Psychodynamic Insights into Treatment-Resistance: A Case Study Exploring Patient-Physician Dynamics and the Impact of Counter-Transference on Adherence to Evidence-Based Practices

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This case report explores the decision-making process physicians undergo when treating patients resistant to traditional therapies, particularly those with underlying personality disorders. The patient in focus underwent extensive treatment with antidepressants, antipsychotics, mood stabilizers, anxiolytics, and hypnotics. This journey sheds light on the multifaceted nature of treatment resistance, emphasizing the active role of patients in influencing and occasionally sabotaging their treatment. The report highlights the delicate balance between minor medication adjustments and a departure from established clinical practices. The pivotal role of the patient-physician relationship is emphasized, with a specific focus on identifying and addressing the patient's past feelings of anger towards physicians as a contributing factor. Failure to recognize this dynamic can result in physician frustration and a sense of helplessness. The exploration also stresses the importance of understanding physician emotions in managing medications for challenging patients. By uncovering the underlying causes of treatment resistance in this case, the physician's confidence improved, enabling a more beneficial course for the patient. However, a lack of continuity and a weak therapeutic relationship led to treatment failure in this instance. In conclusion, this case underscores the critical importance of identifying factors contributing to treatment resistance to disrupt the cyclical pattern of medication changes. Both patient and physician emotions significantly influence deviations from clinical practice. The narrative emphasizes the value of psychodynamic understanding in addressing these challenges, facilitating a more comprehensive and effective approach to patient care. Treatment resistance transference psychotherapy personality disorders psychoanalysis insomnia depression anxiety Figures Figure 1 Figure 2 Introduction In an era where an increasing number of individuals grappling with depression and anxiety seek solace in pharmacologic treatment, the inevitability of encountering treatment resistance looms large. While some cases simply necessitate judicious adjustments to medications, leading to eventual stabilization, a unique subset of patients exhibit resistance due to psychodynamic aspects rather than the medications themselves. Unraveling the complexities of this resistance unveils a critical need to bridge the gap between the biologic psychiatry mindset and the psychoanalytical approach. Beyond the conventional realm of pharmacological considerations, these instances demand a nuanced exploration of underlying causes contributing to treatment resistance. The challenge intensifies when patients exploit physician emotions through counter-transference and dictate treatment. Delving deeper into this realm becomes imperative as it may reveal intricate therapeutic relationship dynamics, such as patients unconsciously transferring their anger to the physician, thereby undermining the prescribed treatment regimen. The literature widely recognizes the advantages of combining pharmacotherapy and psychotherapy to optimize treatment outcomes. Most recently illustrated by Guidi and Fava in a meta-analysis published in JAMA Psychiatry in 2021 (1). Going a step further, Shapiro and Plakun, were pioneers in using psychoanalytical dimensions to optimize pharmacologic treatment (2,3) This case report centers on a patient displaying elevated resistance to conventional psychotropic medications, empowering them to influence treatment decisions and deviate from traditional evidence-based approaches. Specifically, the report delves into the influence of transference on physician confidence, highlighting the significance of a physician's assurance in effectively managing challenging patients. Maintaining confidence is essential as it prevents the patient's subconscious emotions from unintentionally steering the course of treatment, underscoring the need for a mindful and informed approach in such therapeutic scenarios. Patient information This case involves a 45-year-old married woman, currently unemployed, residing with her husband and children. She voluntarily admitted herself to a psychiatric hospital following presentation at a nearby emergency room, where she reported symptoms of anxiety and vague suicidal ideation. Of particular concern to the patient was her severely disrupted sleep, despite an extensive medication regimen. The patient met criteria for admission due to her suicidal ideation. The goal of inpatient treatment was to ensure patient safety and control the suicidal thoughts. Additionally, the patient will benefit from the extensive behavioral therapy. Along with the suicidal thoughts, the patient reported generalized anxiety and occasional panic attacks marked by chest tightness. She reported an extensive history of insomnia due to the anxiety. However, she denied other panic attack symptoms such as shortness of breath, palpitations, a sense of doom, or tingling in her hands. The patient revealed a history of a traumatic childhood experience, which originated from her mother being diagnosed with ALS when she was 11 years old. This proved particularly challenging as her mother, a pediatric nurse, served as the primary caregiver, while her father, a surgeon, was predominantly focused on his career. The subsequent deterioration and eventual passing of her mother during the patient's senior year of college had a profound impact, leading to ongoing difficulties in fully comprehending and coping with this loss. Notably, there were no reports of emotional, physical, or sexual abuse, and the patient denied experiencing symptoms commonly associated with PTSD, such as nightmares or flashbacks. Further exploration revealed a prolonged struggle with mental health challenges. While the patient experienced multiple traumatic events during childhood, she did not pursue mental health treatment until age 30. From the age of 30 until 44, the patient was consistently treated for anxiety and depression. The treatment during this 14 year period was self-reported as “fairly consistent”. The patient did report occasional changes in the specific SSRI and SNRI during this time. The full list of medications the patient has tried is illustrated in figure 1. Before the age of 44 the patient found the most consistent benefit with paroxetine. Approximately a year ago, the patient was hospitalized for suicidal ideation. In the months leading up to this hospitalization, the patient found her medication regimen to be much less helpful. During the hospitalization she was stabilized and advised that her response to medications may change during the perimenopausal timeframe. In addition, the patient underwent psychological testing during this hospitalization and the patient was formally diagnosed with Cluster B personality disorder with features of borderline and histrionic personality. Once discharged from the hospital she underwent nearly a year of intensive outpatient therapy without improvement. Of note, her outpatient therapy seemed to largely revolve around medication management rather than psychotherapy. The patient reported seeing her psychiatrist extensively over the past year. She was never able to go more than 6 weeks without an appointment to change the medication regimen. When asked about her experience with therapy the patient was largely dismissive. On review of the last discharge, it was advised for her to complete a partial hospitalization program where she would have had group and individual therapy every weekday for 2 weeks. However, the patient refused and would only agree to seeing a therapist weekly. When questioned about her experience with this therapy, the patient was dismissive stating that she “tried for months and it did nothing”. This case report will focus on the patients medication management over the last 18 months which has been extremely unstable. Specifically, her anxiety and insomnia have not been controlled. In addition to lack of clinical improvement, the patient has been dependent on benzodiazepines multiple times. Her outpatient provider, seemed to be at a loss after 12 months of medications changes many of which were trials that did not follow evidence based practices. Consequently, she was referred to a specialist on treatment resistance in the area. Before the appointment with the specialist, the patient felt extremely helpless and presented in the emergency room. In the ER, she was given Ativan for her anxiety and helplessness, but reported that this “made everything worse”. When questioned further, she was not able to describe how the lorazepam worsened her symptoms other than just repeating “it made me more anxious”. During discussions about treatment options, the patient's history of non-adherence to medication regimens since her previous hospitalization emerged. A common pattern of dictating treatment and switching drugs emerged. Diagnostic assessment Upon admission, the patient underwent a physical examination by a medical doctor and was diagnosed with hypertension and GERD. The patient was found to be adequately managed and advised to continue outpatient management. The patient also had labs performed which included CBC, CMP, thyroid panel, lipid panel, and vit D. The patient had slightly elevated lipid levels but did not warrant medication at this time. The patient was also found to be deficient in vitamin D with a level of 20.7. The patient was started on vitamin D replacement. All other labs were found to be within normal limits. The patient’s previous psychological testing was reviewed from the previous hospitalization. The diagnosis made at the time based on the DSM-5 criteria were generalized anxiety disorder, panic disorder, major depressive disorder recurrent severe without psychosis, benzodiazepine use disorder moderate, and cluster B personality disorder with features of borderline and historionic personality. The patient was evaluated on admission by a psychiatrist who found her admitting diagnoses to be generalized anxiety disorder, major depressive disorder recurrent moderate without psychosis, and benzodiazepine use disorder moderate The history of cluster B personality disorder and panic disorder were still present but not apparent in the initial interview. After further evaluating the patient daily throughout the hospitalization, the diagnosis of cluster B personality disorder was much more apparent with borderline features such as splitting. The benzodiazepine use was found to be severe rather than moderate. The prognosis after a week of inpatient treatment was extremely poor due to the patient’s poor insight and lack of compliance. More specifically, the resistance to individual psychotherapy was a large barrier to successful treatment. Hospital Course The objective of inpatient treatment was to stabilize the patient, address suicidal ideations, and alleviate feelings of helplessness. Additionally, hospitalization aimed to reduce acute symptoms and provide guidance for her subsequent outpatient care. Noteworthy, due to her extensive psychiatric history the prognosis of completely resolving her symptoms during this hospitalization was poor. The patient's history of psychotropic medication trials, meticulously documented in Figure 1, guided the selection of the most appropriate regimen. Considering her previous responses and adhering to evidence-based practice, imipramine, gabapentin, and mirtazapine were deemed suitable. Daily interactions with the patient primarily revolved around medication discussions. The patient consistently expressed dissatisfaction and pressured the physician for changes well before the therapeutic benefits could be thoroughly assessed. This persistent push for alterations is reflected in Figure 2, illustrating extensive deviations from standard clinical practice. Subsequently, the patient was exposed to much more side effects than if a consistent medication regimen had been properly adhered to. The therapeutic relationship and physician behavior, particularly countertransference, are clear during this hospitalization. A psychoanalytic interview revealed a difficult upbringing contributing to a personality disorder and medication resistance, emphasizing unresolved anger towards her absent father who was a physician and suppressed memories. Post-interview, it was clear that true psychoanalysis would benefit the patient however she resisted and continued to focus on medications. On the 8th day, a suitable long-term inpatient facility was found, emphasizing psychotherapy. Despite some progress and the physician identifying what the patient truly needed, the patient sought another doctor, resumed Klonopin, and refused the medications that had contributed to her slight improvement. The weak therapeutic relationship is detrimental in this case because the physician was not able to provide the best care for this patient. Over the week there were slight improvements, but the patient's self-sabotaging behavior ultimately was not able to be overcome. The course of treatment underscores the interplay of psychotropic medications, patient autonomy, and the therapeutic relationship. Comprehensive approaches considering both pharmacological and psychoanalytical dimensions are crucial. The patient's recovery ultimately hinges on securing proficient professionals who guide treatment confidently, avoiding patient-driven decisions for successful outcomes. This highlights the necessity for a comprehensive approach that takes into account physician emotions in medication management. The extensive medication changes illustrated in Figure 2 show how the patient dictated treatment and deviated from standard practice. This unique situation shows how a lack of continuity in care can be detrimental to treatment. Follow-up and Outcomes Throughout the hospitalization, the patient displayed poor adherence and tolerability to medications. Multiple adverse events, including severe suicidal ideation and dissatisfaction with the psychiatrist, were reported. Despite a week of inpatient management and numerous medication changes, the patient's symptoms remained largely unchanged. Clinical improvement was minimal, and the prognosis for this patient is deemed extremely unfavorable due to lack of insight, poor judgment, and resistance to psychotherapy. The weak therapeutic relationship and excessive polypharmacy, not following evidence-based guidelines, contributed to the overall poor outcomes. The patient's resistance to treatment and the impact of physician emotions on decision-making are evident in this challenging case. Discussion This case report underscores the profound influence of physician emotions on medication management. In an ideal scenario, physicians should make decisions impartially, but a lack of confidence may lead them toward the path of least resistance, jeopardizing the best interests of the patient. Straying from evidence-based clinical practices exposes patients to considerable side effects without apparent benefits, as highlighted by the significant adverse effects our patient encountered during hospitalization. A nuanced comprehension of the patient-physician relationship is essential for adeptly addressing challenging cases characterized by treatment resistance. One noteworthy takeaway from this case report, with direct clinical relevance, underscores the importance of a resilient physician who acknowledges their own emotions and avoids yielding to the patient's preferences. Furthermore, maintaining continuity in care is imperative for this particular subset of patients. Given the complexity of their psychiatric history and underlying symptoms, a substantial amount of time is required to gain a comprehensive understanding and provide optimal treatment. This specific scenario aligns with the literature on the psychodynamics of psychopharmacology. The paper by Silvio and Condemarin explore how over the past 20 years there has been an increase focus on the psychodynamics of pharmacology itself (4). In their paper, they recognize the importance of interpersonal factors in patient compliance and ultimate success. A similar study by Li confirmed the importance of being mindful of psychodynamic factors and utilizing dialectics in clinical practice (5). A common theme within the realm of psychodynamics of psychopharmacology is the therapeutic alliance. This is a concept that has been researched extensively and is agreed to be integral in the success of treatment. The meta-analysis by Martin et al in 2000, showed the significance of a positive therapeutic relationship (6). Taking these concepts and applying them into clinical practice can be a challenge. The book by Reba and Balon focuses on combining pharmacotherapy and psychotherapy (7). They emphasize the importance of a comprehensive initial diagnostic assessment. In practice, a comprehensive assessment can be extremely challenging when patients are resistant as in our case report. The concepts in their book were confirmed by the meta-analysis performed by Karyotaki et al in 2016 (8). Nonetheless, it is important to still understand the psychodynamic aspects even if psychotherapy is not an option for treatment. For example, Forrest talks about how being aware of certain character styles can improve the therapeutic alliance and medication regimen (9). We can delve deeper into the specific nuances that contributed to the poor therapeutic relationship in our case report. Our patient utilized transference as a coping mechanism for the subconscious deep-seated anger towards her father, coincidentally a physician. Multiple physicians proceeded to deviate from traditional practice and made excessive medication changes. We believe these excessive medication changes were related to the physician feeling helpless themselves due to counter-transference. Transference, initially introduced by Freud and further developed by Carl Rogers, has evolved into the contemporary concept of the therapeutic alliance. A comprehensive review of transference by Horvath in 2000 explores its current implications in clinical practice (10). The primary takeaway emphasizes the critical importance of identifying transference early in the therapeutic relationship and recognizing the collaborative framework's significance in determining the most effective therapy. Similar papers by Marcus in 2007 and Gabbard in 2020 echoed many of the same concepts but delved deeper into how physicians should use their emotions to better understand their patient’s subconscious (11, 12). The paper by Marcus specifically explored the transference and counter-transference related to medications. He concluded that both of these ego defenses are highly specific diagnostic indicators (11). While this case report was not successful in treating the patient, the identification of counter-transference was used to understand the underlying emotions and create a plan for a future physician to follow. This unique case underscores the impact of subconscious emotions on the success of treatment in patients with underlying personality disorders. Our case report emphasizes the significance of seamlessly integrating psychoanalytical and pharmacological perspectives. While using a patients transference and the phsyicians counter-transference as a diagnostic tool is helpful, we looked to use these concepts to optimize the pharmacological treatment as well. To understand how to apply these concepts to management we can draw upon "A View from Riggs" publication series, particularly focusing on the psychodynamic approach to understanding treatment resistance. In Plakun's foundational paper, he underscores the necessity of tolerating negative transference as a frequent component associated with treatment resistance (2). Plakun argues that recognizing the provider's own negative emotions in countertransference is crucial. Furthermore, the paper highlights the importance of not relinquishing authority to the patient, emphasizing the need for maintaining control over treatment strategies and admission terms. In another publication from the same series, Shapiro delves into the dynamics of the patient's living situation and authority (3). The paper highlights the risk of physicians adhering solely to the current treatment paradigm, neglecting the individual's personality and psyche. Without a comprehensive psychological understanding, biological interventions offer limited benefits. For these patients, resistance to treatment may not only be a reenactment of painful experiences but also a mode of communication. Their resistance may be a coping mechanism for suppressed anger, allowing them to assert control over providers they deem untrustworthy. Both our case report and the "A View from Riggs" publication series exemplify how recognizing individuals' subconscious psychodynamics can transform physicians into competent allies, leading to a shift in their own perspectives. Our case report highlights the inherent challenges in managing patients with complex medical conditions. When a therapeutic alliance is weak, the repercussions of excessive polypharmacy become particularly pronounced. In such instances, clinical pharmacologists play a pivotal role as a crucial safeguard. The study conducted by Stuhec and Zorjan underscores the significance of an external perspective in evaluating reported benefits and clinical relevance within a specified timeframe (13). Clinical pharmacists, as demonstrated in their interventions with ambulatory psychogeriatric patients, contribute valuable insights to the decision-making process. Their specialized knowledge enables a more comprehensive and well-informed approach to combining different medications (13). This collaborative strategy not only adds an additional layer of scrutiny to medication choices but also serves to counterbalance the potential influence of physician emotions on decision-making. The outcome is a more objective and patient-centered approach to care. Conclusion In conclusion, the optimal care for challenging cases necessitates the integration of psychopharmacological and psychoanalytical perspectives. Recognizing and addressing transference and unresolved anger early in the therapeutic relationship are crucial components that underscore the active role of patients in influencing treatment decisions. To mitigate variance from evidence-based practice, physicians must confidently navigate these dynamics. A strong therapeutic relationship and a multidisciplinary approach are pivotal for the proper management of these unique patients. Therefore, adopting a holistic approach that considers both pharmacological and psychoanalytical dimensions is essential for ensuring comprehensive and effective care in challenging cases. Declarations Ethics approval and consent to participate The informed consent procedure for this case report commenced with the healthcare professional approaching the patient, acknowledging them by their name and date of birth. A comprehensive explanation of the report's purpose, content, and potential implications was provided to the patient. Emphasis was placed on the voluntary nature of participation, ensuring the patient understood that their decision would not affect their medical care. Discussions encompassed protective measures for anonymity, potential impacts on the scientific community, and the opportunity for the patient to seek clarification by asking questions. The patient's comprehension and agreement were meticulously documented, and contact information was furnished for any subsequent inquiries or withdrawal of consent. This approach was employed to uphold ethical standards in obtaining informed consent for participation in the case report. Consent for Publication Upon completion of the case report, the patient was given the opportunity to examine the comprehensive document. Subsequent to review, they expressed consent for the publication of the final case report in an open-access journal, including any identifiable information present in the manuscript and accompanying images. Availability of Data and Materials The data supporting this case report are available upon request, subject to Institutional Review Board (IRB) approval. Requests for data access should be directed to the corresponding author at [email protected] . Data will be de-identified to ensure patient privacy. Access is granted for research purposes only, pending IRB approval and compliance with ethical guidelines. Funding Statement This case report was conducted without receiving any external funding. Conflict of Interest There are no conflicts of interest to disclose in relation to the case report. References Guidi J, and Fav G. (2021). Sequential combination of pharmacotherapy and psychotherapy in major depressive disorder. JAMA Psychiatry 78, 261. doi:10.1001/jamapsychiatry.2020.3650. Plakun E. (2006). A view from Riggs—treatment resistance and patient authority: I. A psychodynamic perspective on treatment resistance. The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 34, 349–366. doi:10.1521/jaap.2006.34.2.349. Shapiro E. (2009). A view from Riggs: Treatment Resistance and patient authority—XII. examined living: A psychodynamic treatment system. The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 37, 683–698. doi:10.1521/jaap.2009.37.4.683. Silvio JR, Condemarín R. Psychodynamic psychiatrists and Psychopharmacology. The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry (2011) 39:27–40. doi:10.1521/jaap.2011.39.1.27 Li TC, Psychodynamic aspects of Psychopharmacology. The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry (2010) 38:655–674. doi:10.1521/jaap.2010.38.4.655 Martin DJ, Garske JP, Davis MK. Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology (2000) 68:438–450. doi:10.1037/0022-006x.68.3.438 Riba MB, Balon R, Roberts LW. Competency in combining pharmacotherapy and psychotherapy: Integrated and split treatment. Arlington, VA: American Psychiatric Association Publishing (2018). Karyotaki E, Smit Y, Holdt Henningsen K, Huibers MJH, Robays J, de Beurs D, Cuijpers P. Combining pharmacotherapy and psychotherapy or monotherapy for major depression? A meta-analysis on the long-term effects. Journal of Affective Disorders (2016) 194:144–152. doi:10.1016/j.jad.2016.01.036 Forrest DV. Elements of dynamics II: Psychodynamic prescribing. The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry (2004) 32:359–380. doi:10.1521/jaap.32.2.359.35271 Horvath A. (2000). The therapeutic relationship: From transference to alliance. Journal of Clinical Psychology 56, 163–173. doi:10.1002/(sici)1097-4679(200002)56:2<163::aid-jclp3>3.0.co;2-d. Marcus ER. Transference and countertransference to medication and its implications for ego function. The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry (2007) 35:211–218. doi:10.1521/jaap.2007.35.2.211 Gabbard GO. The role of countertransference in contemporary psychiatric treatment. World Psychiatry (2020) 19:243–244. doi:10.1002/wps.20746 Stuhec M, Zorjan K. Clinical pharmacist interventions in ambulatory psychogeriatric patients with excessive polypharmacy. Sci Rep 12, 11387 (2022). https://doi.org/10.1038/s41598-022-15657-x Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4014218","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":277446697,"identity":"df195166-34eb-469a-a5c7-c101268531b5","order_by":0,"name":"Alexander Baur","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYDACdgYGZhDNxt5+8AGQ5uEjqIUZqoWP50yyAUgLG9Fa5CQSzCTA1hHSwd/MfEy6oOZwPhtDQlrl1xw7GTYG5oePbuDRInGYLdl4xrHDlm0MB4/dlt2WDHQYm7FxDj5rDvMYPuZhO2zAxtiQdltyGzNQCw+bND4t8of5Pxzm+QfUwsxgViy5rZ6wFoPDPIyPeduAWtgYzBg/bjtMWIvhYaDLZ/alG7Dx8CRLM247zsPGTMAvcsebn0kXfLM2kJ///ODHn9uq7fnZmx8+xut9ZMDMAyaJVQ4CjD9IUT0KRsEoGAUjBgAAji4/GWx6XboAAAAASUVORK5CYII=","orcid":"","institution":"Liberty University College of Osteopathic Medicine","correspondingAuthor":true,"prefix":"","firstName":"Alexander","middleName":"","lastName":"Baur","suffix":""},{"id":277446698,"identity":"eb3c4f9a-85a2-4842-af2e-b6b3c279de4b","order_by":1,"name":"Leslie Kryzanoski","email":"","orcid":"","institution":"VBPC","correspondingAuthor":false,"prefix":"","firstName":"Leslie","middleName":"","lastName":"Kryzanoski","suffix":""}],"badges":[],"createdAt":"2024-03-04 19:49:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4014218/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4014218/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":52542226,"identity":"37e97d9d-dec2-4adc-af66-96c44ff0d26f","added_by":"auto","created_at":"2024-03-12 17:39:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":17383309,"visible":true,"origin":"","legend":"\u003cp\u003eMedication history and response\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4014218/v1/d6ad2566446c6a2b34b875f2.png"},{"id":52542224,"identity":"49f5e968-21d7-486f-9550-abcba7aeaf57","added_by":"auto","created_at":"2024-03-12 17:39:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":161686,"visible":true,"origin":"","legend":"\u003cp\u003eSummarized hospital course\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4014218/v1/98092a6ad8be15c0b475f647.png"},{"id":60466776,"identity":"786095bd-d9ea-42f2-bfc6-a3a2f8d89fb5","added_by":"auto","created_at":"2024-07-17 05:33:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":18884582,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4014218/v1/774fae73-c232-46bf-bc5b-e8b0ad178566.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Psychodynamic Insights into Treatment-Resistance: A Case Study Exploring Patient-Physician Dynamics and the Impact of Counter-Transference on Adherence to Evidence-Based Practices","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn an era where an increasing number of individuals grappling with depression and anxiety seek solace in pharmacologic treatment, the inevitability of encountering treatment resistance looms large. While some cases simply necessitate judicious adjustments to medications, leading to eventual stabilization, a unique subset of patients exhibit resistance due to psychodynamic aspects rather than the medications themselves. Unraveling the complexities of this resistance unveils a critical need to bridge the gap between the biologic psychiatry mindset and the psychoanalytical approach.\u003c/p\u003e\n\u003cp\u003eBeyond the conventional realm of pharmacological considerations, these instances demand a nuanced exploration of underlying causes contributing to treatment resistance. The challenge intensifies when patients exploit physician emotions through counter-transference and dictate treatment. Delving deeper into this realm becomes imperative as it may reveal intricate therapeutic relationship dynamics, such as patients unconsciously transferring their anger to the physician, thereby undermining the prescribed treatment regimen.\u003c/p\u003e\n\u003cp\u003eThe literature widely recognizes the advantages of combining pharmacotherapy and psychotherapy to optimize treatment outcomes. Most recently illustrated by Guidi and Fava in a meta-analysis published in JAMA Psychiatry in 2021 (1). Going a step further, Shapiro and Plakun, were pioneers in using psychoanalytical dimensions to optimize pharmacologic treatment (2,3)\u003c/p\u003e\n\u003cp\u003eThis case report centers on a patient displaying elevated resistance to conventional psychotropic medications, empowering them to influence treatment decisions and deviate from traditional evidence-based approaches. Specifically, the report delves into the influence of transference on physician confidence, highlighting the significance of a physician\u0026apos;s assurance in effectively managing challenging patients. Maintaining confidence is essential as it prevents the patient\u0026apos;s subconscious emotions from unintentionally steering the course of treatment, underscoring the need for a mindful and informed approach in such therapeutic scenarios.\u003c/p\u003e"},{"header":"Patient information","content":"\u003cp\u003eThis case involves a 45-year-old married woman, currently unemployed, residing with her husband and children. She voluntarily admitted herself to a psychiatric hospital following presentation at a nearby emergency room, where she reported symptoms of anxiety and vague suicidal ideation. Of particular concern to the patient was her severely disrupted sleep, despite an extensive medication regimen. The patient met criteria for admission due to her suicidal ideation. The goal of inpatient treatment was to ensure patient safety and control the suicidal thoughts. Additionally, the patient will benefit from the extensive behavioral therapy.\u003c/p\u003e\n\u003cp\u003eAlong with the suicidal thoughts, the patient reported generalized anxiety and occasional panic attacks marked by chest tightness. She reported an extensive history of insomnia due to the anxiety. However, she denied other panic attack symptoms such as shortness of breath, palpitations, a sense of doom, or tingling in her hands.\u003c/p\u003e\n\u003cp\u003eThe patient revealed a history of a traumatic childhood experience, which originated from her mother being diagnosed with ALS when she was 11 years old. This proved particularly challenging as her mother, a pediatric nurse, served as the primary caregiver, while her father, a surgeon, was predominantly focused on his career. The subsequent deterioration and eventual passing of her mother during the patient\u0026apos;s senior year of college had a profound impact, leading to ongoing difficulties in fully comprehending and coping with this loss. Notably, there were no reports of emotional, physical, or sexual abuse, and the patient denied experiencing symptoms commonly associated with PTSD, such as nightmares or flashbacks.\u003c/p\u003e\n\u003cp\u003eFurther exploration revealed a prolonged struggle with mental health challenges. While the patient experienced multiple traumatic events during childhood, she did not pursue mental health treatment until age 30. From the age of 30 until 44, the patient was consistently treated for anxiety and depression. The treatment during this 14 year period was self-reported as \u0026ldquo;fairly consistent\u0026rdquo;. The patient did report occasional changes in the specific SSRI and SNRI during this time. The full list of medications the patient has tried is illustrated in figure 1. Before the age of 44 the patient found the most consistent benefit with paroxetine.\u003c/p\u003e\n\u003cp\u003eApproximately a year ago, the patient was hospitalized for suicidal ideation. In the months leading up to this hospitalization, the patient found her medication regimen to be much less helpful. During the hospitalization she was stabilized and advised that her response to medications may change during the perimenopausal timeframe. In addition, the patient underwent psychological testing during this hospitalization and the patient was formally diagnosed with Cluster B personality disorder with features of borderline and histrionic personality. Once discharged from the hospital she underwent nearly a year of intensive outpatient therapy without improvement. Of note, her outpatient therapy seemed to largely revolve around medication management rather than psychotherapy. The patient reported seeing her psychiatrist extensively over the past year. She was never able to go more than 6 weeks without an appointment to change the medication regimen. When asked about her experience with therapy the patient was largely dismissive. On review of the last discharge, it was advised for her to complete a partial hospitalization program where she would have had group and individual therapy every weekday for 2 weeks. However, the patient refused and would only agree to seeing a therapist weekly. When questioned about her experience with this therapy, the patient was dismissive stating that she \u0026ldquo;tried for months and it did nothing\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003eThis case report will focus on the patients medication management over the last 18 months which has been extremely unstable. Specifically, her anxiety and insomnia have not been controlled. In addition to lack of clinical improvement, the patient has been dependent on benzodiazepines multiple times.\u003c/p\u003e\n\u003cp\u003eHer outpatient provider, seemed to be at a loss after 12 months of medications changes many of which were trials that did not follow evidence based practices. Consequently, she was referred to a specialist on treatment resistance in the area. Before the appointment with the specialist, the patient felt extremely helpless and presented in the emergency room. In the ER, she was given Ativan for her anxiety and helplessness, but reported that this \u0026ldquo;made everything worse\u0026rdquo;. When questioned further, she was not able to describe how the lorazepam worsened her symptoms other than just repeating \u0026ldquo;it made me more anxious\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003eDuring discussions about treatment options, the patient\u0026apos;s history of non-adherence to medication regimens since her previous hospitalization emerged. A common pattern of dictating treatment and switching drugs emerged. \u0026nbsp;\u003c/p\u003e"},{"header":"Diagnostic assessment","content":"\u003cp\u003eUpon admission, the patient underwent a physical examination by a medical doctor and was diagnosed with hypertension and GERD. The patient was found to be adequately managed and advised to continue outpatient management. The patient also had labs performed which included CBC, CMP, thyroid panel, lipid panel, and vit D. The patient had slightly elevated lipid levels but did not warrant medication at this time. The patient was also found to be deficient in vitamin D with a level of 20.7. The patient was started on vitamin D replacement. All other labs were found to be within normal limits.\u003c/p\u003e\n\u003cp\u003eThe patient\u0026rsquo;s previous psychological testing was reviewed from the previous hospitalization. The diagnosis made at the time based on the DSM-5 criteria were generalized anxiety disorder, panic disorder, major depressive disorder recurrent severe without psychosis, benzodiazepine use disorder moderate, and cluster B personality disorder with features of borderline and historionic personality.\u003c/p\u003e\n\u003cp\u003eThe patient was evaluated on admission by a psychiatrist who found her admitting diagnoses to be generalized anxiety disorder, major depressive disorder recurrent moderate without psychosis, and benzodiazepine use disorder moderate The history of cluster B personality disorder and panic disorder were still present but not apparent in the initial interview.\u003c/p\u003e\n\u003cp\u003eAfter further evaluating the patient daily throughout the hospitalization, the diagnosis of cluster B personality disorder was much more apparent with borderline features such as splitting. The benzodiazepine use was found to be severe rather than moderate.\u003c/p\u003e\n\u003cp\u003eThe prognosis after a week of inpatient treatment was extremely poor due to the patient\u0026rsquo;s poor insight and lack of compliance. More specifically, the resistance to individual psychotherapy was a large barrier to successful treatment.\u003c/p\u003e"},{"header":"Hospital Course","content":"\u003cp\u003eThe objective of inpatient treatment was to stabilize the patient, address suicidal ideations, and alleviate feelings of helplessness. Additionally, hospitalization aimed to reduce acute symptoms and provide guidance for her subsequent outpatient care. Noteworthy, due to her extensive psychiatric history the prognosis of completely resolving her symptoms during this hospitalization was poor.\u003c/p\u003e\n\u003cp\u003eThe patient\u0026apos;s history of psychotropic medication trials, meticulously documented in Figure 1, guided the selection of the most appropriate regimen. Considering her previous responses and adhering to evidence-based practice, imipramine, gabapentin, and mirtazapine were deemed suitable.\u003c/p\u003e\n\u003cp\u003eDaily interactions with the patient primarily revolved around medication discussions. The patient consistently expressed dissatisfaction and pressured the physician for changes well before the therapeutic benefits could be thoroughly assessed. This persistent push for alterations is reflected in Figure 2, illustrating extensive deviations from standard clinical practice. Subsequently, the patient was exposed to much more side effects than if a consistent medication regimen had been properly adhered to.\u003c/p\u003e\n\u003cp\u003eThe therapeutic relationship and physician behavior, particularly countertransference, are clear during this hospitalization. A psychoanalytic interview revealed a difficult upbringing contributing to a personality disorder and medication resistance, emphasizing unresolved anger towards her absent father who was a physician and suppressed memories.\u003c/p\u003e\n\u003cp\u003ePost-interview, it was clear that true psychoanalysis would benefit the patient however she resisted and continued to focus on medications. On the 8th day, a suitable long-term inpatient facility was found, emphasizing psychotherapy. Despite some progress and the physician identifying what the patient truly needed, the patient sought another doctor, resumed Klonopin, and refused the medications that had contributed to her slight improvement. The weak therapeutic relationship is detrimental in this case because the physician was not able to provide the best care for this patient. Over the week there were slight improvements, but the patient\u0026apos;s self-sabotaging behavior ultimately was not able to be overcome.\u003c/p\u003e\n\u003cp\u003eThe course of treatment underscores the interplay of psychotropic medications, patient autonomy, and the therapeutic relationship. Comprehensive approaches considering both pharmacological and psychoanalytical dimensions are crucial. The patient\u0026apos;s recovery ultimately hinges on securing proficient professionals who guide treatment confidently, avoiding patient-driven decisions for successful outcomes.\u003c/p\u003e\n\u003cp\u003eThis highlights the necessity for a comprehensive approach that takes into account physician emotions in medication management. The extensive medication changes illustrated in Figure 2 show how the patient dictated treatment and deviated from standard practice. This unique situation shows how a lack of continuity in care can be detrimental to treatment.\u003c/p\u003e"},{"header":"Follow-up and Outcomes","content":"\u003cp\u003eThroughout the hospitalization, the patient displayed poor adherence and tolerability to medications. Multiple adverse events, including severe suicidal ideation and dissatisfaction with the psychiatrist, were reported. Despite a week of inpatient management and numerous medication changes, the patient\u0026apos;s symptoms remained largely unchanged. Clinical improvement was minimal, and the prognosis for this patient is deemed extremely unfavorable due to lack of insight, poor judgment, and resistance to psychotherapy. The weak therapeutic relationship and excessive polypharmacy, not following evidence-based guidelines, contributed to the overall poor outcomes. The patient\u0026apos;s resistance to treatment and the impact of physician emotions on decision-making are evident in this challenging case.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case report underscores the profound influence of physician emotions on medication management. In an ideal scenario, physicians should make decisions impartially, but a lack of confidence may lead them toward the path of least resistance, jeopardizing the best interests of the patient. Straying from evidence-based clinical practices exposes patients to considerable side effects without apparent benefits, as highlighted by the significant adverse effects our patient encountered during hospitalization. A nuanced comprehension of the patient-physician relationship is essential for adeptly addressing challenging cases characterized by treatment resistance.\u003c/p\u003e\n\u003cp\u003eOne noteworthy takeaway from this case report, with direct clinical relevance, underscores the importance of a resilient physician who acknowledges their own emotions and avoids yielding to the patient\u0026apos;s preferences. Furthermore, maintaining continuity in care is imperative for this particular subset of patients. Given the complexity of their psychiatric history and underlying symptoms, a substantial amount of time is required to gain a comprehensive understanding and provide optimal treatment.\u003c/p\u003e\n\u003cp\u003eThis specific scenario aligns with the literature on the psychodynamics of psychopharmacology. The paper by Silvio and Condemarin explore how over the past 20 years there has been an increase focus on the psychodynamics of pharmacology itself (4). In their paper, they recognize the importance of interpersonal factors in patient compliance and ultimate success. A similar study by Li confirmed the importance of being mindful of psychodynamic factors and utilizing dialectics in clinical practice (5).\u003c/p\u003e\n\u003cp\u003eA common theme within the realm of psychodynamics of psychopharmacology is the therapeutic alliance. This is a concept that has been researched extensively and is agreed to be integral in the success of treatment. The meta-analysis by Martin et al in 2000, showed the significance of a positive therapeutic relationship (6). Taking these concepts and applying them into clinical practice can be a challenge. The book by Reba and Balon focuses on combining pharmacotherapy and psychotherapy (7). They emphasize the importance of a comprehensive initial diagnostic assessment. In practice, a comprehensive assessment can be extremely challenging when patients are resistant as in our case report. The concepts in their book were confirmed by the meta-analysis performed by Karyotaki et al in 2016 (8). Nonetheless, it is important to still understand the psychodynamic aspects even if psychotherapy is not an option for treatment. For example, Forrest talks about how being aware of certain character styles can improve the therapeutic alliance and medication regimen (9).\u003c/p\u003e\n\u003cp\u003eWe can delve deeper into the specific nuances that contributed to the poor therapeutic relationship in our case report. Our patient utilized transference as a coping mechanism for the subconscious deep-seated anger towards her father, coincidentally a physician. Multiple physicians proceeded to deviate from traditional practice and made excessive medication changes. We believe these excessive medication changes were related to the physician feeling helpless themselves due to counter-transference.\u003c/p\u003e\n\u003cp\u003eTransference, initially introduced by Freud and further developed by Carl Rogers, has evolved into the contemporary concept of the therapeutic alliance. A comprehensive review of transference by Horvath in 2000 explores its current implications in clinical practice (10). The primary takeaway emphasizes the critical importance of identifying transference early in the therapeutic relationship and recognizing the collaborative framework\u0026apos;s significance in determining the most effective therapy. Similar papers by Marcus in 2007 and Gabbard in 2020 echoed many of the same concepts but delved deeper into how physicians should use their emotions to better understand their patient\u0026rsquo;s subconscious (11, 12). The paper by Marcus specifically explored the transference and counter-transference related to medications. He concluded that both of these \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;ego defenses are highly specific diagnostic indicators (11). While this case report was not successful in treating the patient, the identification of counter-transference was used to understand the underlying emotions and create a plan for a future physician to follow. This unique case underscores the impact of subconscious emotions on the success of treatment in patients with underlying personality disorders.\u003c/p\u003e\n\u003cp\u003eOur case report emphasizes the significance of seamlessly integrating psychoanalytical and pharmacological perspectives. While using a patients transference and the phsyicians counter-transference as a diagnostic tool is helpful, we looked to use these concepts to optimize the pharmacological treatment as well. To understand how to apply these concepts to management we can draw upon \u0026quot;A View from Riggs\u0026quot; publication series, particularly focusing on the psychodynamic approach to understanding treatment resistance. In Plakun\u0026apos;s foundational paper, he underscores the necessity of tolerating negative transference as a frequent component associated with treatment resistance (2). Plakun argues that recognizing the provider\u0026apos;s own negative emotions in countertransference is crucial. Furthermore, the paper highlights the importance of not relinquishing authority to the patient, emphasizing the need for maintaining control over treatment strategies and admission terms.\u003c/p\u003e\n\u003cp\u003eIn another publication from the same series, Shapiro delves into the dynamics of the patient\u0026apos;s living situation and authority (3). The paper highlights the risk of physicians adhering solely to the current treatment paradigm, neglecting the individual\u0026apos;s personality and psyche. Without a comprehensive psychological understanding, biological interventions offer limited benefits. For these patients, resistance to treatment may not only be a reenactment of painful experiences but also a mode of communication. Their resistance may be a coping mechanism for suppressed anger, allowing them to assert control over providers they deem untrustworthy.\u003c/p\u003e\n\u003cp\u003eBoth our case report and the \u0026quot;A View from Riggs\u0026quot; publication series exemplify how recognizing individuals\u0026apos; subconscious psychodynamics can transform physicians into competent allies, leading to a shift in their own perspectives.\u003c/p\u003e\n\u003cp\u003eOur case report highlights the inherent challenges in managing patients with complex medical conditions. When a therapeutic alliance is weak, the repercussions of excessive polypharmacy become particularly pronounced. In such instances, clinical pharmacologists play a pivotal role as a crucial safeguard. The study conducted by Stuhec and Zorjan underscores the significance of an external perspective in evaluating reported benefits and clinical relevance within a specified timeframe (13).\u003c/p\u003e\n\u003cp\u003eClinical pharmacists, as demonstrated in their interventions with ambulatory psychogeriatric patients, contribute valuable insights to the decision-making process. Their specialized knowledge enables a more comprehensive and well-informed approach to combining different medications (13). This collaborative strategy not only adds an additional layer of scrutiny to medication choices but also serves to counterbalance the potential influence of physician emotions on decision-making. The outcome is a more objective and patient-centered approach to care.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, the optimal care for challenging cases necessitates the integration of psychopharmacological and psychoanalytical perspectives. Recognizing and addressing transference and unresolved anger early in the therapeutic relationship are crucial components that underscore the active role of patients in influencing treatment decisions. To mitigate variance from evidence-based practice, physicians must confidently navigate these dynamics. A strong therapeutic relationship and a multidisciplinary approach are pivotal for the proper management of these unique patients. Therefore, adopting a holistic approach that considers both pharmacological and psychoanalytical dimensions is essential for ensuring comprehensive and effective care in challenging cases.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe informed consent procedure for this case report commenced with the healthcare professional approaching the patient, acknowledging them by their name and date of birth. A comprehensive explanation of the report\u0026apos;s purpose, content, and potential implications was provided to the patient. Emphasis was placed on the voluntary nature of participation, ensuring the patient understood that their decision would not affect their medical care. Discussions encompassed protective measures for anonymity, potential impacts on the scientific community, and the opportunity for the patient to seek clarification by asking questions.\u003c/p\u003e\n\u003cp\u003eThe patient\u0026apos;s comprehension and agreement were meticulously documented, and contact information was furnished for any subsequent inquiries or withdrawal of consent. This approach was employed to uphold ethical standards in obtaining informed consent for participation in the case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUpon completion of the case report, the patient was given the opportunity to examine the comprehensive document. Subsequent to review, they expressed consent for the publication of the final case report in an open-access journal, including any identifiable information present in the manuscript and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting this case report are available upon request, subject to Institutional Review Board (IRB) approval. Requests for data access should be directed to the corresponding author at \u003ca href=\"mailto:[email protected]\"\[email protected]\u003c/a\u003e. Data will be de-identified to ensure patient privacy. Access is granted for research purposes only, pending IRB approval and compliance with ethical guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case report was conducted without receiving any external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are no conflicts of interest to disclose in relation to the case report.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eGuidi J, and Fav G. (2021). Sequential combination of pharmacotherapy and psychotherapy in major depressive disorder. JAMA Psychiatry 78, 261. doi:10.1001/jamapsychiatry.2020.3650.\u003c/li\u003e\n \u003cli\u003ePlakun E. (2006). A view from Riggs\u0026mdash;treatment resistance and patient authority: I. A psychodynamic perspective on treatment resistance. The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 34, 349\u0026ndash;366. doi:10.1521/jaap.2006.34.2.349.\u003c/li\u003e\n \u003cli\u003eShapiro E. (2009). A view from Riggs: Treatment Resistance and patient authority\u0026mdash;XII. examined living: A psychodynamic treatment system. The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 37, 683\u0026ndash;698. doi:10.1521/jaap.2009.37.4.683.\u003c/li\u003e\n \u003cli\u003eSilvio JR, Condemar\u0026iacute;n R. Psychodynamic psychiatrists and Psychopharmacology. The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry (2011) 39:27\u0026ndash;40. doi:10.1521/jaap.2011.39.1.27\u003c/li\u003e\n \u003cli\u003eLi TC, Psychodynamic aspects of Psychopharmacology. The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry (2010) 38:655\u0026ndash;674. doi:10.1521/jaap.2010.38.4.655\u003c/li\u003e\n \u003cli\u003eMartin DJ, Garske JP, Davis MK. Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology (2000) 68:438\u0026ndash;450. doi:10.1037/0022-006x.68.3.438\u003c/li\u003e\n \u003cli\u003eRiba MB, Balon R, Roberts LW. Competency in combining pharmacotherapy and psychotherapy: Integrated and split treatment. Arlington, VA: American Psychiatric Association Publishing (2018).\u003c/li\u003e\n \u003cli\u003eKaryotaki E, Smit Y, Holdt Henningsen K, Huibers MJH, Robays J, de Beurs D, Cuijpers P. Combining pharmacotherapy and psychotherapy or monotherapy for major depression? A meta-analysis on the long-term effects. Journal of Affective Disorders (2016) 194:144\u0026ndash;152. doi:10.1016/j.jad.2016.01.036\u003c/li\u003e\n \u003cli\u003eForrest DV. Elements of dynamics II: Psychodynamic prescribing. The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry (2004) 32:359\u0026ndash;380. doi:10.1521/jaap.32.2.359.35271\u003c/li\u003e\n \u003cli\u003eHorvath A. (2000). The therapeutic relationship: From transference to alliance. Journal of Clinical Psychology 56, 163\u0026ndash;173. doi:10.1002/(sici)1097-4679(200002)56:2\u0026amp;amp;lt;163::aid-jclp3\u0026amp;amp;gt;3.0.co;2-d.\u003c/li\u003e\n \u003cli\u003eMarcus ER. Transference and countertransference to medication and its implications for ego function. The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry (2007) 35:211\u0026ndash;218. doi:10.1521/jaap.2007.35.2.211\u003c/li\u003e\n \u003cli\u003eGabbard GO. The role of countertransference in contemporary psychiatric treatment. World Psychiatry (2020) 19:243\u0026ndash;244. doi:10.1002/wps.20746\u003c/li\u003e\n \u003cli\u003eStuhec M, Zorjan K. Clinical pharmacist interventions in ambulatory psychogeriatric patients with excessive polypharmacy. \u003cem\u003eSci Rep\u003c/em\u003e 12, 11387 (2022). https://doi.org/10.1038/s41598-022-15657-x\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Treatment resistance, transference, psychotherapy, personality disorders, psychoanalysis, insomnia, depression, anxiety","lastPublishedDoi":"10.21203/rs.3.rs-4014218/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4014218/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePharmacological resistance poses a significant challenge for individuals with severe recurrent mood or anxiety disorders in the evolving landscape of biological psychiatry. This case report explores the decision-making process physicians undergo when treating patients resistant to traditional therapies, particularly those with underlying personality disorders.\u003c/p\u003e\n\u003cp\u003eThe patient in focus underwent extensive treatment with antidepressants, antipsychotics, mood stabilizers, anxiolytics, and hypnotics. This journey sheds light on the multifaceted nature of treatment resistance, emphasizing the active role of patients in influencing and occasionally sabotaging their treatment.\u003c/p\u003e\n\u003cp\u003eThe report highlights the delicate balance between minor medication adjustments and a departure from established clinical practices. The pivotal role of the patient-physician relationship is emphasized, with a specific focus on identifying and addressing the patient's past feelings of anger towards physicians as a contributing factor.\u003c/p\u003e\n\u003cp\u003eFailure to recognize this dynamic can result in physician frustration and a sense of helplessness. The exploration also stresses the importance of understanding physician emotions in managing medications for challenging patients.\u003c/p\u003e\n\u003cp\u003eBy uncovering the underlying causes of treatment resistance in this case, the physician's confidence improved, enabling a more beneficial course for the patient. However, a lack of continuity and a weak therapeutic relationship led to treatment failure in this instance.\u003c/p\u003e\n\u003cp\u003eIn conclusion, this case underscores the critical importance of identifying factors contributing to treatment resistance to disrupt the cyclical pattern of medication changes. Both patient and physician emotions significantly influence deviations from clinical practice. The narrative emphasizes the value of psychodynamic understanding in addressing these challenges, facilitating a more comprehensive and effective approach to patient care.\u003c/p\u003e","manuscriptTitle":"Psychodynamic Insights into Treatment-Resistance: A Case Study Exploring Patient-Physician Dynamics and the Impact of Counter-Transference on Adherence to Evidence-Based Practices","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-12 17:39:37","doi":"10.21203/rs.3.rs-4014218/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9a5e73f2-3b64-4a98-8466-47bda7469666","owner":[],"postedDate":"March 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-17T05:08:53+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-12 17:39:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4014218","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4014218","identity":"rs-4014218","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}