Findings refute reducing CFS to somatization, but there is a subgroup of CFS whose lacking access to emotional distress is associated with heightened physical symptomatology.

Chronic fatigue syndrome (CFS) presents challenges in differential diagnosis and treatment. Complicating diagnosis is that its symptoms overlap with those of depression. This study applies psychoanalytic concepts to understand emotional regulation (ER) in women with CFS and/or depression. One hundred eighty-six women were assigned to four groups and compared: (a) CFS plus high er depression (CFS-HD); (b) CFS plus lower depression (CFS-LD); (c) depressive disorder (DD); and (d) healthy controls (HC). ER was operationalized by measures of capacity to form internal representations and adaptive defenses. The study’s premise was that difficulties metabolizing emotions psychologically would be associated with their greater somatic expression. Some support was found for the hypothesis that CFS participants would exhibit more impairment in representing emotions and in adaptive defenses compared to the DD and HC groups, but this held only for the CFS-HD group. Although CFS-LD participants were expected to be more purely somatizing than the CFS-HD group, they instead showed more sophisticated capacities for ER than that group and recalled less distressing early relationships, revealing more resilience. Still, however, we found support for somatization in some CFS sufferers: Within both the CFS-HD and the CFS-LD groups, weaknesses in representing emotions and in defensive functioning were associated with more severe physical symptoms. Clinically, the heterogeneity of CFS and those who suffer from it indicates the need for individual assessment and depression treatment.

Although emphasis on psychodynamic thinking has waned in assessment training, the ascendant Rorschach Performance Assessment System (R-PAS; Meyer et al., 2011) has reintegrated psychoanalytic concepts into empirical Rorschach assessment: R-PAS adds scores involving object relations, implicit dependency, aggressive ideation, and ego impairment. R-PAS has, however, excluded the psychodynamic framework for assessing ego involvement in the regulation of anxiety/dysphoria by eliminating the coding of Form Dominance in Shading and Achromatic Color (FDSHAC) that has been part of the Comprehensive System (Exner, 2003). This decision was based in part on concerns about efficiently and reliably coding distinctions among Form Dominant, Form Secondary, and Formless levels of FDSHAC. To establish that such distinctions can be coded reliably, we applied supplemental guidelines (Viglione, 2010) to evaluate reliability among four experienced assessors who coded determinants for 155 Rorschach responses, 115 of which required FDSHAC determination. Applying Gwet's AC2′s to ordinal scales, interrater reliabilities were good to excellent. Reliabilities were strongest for Form Dominance in Texture and Achromatic Color, modestly so for Form Dominance in Diffuse Shading, and problematic for Form Dominance of Vista. Among levels of Form involvement across FDSHAC variables, raters had the most difficulty distinguishing Form Secondary. We discuss considerations for clinical coding, psychodynamic configurational analyses for interpretation, and construct validation research.