Psychodynamics - Ego Functions Assessment

It is the 21st century. The Mental Health Service Delivery (MHSD) system and its practitioners are required to comply with a less-than-precise diagnostic classification scheme (DSM 5) while trying to strike a balance between insurance claims and pharmaceutical companies. Aside from some perfunctory questions, State Licensure exams do not press for diagnostic proficiency, or even rudimentary knowledge of signs' and symptoms' nomenclature.

Accuracy of assessments and accountability ought to be of “paramount professional concern to psychiatry… “[1] However, as we simultaneously observe the emergence of a menu of ‘course du jour’ treatment regiments that range from CBT to Mindfulness, from SFBT, to EMDR, and others too many to mention, we begin to wonder if the mental health profession has transformed into more of an economic enterprise and less of a reliable venue for those in need.

Extensive disquisitions are no longer essential processes to diagnostics, and all conditions are dispossessed of complex dynamics.

Be it medications, or psychotherapies, or both. Almost every child that visits a professional’s office is diagnosed with ADD, and prescribed some sort of Amphetamine; Adults are either ‘Bipolar’, or suffering from a ‘Major Depressive Disorder’ and all are placed on a cocktail of pharmaceuticals. Nowadays more and more adults are also assigned the ADD label (according to WebMD a 43% increase in California). Both, children as well as adults enter some poorly tested and inadequately validated psychotherapeutic treatment regimens. Suffice it to mention that “psychiatric diagnoses lack scientific validity and are biased by influences form pharma companies and the insurance industry.” [2], [3].

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General Observations

Thought Processes.

The quality and efficiency of one to transition from one thought to another increasing the probability of comprehension, analysis, synthesis, expression, organization, and communication, ? and all towards drive discharge through suppression, repression, modification, and adaptation.

Consciousness.

The quantity of a highly mobile neutralized energy that serves as an attention cathexis.; In plain English: How much of my brain is available to focus and tend to details needed at a given task.

If I have anxiety, a burden, depression, … etc., then a great deal of consciousness is taken up by these, leaving increasingly lesser amounts for functioning. The Ego-Function of Consciousness is responsible to do the following:

1.   Withdraw energy from drive-cathected ideas to block their emergence into consciousness. (it accomplishes this through Mature Defense Mechanisms)

2.   Increase neutralized energy in the attention cathexes as a defensive resistance to the proclivity towards autistic preoccupations.

3.   Direct energy towards constriction of attention and redirection towards acceptable.

Motoric Activity.

Motor Activity refers to the amount, frequency, and variability of movement thought to be regulated by dopaminergic activity that is reflected in posture, coordination, muscle tone, strength, and symmetry.

It is thought to be one ofthe cardinal signshttps://pubmed.ncbi.nlm.nih.gov/6847335/ of Bipolar Disorder, Schizophrenia, and a kind of sequela related to certain medications. Little evidence was found, however, to support the hypothesis that hyperactivity is an artifact ofattentional issues.https://doi.org/10.1016/j.jad.2009.04.018

Additionally, it can alert us to a number of neurological issues in need of expert medical evaluations.

Motor Activity can be assessed and evaluated in terms of 5 processes, each on a spectrum of variance.

1. Voluntary or Involuntary
2. Goal-Directed or Aimless
3. Compulsive, or Repetative
4. Labored or Effortless
5. Active or Reactive

Defensive Functioning

Part of the set of ebservations within psychodynamics is the patients' process of using unconscious mechanisms (Known as 'defence mechanisms') in the face of anxiety, painful experiences, or maintainig a state of balance and homeostasis.

Defence Mechanisms is the topic of a separate article.

Psychodynamics

At the risk of being presumptuous and forced to accept the fact that little if anything can be done at the present, I like to heed the words of the Hippocratic Oath and offer that we might stay clear of diagnostic labels and shift our attention to Psychodynamics. Credence to this may be given by the many challenges brought against the now debunked theories of hormonal, or chemical imbalances as the root cause of mental conditions, [4], [5], [6], ... as well the endless array of critiques of the DSM 5 and ICD 11.

Psychodynamics[7], both a classic and an early adopter of modern frameworks, is a highly developed and multifaceted theory of human development and interaction, that rather than merely assessing, or treating symptoms, it endeavors to cover 5 areas of imperative assessment and treatment needs:

1. Identify distinct regions of one’s ‘Ego’ whose function is less than optimal. (Ego Functions)
2. Trace personality traits, and/or maladaptive patterns to their presumed origin. (Dynamic Formulations)
3. Explore the dynamics of early interactions with significant others and embedded introjects (Object Relations)
4. Assess schemes and machinations employed that interfere with insight and awareness (Defense-Mechanisms)
5. Evaluate the character of the transference for clues that may exemplify the Dynamic Formulations.

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Events in people’s lives are shaped not only by external forces but also by unconscious, or internal, forces as well (Freud, 1939). . [8]  . Psychodynamics is based on the concept of behavioral determinism, that is; that no behavior is ever accidental, and all behavior has two viewpoints: manifest and latent. The manifest content is what an individual asserts as the reason for a thought, feeling, or action. The latent content is that which is repressed, suppressed, or hidden. The aim of psychodynamics is to determine which of the 12 distinct Ego Functions is impaired by probing into the latent content, and what specific defenses have been employed; The patient’s response our sharing our thoughts on the latent content of their productions or reaction to them, may provide, yet another example of the character of the transference.

It’s noted that integrated within Psychodynamics is ‘object relations theory’; a view that enhances our understanding of how we internalize our early childhood attachments and how those beliefs affect our later relationships. The theory suggests that our development is heavily influenced by the interaction and dynamic between our internal self and the objects (aka, important people) in our lives [9], [10]

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Ego Psychology / Ego Functions

In contrast to nosological diagnoses that require a DSM code, or a label, the Ego-Functions assessment provides for an exact description of each one of its 13 individual sub-functions. [11] This well-defined, and incremental process easily yields a Dx and an operationally defined Tx plan. Constructs such as ‘object-permanence’, ‘self and object representations’, ‘ego-synthetic functions’, etc., assure measurable outcomes, and provide, even the beginning practitioner, with a sense of direction, confidence, and expertise.

Rather than presenting a DSM Diagnostic Label that might have little, if any, relevance to Psychotherapeutic Tx-Planning and Delivery, it is suggested that ego functions [12] be used for a multi-variant view of the patient’s status.

That is not to state, or imply, that a DSM diagnosis is not essential, or that it ought not to be included in a comprehensive psychosocial and/or diagnostic summary; It is, however, proffered that the DSM’s value may be more in keeping with pharmaceutical and collateral communications amongst professionals, rather than as the basis for psychotherapeutic treatment planning and delivery. Perhaps, it would not be imprudent to say that the DSM is a rather constrictive tool as a foundation for a multiphasic treatment planning approach.

Our assertion is based on the thesis that the Ego, as the Executor of one’s personality, has a variety of functions that in synergy assist towards growth and adaptation. Failure, or impairment in any one of these functions, may result in illness at worst or dysfunction at best. Accordingly, failure to include an ego-psych functional assessment may obscure measures of progress.

Care, therefore, is taken to assess each one of these functions, and to commence with a strategically planned treatment process that addresses these within a hierarchy.

The need for accurate assessment and accountability is of paramount professional concern to psychiatry. The authors of the AMJ article cited above, state that “ego functions assessment (EFA) is a reliable and valid quantitative technique, useful for these purposes in a variety of psychiatric settings. They suggest its utility for monitoring psychotherapeutic drugs, and treatment progress among other purposes. They conclude the EFA [13] is a dynamically sophisticated and easily learned form of mental status examination and that its refinement by extensive use and simplification is likely.

According to Heinz Hartmann (1956), the ego should be evaluated according to how it performs these functions.

Although Anna Freud, has been said, done little more than continue her father’s work, she was indeed a pioneer in both ego psychology and the psychoanalysis of children. She was the first to introduce 10 ego functions that set the stage for a rebirth of Ego Psychology. [14]

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Autonomous Ego Functions.

The capacities to breathe, walk, eat, sleep, perceive, remember, etc. ? within normative standards.; Autonomous Ego functions may be impaired via illness, inhibitions, anxiety, physical handicaps, or limitations due to age.

Sense of Reality.

The capacity to be cognizant and aware of everything within proximity of my senses; be it external, or internal.

Impairment in this function may result, aside from another sequela, in cognitive distortions, feelings of depersonalization, derealization, fugue, psychotic process, etc.; States of oblivion, aloofness, autism, etc., may give us a hint of impairment within this area, A remarkable Sensorium.

The sense of Reality in someone with strong autistic tendencies is limited to certain elements of the internal world of subjective experience.

Reality Testing.

The capacity to assess all that I am cognizant and aware of, against established external, or normative standards, leading to needed corrections, or modifications of my observations.

Though I may have an unremarkable Sense of Reality, my capacity to test what I perceive against a set of normative standards, may be impaired; That is, I can look at a thermostat and accept that the recorded temperature is 68 degrees, even though I am personally feeling hot. To accomplish this, my Analytic Functions must be unremarkable.

Analytic Ego Functions.

The capacity of the Ego to break down complex elements in individual components, recognizing both gross, as well as subtle differences in the sources of input. Efficiency and functionality are dependent on intellect, previous exposure, etc.

Synthetic Ego Function.

The capacity of the Ego to reconstitute the results of the analytical, and/or Insight process, comprehensively and coherently that will allow for a more in-depth view of a given situation.; This function is dependent on aptitude, experience, attitudes, and the presence, or absence of illness. It is most essential to Reality Testing and the foundation of Judgment. One essential function of the ego, according to Freud, is to synthesize all the impulses and energies of body and mind. Ego Functions https://www.encyclopedia.com/psychology/dictionaries-thesauruses-pictures-and-press-releases/ego-functions.

Insight – Automatic.

Insight is similar to the Sense of Reality; Where the Sense of Reality represents a conscious awareness, Insight represents the capacity to unconsciously integrate all of the conceivable elements within a given situation, regardless of their relevance, or significance; That is, sounds, colors, weather, weight of objects, shape of objects, etc.

Insight – Retrospective.

Retrospective Insight is similar to Automatic insight, as well as the Sense of reality, and Reality testing; Where all three represent levels of awareness, Retrospective Insight represents the capacity to consciously integrate all of the significant elements within a given situation, post-factum; Similar to having failed to accept and realize one's contribution to a fumble one becomes aware of it after watching a video of the action.

Judgement.

The capacity to unconsciously, and automatically, arrange all of the elements in a given situation in order of their relative significance to a given situation, and/or to a prospective action. E.g., The air turbulence of a ceiling fan, will have relevance to an attempt to place a tissue paper on a table, but little if any significance to placing a pencil, though the degree of the table's incline will take precedence.

Most impairments in judgment owing to a defect in insight as well as poorly developed Impulse Control Function, or a state of Impulse Discontrol.

Self-Observing Ego.

The capacity of the person to view the self as an object, and to monitor all thoughts, feelings, or actions a split-second prior, during, and a split second following all thoughts, feelings, and actions; This function is operative on the conscious level to assist in needed corrections or modifications of overt expression, while also operative on an unconscious level aiming at the employment of Defense mechanisms, such as suppression, repression, etc.

Self-Esteem Regulation

involves the capacity to maintain a steady and reasonable level of positive self-regard in the face of distressing or frustrating external events. Painful affective states, including anxiety, depression, shame, and guilt, as well as exhilarating emotions such as triumph, glee, and ecstasy may also undermine self-esteem. Generally speaking, in dominant American culture a measured expression of both pain and pleasure is expressed; excess in either direction is a cause for concern. White Western culture tends to assume that individuals will maintain a consistent and steady level of self-esteem, regardless of external events or internally generated feeling states (Berzhoff, Flanagan, & Hertz, 2011).

Impulse Control.

That part of the Ego which prevents the expression of primitive drives.; Though all of the above functions may be well developed and fully functional, impairment in Impulse Control may prevent their manifest expression.

To the extent that a self-observing ego is functional, but co-opted by the Impulse Control, shame, embarrassment, guilt, self-reproach, etc. may follow.

Modulating and controlling impulses is based on the capacity to hold sexual and aggressive feelings in check without acting on them until the ego has evaluated whether they meet the individual's moral standards and are acceptable in terms of social norms. Adequate functioning in this area depends on the individual's capacity to tolerate frustration, delay gratification, and tolerate anxiety without immediately acting to ameliorate it.

Impulse control also depends on the ability to exercise appropriate judgment in situations where the individual is strongly motivated to seek relief from psychological tension and/or to pursue some pleasurable activity (sex, power, fame, money, etc.). Problems in modulation may involve either too little or too much control over impulses (Berzoff, 2011).

Modulation of Affect.

The ego performs this function by preventing painful or unacceptable emotional reactions from entering conscious awareness, or by managing the expression of such feelings in ways that do not disrupt either emotional equilibrium or social relationships. To adequately perform this function, the ego constantly monitors the source, intensity, and direction of feeling states, as well as the people toward whom feelings will be directed. Monitoring determines whether such states will be acknowledged or expressed and, if so, in what form.

The basic principle to remember in evaluating how well the ego manages this function is that affect modulation may be problematic because of too much or too little expression. As an integral part of the monitoring process, the ego evaluates the type of expression that is most congruent with established social norms. For example, in white American culture, it is assumed that individuals will contain themselves and maintain a high level of personal/vocational functioning except in extremely traumatic situations such as the death of a family member, a very serious illness, or a terrible accident. This standard is not necessarily the norm in other cultures (Berzhoff, Flanagan, & Hertz, 2011).

Mastery.

When conceptualized as an ego function, mastery reflects the epigenetic view that individuals achieve more advanced levels of ego organization by mastering successive developmental challenges. Each stage of psychosexual development (oral, anal, phallic, genital) presents a particular challenge that must be adequately addressed before the individual can move on to the next higher stage. By mastering stage-specific challenges, the ego gains strength in the other structures of the mind and thereby becomes more effective in organizing and synthesizing mental processes. Freud expressed this principle in his statement, “Where id was, shall ego be.”

An undeveloped capacity for mastery can be seen, for example, in infants who have not been adequately nourished, stimulated, and protected during the first year of life, in the oral stage of development. When they enter the anal stage, such infants are not well prepared to learn socially acceptable behavior or to control the pleasure they derive from defecating at will. As a result, some of them will experience delays in achieving bowel control and will have difficulty in controlling temper tantrums, while others will sink into passive, joyless compliance with parental demands that compromise their ability to explore, learn, and become physically competent.

Conversely, infants who have been well gratified and adequately stimulated during the oral stage enter the anal stage feeling relatively secure and confident. For the most part, they cooperate in curbing their anal desires and are eager to win parental approval for doing so. In addition, they are physically active, free to learn, and eager to explore. As they gain confidence in their increasingly autonomous physical and mental abilities, they also learn to follow the rules their parents establish and, in doing so, with parental approval. As they master the specific tasks related to the anal stage, they are well prepared to move on to the next stage of development and the next set of challenges. When adults have problems with mastery, they usually enact them in derivative or symbolic ways (Berzhoff, Flanagan, & Hertz, 2011).

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Object Relations.

Refers to the state of one’s capacity to distinguish between Realistic vs Narcissistic cathexes.; This Function is comprised of three elements.

Object relations involve the ability to form and maintain coherent representations of others and the self. The concept refers not only to the people one interacts with in the external world but also to significant others who are remembered and represented within the mind. Adequate functioning implies the ability to maintain a positive view of the other, even when one feels disappointed, frustrated, or angered by the other's behavior. Disturbances in object relations may manifest themselves through an inability to fall in love, emotional coldness, lack of interest in or withdrawal from interactions with others, intense dependency, and/or an excessive need to control relationships (Berzhoff, Flanagan, & Hertz, 2011).

Self and Object Representations :

The capacity to accurately assess one’s self as viewed by others, as well as the capacity to accurately assess others as others see them. Leading to the capacity of the Ego to establish and observe boundaries between self and others.

Part Object Relations :

A proclivity, or diathesis to relate to only parts of others, with only a part of one’s self; E.g., If I am hungry, the only part of me that will relate to you is the hunger part, and that will only relate to that part of you that is capable of gratifying that need, while excluding other parts of you, such as your being tired, or sick, or hungry yourself.

In-Depth, or Whole Object Relations Function:

A proclivity, or diathesis to relate to others as whole objects; That is, taking into consideration their state of being, intellect, needs, etc., while allowing others to enjoy immediate and spontaneous access to you, and to every part of you be it internal, or external when appropriate and always circumscribed by the nature of the relationship.

Object Constancy / Permanence.

The capacity of the Ego to sustain a mental image of a removed or lost object, so that despair is avoided. A variety of personality disorders are underscored by an impairment in this function.

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Footnotes and Bibliography

 

1.   Published Online:1 Apr 2006. The American Journal of Psychiatry. https://doi.org/10.1176/ajp.133.11.1259

2.   Stein DJ, Shoptaw SJ, Vigo DV, Lund C, Cuijpers P, Bantjes J, Sartorius N, Maj M. Psychiatric diagnosis and treatment in the 21st century: paradigm shifts versus incremental integration. World Psychiatry. 2022 Oct;21(3):393-414. doi: 10.1002/wps.20998. PMID: 36073709; PMCID: PMC9453916.

3.   Phenomena complexes as targets of explanation in psychopathology: The relational analysis of phenomena approach. Kristopher Nielsen. Volume 30, Issue 2. https://doi.org/10.1177/0959354320906462.

4.   Medically reviewed by Heidi Moawad, M.D. — By Jamie Eske on September 26, 2019. Everything you need to know about chemical imbalances in the brain. https://www.medicalnewstoday.com/articles/326475.

5.   Ronald W. Pies, MD. August 2, 2019. Debunking the Two Chemical Imbalance Myths, Again. Psychiatric TimesPsychiatric Times Vol 36, Issue 8. https://www.psychiatrictimes.com/view/debunking-two-chemical-imbalance-myths-again.

6.   Benjamin Ang , Mark Horowitz , Joanna Moncrieff, SSM - Mental Health. December 2022. Is the chemical imbalance an ‘urban legend’? An exploration of the status of the serotonin theory of depression in the scientific literature. https://www.sciencedirect.com/science/article/pii/S266656032200038X.

7.   Psychodynamic Psychotherapy A Clinical Manua. By Deborah L. Cabaniss and Sabrina Cherry, Carolyn J. Douglas, Anna Schwartz. Columbia University Department of Psychiatry, New York, USA. DOI:10.1002/9781119142010

8.   Blanck G, Blanck R. The contribution of ego psychology to understanding the process of termination in psychoanalysis and psychotherapy. J Am Psychoanal Assoc. 1988;36(4):961-84. doi: 10.1177/000306518803600405. PMID: 3069889.

9.   By, L., Fritscher on October 23, 2023, What Is Object Relations Theory? https://www.verywellmind.com/what-is-object-relations-theory-2671995. Verywell Mind. Date accessed: November 10, 2023. Date published: October 23, 2023.

10. By, A., Etherington, on, U., 7, S., & (Hons), L. E. (2023, September 7). Melanie Klein and object relations theory. Simply Psychology. https://www.simplypsychology.org/melanie-klein.html.

11. Object relations theory of personality disorders. Date accessed: November 10, 2023. Date published: October 23, 2023. https://www.mentalhelp.net/personality-disorders/object-relations-theory/

12. Encyclopedia-com, Ego Functions https://www.encyclopedia.com/psychology/dictionaries-thesauruses-pictures-and-press-releases/ego-functions

13. Sharp V, Bellak L. Ego function assessment of the psychoanalytic process. Psychoanal Q. 1978;47(1):52-72. PMID: 625516.

14. Mark D. Kelland. Anna Freud and Ego Psychology. https://socialsci.libretexts.org/Bookshelves/Psychology/Culture_and_Community/Personality_Theory_in_a_Cultural_Context_(Kelland)/05%3A_Neo-Freudian_Perspectives_on_Personality/5.02%3A_Anna_Freud_and_Ego_Psychology