIT): “World Cup and Teddy Bear”. The Teddy Bear is a normal response in this blot. The world cup may represent his high need for achievement. 

B29 (Image 29 of SIT): “Athlete” in this image which is a normal response.

Three Least liked pictures:

A1:  “Creature faces with long noses” in this image which may reflect his conflict with own self-image and focus on bodily features in a negative way. Long nose connotes male phallic symbol which may project his sexual preoccupation which is supported by the case history.

A3 (Image 2 of SIT): “Blood Spot”. This response may indicate hostile and sadistic impulses (Schafer,1954) and impulsivity and poorly controlled impulses (Klopfer & Davidson,1962). Perceiving blood on achromatic image may also indicate destructive impulses, sadistic but contraindicates direct acting – out and conversion tendency (Philips & Smith, 1953).

B27 (Image 27 of SIT): “Ugly alien-like creatures”. A child is the most typical response in this image. Avoiding perceiving a child may indicate conflict and deprivation of affection from his parents (father and mother) which he shared during intervention.

Other Significant responses of patient on SIS-II Booklet:

A9 (Image 6 of SIT): “Female body without a head”.  The patient failed to perceive man and woman dancing which is a most Typical response in this image. Perception of the female body without a head indicates pent-up aggression and frustration towards women. He had physical relationship with several females without intimate relationship might have led to such hostile attitude towards women. Avoiding perceiving dancing male and female may also indicate disturbed romantic life. This attitude may stem from his perceived lack of affection and protection from his mother. 

A12 (Image 7 of SIT): “Snake covering his baby”. This may indicate his desire to be protected as a child which he expected from his mother but was deprived from it leading to frustration. This reflects his craving for maternal affection that he felt was lacking during his childhood.

A15: “Meat or Organ” which is an anatomical response. His avoidance of common response of the foetus may reflect his male inadequacy. This also reflects his preoccupation with bodily sensations. 

A19: “Intestines or could be some elongated creature”. This is unusual as he correctly perceives the anatomical image in the blot, but because of the threat of phallic material, it was perceived as a safer image of elongated creature of some kind. This may reflect certain Oedipal issues involving himself and mother.

A24: “Hugging Humans”. The rejection of normal perception of the female pelvis and substituting it with warm image material reflects the wishful thinking of the patient of being loved by his mother. This represents age regression and a conflicting relationship with his mother. 

A26: “Ultrasound figure with dinosaur-like features”. This may reflect the aggression that he felt throughout his childhood in response to conflicted relationships with his mother and father.

A27 (Image 17 of SIT): “Cartoon-like creature”. The nonperception of the female breast, which is a normal response, indicates deprivation of affection or conflict with mother during his childhood. During the interview, the client confirmed her negative feelings for him. 

A28: “female scratching with nails on male body.” This reflects his sexual preoccupation, which is aggressive in content, representing sexual conflict in him.

On Sack’s Sentence Completion Test, major conflicts were revealed in four areas: attitude towards family members, attitude towards heterosexual relationship, guilt feelings and attitude towards own abilities. On the items related to attitude towards family members, the patient reported that his family was less exciting as compared to others. This is supported by the findings on SIS as well, which consistently reveals his frustration as a result of family conflicts. He has expressed his guilt about previous sexual drives and encounters in the past. Furthermore, his responses on items related to heterosexual relationships reveals conflicts in sexual areas. A similar response was found in SIS where the patient had perceived Blood spots, long nose and female body without head which reveals his pet-up aggression and frustration towards a member of the opposite sex. 

Intervention:

Over a period of 4 months, weekly sessions were conducted which centred around providing a safe space for the patient to express and process their feelings without judgement. The sessions focused on identifying maladaptive thought patterns, challenging cognitive distortions related to bodily preoccupations. In addition, the patient had attended multiple 10-day intensive meditation training courses in the tradition of S.N. Goenka at Vipassana Meditation Center in India. He was continuing his practice at home during treatment. The practice centred around the principle of equanimity, which is a state of awareness where an individual neither craves for a positive experience nor feels an aversion for unpleasant experience. This meditation practice helps the patient become more aware of their emotions without judgement. This technique aimed to enhance the patient's emotional regulation skills and promote self-compassion. Activity scheduling was implemented to boost the patient's activity levels and enhance their sense of mastery and pleasure. The negative thoughts related to the exercise were addressed during the sessions. The cognitive distortions identified were catastrophizing, dichotomous reasoning, jumping to conclusion and excessive monitoring of the bodily symptoms. Cognitive restructuring was done through Socratic questioning. A supportive and compassionate space was provided to the patient where he was allowed to process his guilt related to previous sexual activities. The therapist provided the patient with information about healthy sexual behaviours, consent, and boundaries to help them differentiate between consensual and non-consensual experiences. This aimed to reduce the patient's self-blame and guilt by fostering a clearer understanding of the complexities of sexual interactions. Coping strategies were introduced collaboratively with the patient to manage feelings of guilt effectively. These strategies included acceptance, relaxation techniques, and setting healthy boundaries in relationships. After 4 months of intervention, the patient got employed as an IIT coach in a coaching institute in Jaipur. He has been working since the last 2 months and still continuing therapy to deal with the challenges that arise in his life. 

Conclusion:

The patient had given more than 100 responses which indicates high productivity and functional intelligence. Possessing average intellectual resources. The low number of human responses depicts problems in interpersonal realms and the high number of anatomical responses suggests that the patient has conflicted self-image and is preoccupied with bodily sensations. The findings on assessments reveal parental conflict that contributes to his symptoms of dysthymia and heightened preoccupation with bodily sensations. It reveals a lack of presence of a father figure during childhood and witnessed him being abusive towards the mother. Furthermore, his conflicted relationship with mother also reflects internal aggression, which impacts his ability to maintain a healthy romantic relationship with any woman. Engaging in several sexual encounters, may be acting as release of this internal aggression that has formed due to maternal conflict. The present case study has revealed the sensitivity of projective assessments such as the Somatic Inkblot Test and Sack’s Sentence Completion Test in assessing family conflicts. These assessments serve as a cornerstone in identifying potential risks or harm within familial relationships, shedding light on complex issues such as neglect, or dysfunctional interactions. By delving into family dynamics, these assessments uncover patterns of behaviour, power imbalances, and communication breakdowns that could jeopardise the well-being of individuals, especially children. Their importance lies not only in detection but also in intervention and prevention, providing an opportunity to address conflicts early, offering support, and implementing strategies to foster healthier family environments. The weekly therapy sessions spread over a period of 4 months have led to improvement in socio-occupational functioning as the patient is now working as an IIT coach in a coaching centre. Future interventions will focus on developing conflict resolution strategies and promote constructive ways to address and resolve family conflicts.

References:

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