Psychic structure, unconscious conflict and adolescent psychopathology: The contributions of opd-ca

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Psychic structure, unconscious conflict and
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Nicolás Bagattini
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Psychic structure, unconscious con
flict and adolescent psychopathology The contributions of OPD-CA
–2
NICOLÁS BAGATTINI
Correspondance address Nicolas Bagattini Clinical Research Department – Uno, Mental Health Institute, Psychology
PhD Program- The Catholic University, Montevideo, Uruguay. Email:
dr.bagattini@centrouno.edu.uy
Abstract
Diagnosis has historically suffered from alack of consensus around the categories or dimensions raised by the different psychopathological traditions. This is even more noticeable when working with children and adolescents. In this article, through the presentation of a case, the importance of performing a psychodynamic diagnosis in adolescence (in a complementary way to the categorical diagnosis) is highlighted,
addressing the psychic structure, unconscious con
flicts, and its relationship with the psychopathological presentation. The contributions of the OPD-CA-2 manual, and the self - report questionnaires derived from it for adolescent psychodynamic psychotherapy are discussed.
Keywords: OPD, OPD-CA-2, psychodynamic psychotherapy, psychic structure, unconscious con
flict, adolescent psychopathology
Introduction
For years, psychoanalysis has been opposed to the biological model of psychiatry and the hypotheses of pure behavioral sciences. This is particularly evident in the
field of clinical diagnosis. Psychiatry advocates fora precise diagnosis that discriminates normality from pathology, whereas the psychoanalytic conception defends the recognition of each individuals uniqueness and a continuum between health and illness. This polarization ends up compromising the validity of the diagnostic categories of both
fields: In psychiatry, opera- tionalization improved the diagnostic validity, but it impoverished the contents, and in psychoanalysis resistance to categorization increased imprecision (Bernardi,
2011
, p. 2). For example, the
“borderline” category recognized by the DSM III, validated a legitimized psychoanalytic concept at the cost of losing its original meaning, referring more to a level of functioning than to a category (McWilliams,
2011
).
In adolescence, the controversy over diagnostic categories and dimensions is even greater. Adolescence is characterized by a complex psychic reorganization induced by the biological, morphological, and cognitive changes of this stage, which jeopardize the libidinal
Clinical Research Department Uno, Mental Health Institute, Psychology PhD Program- The Catholic University,
Montevideo, Uruguay 2021 The Editors of Nordic Psychology
Nordic Psychology, 2021
https://doi.org/10.1080/19012276.2021.2001680
RESEARCH ARTICLE

and identifying investments that took place during childhood and the latency period. This reorganization of the mental structure has as its central task the consolidation of identity,
an extremely complex challenge that the adolescent must inexorably face.
On structure, con
flict, and diagnosis in children and adolescents
It is understandable that there are different positions regarding diagnoses made in children and adolescents. This stage of development is a critical process characterized by its variability.
With regard to psychic structure, the differences are evident in contemporary psychiatric and psychoanalytic literature while Paulina Kernberg published her book
“Personality disorders in children and adolescents in 2000 (Kernberg et al.,
2000
) and Roger Mis
es published in Actuality of borderline pathologies in children (Mises,
2004
), DSM-5 (American
Psychiatric Association) explicitly warns about using the diagnosis of personality disorder in children under 18 years old. Inline with previous developments, the recent ICD-11
(World Health Organization) proposes a dimensional view of personality impairment and excludes warnings about diagnosis in those under 18 years of age. A review of empirical evidence suggests that emerging patterns of personality pathology in adolescence are highly prevalent and persistent and that early detection is crucial to prevent deterioration of a developing personality (Chanen et al.,
2017
; Sharp & Fonagy,
2015
). Regarding unconscious con
flict, its multiple understandings presented challenges for researchers who have attempted to construct valid and reliable assessment methods (Benjamin et al.,
2006
;
Luborsky et al.,
1994
). Its operationalized evaluation has followed a complex path
(Simmonds et al.,
2015
).
In recent years, a step has been taken towards the integration of all these developments.
The Operationalized Psychodynamic Diagnostic manual (OPD) was developed as a response to the disagreements with the descriptive classi
fication systems. The manual synthesizes previous psychoanalytic developments, both at a theoretical and research level, to later propose its operationalization in 5 axes I Prerequisites for treatment, II ¼ Relationship,
III
¼ Conflict, IV ¼ Structure, V ¼ ICD-10 diagnosis (OPD Task Force & Von Der Tann, 2008). It has demonstrated its clinical utility, reliability and validity (Cierpka et al.,
2007
). The OPD for
Children and Adolescents is currently in its second edition. It takes the OPD mental model and adapts its concepts to the different stages of infant and adolescent development. The manual has also derived tools, amongst which are the self-report questionnaires that are used in this article.
Regarding the relationship between con
flict, structure, and psychopathology in children and adolescents, there is still much to investigate. An important question is, how these dimensions relate to each other in this particular age group?
Materials and methods
Through the description of a case, informed by self-report tools, the relationship between descriptive psychopathology, the level of structural integration, and the unconscious con
flict in adolescence is addressed. The case was selected intentionally from an initial sample of patients belonging to an ongoing study in Uruguay, for being a good example with respect
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to the relationships between the dimensions studied (Seawright & Gerring,
2014
), and to demonstrate the contributions of OPD
–CA–2 self-report questionnaires to the interpretation of clinical phenomena. The discussion regarding the reasons for the patient outcome exceeds the scope of this article. The research was carried out in a center for assistance in psychiatry and psychodynamic psychotherapy of children and adolescents in Uruguay. The study is conducted by a clinical research team composed of pediatricians, child psychiatrists,
and psychoanalysts in which the author is the main researcher. The study has the approval of the Ethics Committee of the Catholic University of Uruguay. Data was obtained with prior written and verbally informed consent from parents and the patient, requested during an interview in which the research was described in detail. The patients right to get access or delete the data at anytime was also ensured.
The patient received psychodynamic psychotherapy (conducted by the author) biweekly during the
first year and on a weekly basis during the second year. The patient was asked to answer the self-report questionnaires both at the beginning of psychotherapy (Time and after two years of treatment (Time 2). The use of the questionnaires did not alter the therapeutic relationship. At both times, a written report of the patients presentation was made by the psychotherapist. The patient completed the following self-report questionnaires Youth Self Report (YSR, Achenbach,
1991
), OPD Structure - Questionnaire (OPD-CA-SQ,
Kassin & Hackradt,
2018
) and the OPD - Con
flict Questionnaire (OPD-KJ-KF, Seiffge-Krenke &
Escher,
2018
).
Measures
The YSR is a self-report questionnaire for young people, which is part of the Achenbach
System of Empirically Based Assessment (Achenbach et al., 2008). It was designed to obtain systematized information directly from children and adolescents aged between 11 and years old. The second part of the questionnaire, which consists of 112 items, assesses the frequency of a wide range of problematic behaviors. The following YSR empirically derived scales were developed through factor analysis of data from the general adolescent population Anxious/Depressed, Withdrawn/Depressed, Somatic Complaints, Social Problems,
Thought Problems, Attention Problems, Rule Breaking Behavior, and Aggressive Behavior.
The OPD-CA-SQ is a self-report questionnaire for adolescents between 12 and 18 years old, to assess the four dimensions of personality structure proposed by the OPD-CA
–2:
Control, Identity, Interpersonality, and Attachment (OPD Task Force et al., 2017). The questionnaire has 81 questions with a step answering format (0
¼ no, 4 ¼ yes. The four resulting primary scales are each composed by several subscales. In addition, a total score is obtained from all items to quantify a general severity level of structural impairment. Scores clearly above the average (T-scores above 60) denote plausible risk fora current personality disorder. The questionnaire was recently validated in Spanish (Kassin & Hackradt,
2018
). In this study, the reliability of the scales was good, with Cronbach
’s alpha .96 for the total scale and with .85, .87, .87 and .75 for the primary scales (Control, Identity, Interpersonality,
and Attachment, Kassin & Hackradt,
2018
).
The OPD-KJ-KF is a self-report questionnaire based on the OPD-CA-2 axis of con
flict. It assesses the type and severity of unconscious con
flicts in adolescents, in seven operational- ized con
flicts: Closeness vs. Distance, Submission vs. Control, Taking Care of Oneself vs.
Psychic structure, unconscious con
flict and adolescent psychopathology
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Receiving Care, Self-Esteem, Guilt, Oedipal, and Identity (Seiffge-Krenke & Escher. The questionnaire has 28 questions, with a step answering format (0
¼ no, 4 ¼ yes. From the questions, 14 represent values for passive and 14 questions represent values for active con
flict coping strategies. Furthermore, 7 means are calculated corresponding to the 7 con-
flicts and their severities, ranging from 0 to Case description
Octavio is 12 years old when his parents initially consult to start psychotherapy. They say that Octavio has been getting very angry and has been yelling at others in the recent months. He does not know how to lose and does not tolerate any criticism. His mother spe- ci
fically says that he takes losing to heart and so needs equality During the interview, it is clear that the parental discourse itself shows a logic related to value whereas Octavio is
“the most sensitive the others are easygoing and happier While he is the most self- demanding and the more responsible his younger brother is a genius and totally outgoing Although Octavio plays football well it is also noted that most of the others play better At age 4 he was diagnosed with hypothyroidism, which has led to his height being below the class average.
A relevant obstetric history also emerges during Octavio
’s gestation, his mother suffered a placental collapse that led to prolonged bed rest.
When I meet Octavio, he strikes meas very underdeveloped for his age, both physically and mentally. I infer he is intelligent, although without much self-re
flective capacity. During the
first months of treatment, he plays creating a story Hank is a child-superhero, who was born
“with dragon things and in whose family everyone is normal In an almost direct allusion to the fantasy of his own gestation and short stature, Octavio tells me that
Hank
“was a rare case, because his mother had had a disease that affected her uterus”
which is why Hank was born
“not with a deformity, but with superpowers Hank always ends up saving everyone and travels to a world where he is
“very big and he occupies half of the other world One day, after an intervention about what Hank might feel,
Octavio abruptly abandons the story. I think he has had an insight into the displacement of his own aspects in the character, but that he has received it in a persecutory way. After some later reluctance, he is able to reestablish a bond of trust. Another day, as he talks about his height and how dif
ficult it is to be the shortest I tell him that I think this must be dif
ficult for him. Octavio listens tome and abruptly cries uncontrollably. He lowers his head on the desk and says:
“You are making fun of me and Why are you making fun of me These moments are also present in relational patterns with his peers, where Octavio always feels that he is
“excluded” and left aside by his friends.
Different diagnostic hypotheses emerged from this initial assessment the clinical presentation could be due to a developmental and/or situational crisis being handled in an unfavorable way. In this sense, the crisis maybe due to
“a temporary moment of imbalance driven by development, when faced with autonomy, new cognitive demands, etc.
”
(McWilliams,
2011
, p 389). Irritability could also bean indication of an ongoing depressive/
anxious disorder. Many times,
“the metabolization of anger is a specific problem of the introjective subtype of depression in adolescence (Belvederi Murri et al.,
2017
; Lingiardi &
McWilliams,
2017
, p. Nicolas Bagattini
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Prior to knowing the self
–report results, the psychodynamic inferences posed an initial hypothesis of a self-esteem con
flict which referred to the value of oneself versus the value of others. This may have been underpinned by an environment full of strong ideals as evidenced by the family discourse. Projective moments in sessions also raised a question with regard to Octavi

os level of psychic structure integration. These moments could bean expression of an impairment in self
–object differentiation and/or regulation of self-esteem.
Results
At the beginning of psychotherapy (Time 1), the analysis of the YSR shows the syndromic grouping mainly in the categories
“Anxious/Depressed” (T ¼ 69), and Aggressive Behavior”
(T
¼ 66). These are located in the limit between the borderline and the clinical range (Figure. This indicates that Octavio reports more problems than those typically reported by 12- year-old adolescents (Achenbach,
1991
).
Figure 1. 1.1 Youth self report - Time 1. 1.2. Structure questionnaire (OPD
–CA–SQ) – Time Psychic structure, unconscious con
flict and adolescent psychopathology
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The analysis of the OPD-CA-SQ (Figure 1.2
) shows that the patient has a well-integrated personality structure value in a generic way (T
< 60); nonetheless, the dimension referring to
“control” is mild to moderately affected (T > 60-70). The sub-dimension referring to the
“capacity to separate stands out as important, also in the clinical range.
The OPD-KJ-KF analysis showed a clinical range con
flicting pattern. Two areas of conflict clearly predominate as the most compromised the
“Oedipal Conflict” (Average ¼ 2.5) and the con
flict over his Identity (Average ¼ After two years of treatment (Time 2) the YSR analysis (Figure 2.1
) shows that the previously compromised syndromic grouping has decreased in its level from the borderline range to the normal range (
“Anxious/Depressed” T ¼ 62 and Aggressive Behavior T ¼ The analysis of the OPD-CA-SQ (Figure 2.2
) shows that none of the structural dimensions are impaired, depicting a personality structure that is well integrated and age appropriate in all dimensions (T
< 60).
The analysis of the OPD-KJ-KF shows that the prior con
flicts are no longer in the clinical range, but instead are now in the normal range. The self-worth con
flict has increased, being
Figure 2. 2.1 Youth self report - Time 2. 2.2 Structure questionnaire (OPD
–CA–SQ) – Time 2.
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more present than before, but is not signi
ficant (Mean ¼ Figure shows the con
flict evolution between the two times of assessment.
Discussion
The present work aims to highlight the importance of psychodynamic diagnosis in adolescents in a complementary way to the phenomenological, observable and categorical diagnosis. In particular, the contributions of the OPD-CA-2 and the self-report questionnaires derived from it, to the clinical and meta - psychological discussion are stressed.
As described in the results section, at time 1, the YSR results showed that Octavio
’s symp- tomatology aggregates around anxious-depressive syndrome and aggressive behaviors in the borderline/clinical range. These results are consistent with the type of symptoms reported by his parents as well as with the severity of them. We can thus say that the symptomatology presented by Octavio is the product of an ongoing
“depressive/anxious”
disorder. This descriptive diagnosis does not rule out the developmental crisis posed in the diagnostic hypotheses.
The assessment of psychic structure integration is also consistent with the episodes of irritability and aggressive behaviors for which Octavio was referred. It is worth asking whether this dimension of the psychic structure has always been compromised or is this a secondary
finding due to the current depressive aspects The regulation of self-esteem is in the normal range and the dimension referred to
“self-object differentiation is intact. This is consistent with the clinical impression, which denotes a predominantly
“neurotic” experience with the patient (McWilliams,
2011
), and suggests that the hypothesis around the structural impairment derived from his projective moments should be discarded. The alteration of the speci
fic ability to separate sub-dimension highlights an area of fragility referring to the natural separation process of his age and which must be integrated into the initial clinical formulation.
The results from the OPD
–KJ–KF questioned the hypothesis about Octavio’s core conflicts:
the story about
“Hank” is full of grandiose self-images and had initially led to the discussion around self-esteem con
flict vs. self-esteem structural regulation capacity. The self–report assessment brought into account the
“Oedipal” and Identity conflict aspects. Is the theme around
“value,” so present in Octavio’s discourse, related to the value of his body, and his
Figure 3. Con
flict questionnaire (OPD–KJ–KF) - Time 1 vs Time Psychic structure, unconscious con
flict and adolescent psychopathology
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body in relation to his parents In this sense, the phenomenon of feeling
“left out being
“excluded” and being smaller including the projective moments inside the sessions, could be interpreted as
“conflict driven and as referring to the Oedipal dimension. This could imply the presence of an unconscious comparison and competition with the father
figure with its consequent castration anxiety, immersed in a fragile separation-individuation process. An excerpt from a session almost a semester after the beginning of psychotherapy, in which Octavio
’s raps with the music, shows these aspects in Octavio’s discourse:
“I may not be very strong, but if I fall, I getup. Although I am not going that fast, I hit high, I am a monkey climbing to the top, but be careful that the elephant is waiting. We are not going to cry. We are going to try to make friends. The snake is also therewith its
fierce teeth … They are not dangerous, they are friendly, we are going to build a very vulnerable friendship.”
Initially, Octavio
’s psychotherapy was focused on the creation of a bond of trust framed in the
“supportive” pole of interventions (Luborsky,
2003
). A general empathetic attitude,
adapted to his level of psychic structure integration, was adopted by the therapist, allowing
Octavio to progressively mentalize his emotional regulation his need for validation and self- competence (Sahin et al.,
2017
). After a few months, the evolution of the relationship gave way to interventions located in the
“expressive” pole where, predominantly displaced through play, the con
flictive aspects relating to the tripartite scenes of competitiveness,
idealization and self-devaluation were interpreted.
After two years of treatment (Time 2), his irritability has disappeared and Octavio tolerates losing in sessions. He plays without mood swings, idealizations, or excessive devaluations.
He chooses chess to process the Oedipal competitiveness and enjoys the process. Projective moments have disappeared. In his relational patterns with peers, con
flictive moments related to value and competence in groups of three have also vanished. He has grown physically and no longer appears as small for his age. Secondary sexual characteristics as well as age-appropriate exogamic fantasies began during treatment. In sessions, Octavio speaks about himself directly and addresses his problems more easily and with greater symbolic display.
Prior to the self
–report assessment at time 2, it was presumed that the depressive/anxious symptomatology had disappeared. The inferences about the evolution of his structural vulnerability and con
flicts were similar. The results of the YSR were inline with the clinical impression showing an improvement in previously impaired areas, currently in the normal range. The results of the OPD-CA-SQ also showed an improvement in the previously impaired dimensions, consistent with the disappearance of episodes of irritability and lack of impulse control. The
findings of the OPD-KJ-KF show globally, that conflicts are now in the normal range.
The
findings referring to the self-esteem conflict and its increase overtime, although it is not clinically expressed, was integrated into the work with the patient to assess its signi
fi- cance. It was hypothesized that this could be the natural evolution of the con
flict restructuring, informed by his biological history. One may wonder if his altered growth made the regulation of the normal and inevitable con
flicts of his age more difficult for him, with a consequent emergence of depressive symptoms and a secondary impairment in impulse control. The importance of his growth process can be highlighted in which body con
fidence also played a role coping with individuation and the Oedipal con
flict. It cannot be ruled out
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that, without help or facing a traumatic experience, Octavio could have gone onto experience an even more disintegrated level of psychic structure integration.
The limitations of the present work are multiple generalization of these
findings is not possible due to its case report character it is not possible to establish cause effect relationships and there is danger of over
–interpretation. Not all patients, due to their illness,
will be able to give such a clear clinical picture nonetheless, it highlights the importance of integrating psychodynamic diagnosis and self-report forms into clinical work. The use of these tools enriches the adolescent assessment and favors the meta-psychological elaboration as well as the interpretation of phenomena, guiding the therapeutic attitude towards the patient.
Acknowledgments
The author is grateful for the help of Laura Alava in the data processing as well as for the collaboration of Dr. Del
fina Miller and Dr. Ricardo Bernardi regarding the formal structuring and scope of the present article.
Disclosure statement
The authors declare no con
flict of interest with respect to the authorship and publication of this article.
Ethics
The study has the approval of the Ethics Committee of the Catholic University of Uruguay
ORCID
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as Bagattini http://orcid.org/0000-0001-7389-9326
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