1. Metaphor Making in the Relational Brain
Dr Sue Mizen
Exeter

2. Characteristics of Severe and Complex PD
RISK
Personality disorder,
Eating disorder,
Somatisation,
Autistic spectrum disorder
Substance misuse
Characteristics of Severe and Complex PD

3. Symbolisation in the brain

5. Jaak Panksepp Basic Emotion Command Systems SEEKING PANIC FEAR RAGE
PLAY

6. Basic emotion Command Systems

7. AFFECT: The PANIC and SEEKING systems
SEEKING (Dopamine)
Exploration
Foraging
MANIA and PSYCHOSIS
Stimulants
PANIC (Opiates and Oxytocin)
Separation distress
Proximity seeking
Depression
Opiates

9. Relating and Triangulation
Year 1
Face to Face interaction with mother
(Primary intersubjectivity)
At 1 year
Triangulation
(Secondary intersubjectivity)
Autistic Spectrum Disorder
Hobson (2002)

10. Triangulation in psychoanalysis
Ron Britton
The collapse of triangular space in narcissistic disorder.

11. Summary of failures of symbolisation
Symbolisation requires:
Affective engagement
Relating
First and third person position taking (Triangulation)
Triangulation fails because of:
Inadequate affective engagement
Relational failures
Psychodynamic defences

12. Narcissism and Territory

13. Narcissism: A disordered sense of what belongs to whom.
A bodily sense of territory.
That which is within my control belongs to the myself and is loved.
That which is outside my control is defined as other and hated.
The boundary of the psychic and somatic self is drawn along the line between this definition of self and other
This boundary is fluid, but in normal conditions coincides with the skin.

14. Solms and Kaplan-Solms: Right Hemisphere damage
Unaware of loss of function (Anosognosia)
Believe the Paralysed limb belongs to someone else (Somatoparaphrenia)
Feel disgusted by the paralysed limb and may attack it. (Misoplegia)

15. Mr C
Mr C presented as aloof, egocentric and imperious, oblivious to the world around him except insofar as it affected his own wellbeing. He appeared unable to see things from the other person’s point of view, eschewing social convention. He only took the initiative to address a complaint. He took nothing in and never expressed gratitude, seeming to have withdrawn into a cocoon of self-sufficiency, and yet, he was simultaneously very needy and demanding. He was hypochondriacal and intolerant of frustration of any kind, expressed mostly to the nursing staff, whom he treated as though they were combined into one big mother, whose function was to meet his personal needs immediately. His intolerance of frustration was also expressed towards his arm and his rehabilitation regime. He expected and demanded to make a total and complete recovery. He seemed to harbour an intense need to regress, to be looked after and cared for, and yet consciously abhorred dependence and vulnerability of any kind. He closely resembled ‘his majesty the baby’, in a word he was narcissistic.
He treated the left side of his body in the same way he did the nursing staff, as though it was another piece of external reality which refused to do his bidding. It was therefore an annoyance, but otherwise of no interest to him. It was as though he had redrawn the boundary of his physical self, so that only his torso and right limb really belonged to him. His left arm was treated like a disobedient servant.
(Solms and Kaplan Solms, 2000, p162-3)

16. Morin et al (2014) DT

17. Xenophobia and psychic atopia
Ramachandran: Apotemnophilia and Acrotomania

18. Narcissistic defences against loss and Separation

19. Separation and loss
SELF
OTHER
Need

20. Britton: Acquisitive Projective Identification (Thin skinned narcissism)
Hyper-subjectivity

21. Mr Z

22. Britton: Attributive Projective Identification (Thick Skinned narcissism)
Hyper-objectivity

23. Miss x

24. The Relational Affective Formulation

25. Clinical IMplications

26. ‘Trapped’ and ‘Dropped’ in the mental health system

27. The Model: A graduated Pathway
Tier 4
Inpatient
Tier 3E
Day
Programme
Tier 3
Specialist outpatient

28. A therapeutic team working to a formulation
The Team
The RA Formulation
Consultant Medical Psychotherapists
Contain the team
Prescribing
Physical health
MHA
Psychotherapists
Individual
Group
Family
Psychosocial Practice

29. Therapeutic implications
Prosody and affective availability
States of identity
Relating to the body and relating to other
Eating disorders
Psychosomatic disorders
The boundary of the body and the self and battles for control
Triangulating interpretations
Claustro-agoraphobic crises and containment

30. Relational Affective Model
References:
Mizen, C. S. (2014a) Narcissistic disorder and the failure of symbolisation- A Relational Affective Hypothesis. Medical Hypotheses: Volume 83, Issue 3, Pages
Mizen, C. S. (2014b) Towards a Relational Affective Theory of Personality Disorder Psychoanalytic Psychotherapy 28:
Mizen, C. S. (2015) Neuroscience, mind and meaning: an attempt at synthesis in a Relational Affective Hypothesis. Psychoanalytic Psychotherapy 29:
Mizen, C. S. (2017) Preliminary thoughts on the neurobiology of innate unconscious structures and the psychodynamics of language acquisition. The Journal of Analytical Psychology (November edition)