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This paper sets out a falsifiable Relational Affective Hypothesis, describing a neurological and relational pathway, through which affect and sensations arising from the interior of the body are translated, in a relational context, into language and a capacity for symbolisation. It describes the role of psychodynamic defences in narcissistic disorder, which can result in collapse in the function of this pathway. The hypothesis arose from clinical psychodynamic work with patients with severe and complex narcissistic disorders. They are characterised as severe, because they are at high risk of completed suicide and so are commonly treated in locked units, and complex because of their anorexic and bulimic eating patterns, tendency towards somatisation and the co-occurrence of autistic difficulties. A more or less profound failure of symbolisation is a feature common to these presentations. This interdisciplinary thinking offers a perspective on brain and psychological development, taking into account the complex interplay between genetic, environmental, relational and dynamic influences. It can be tested empirically and has implications for psychoanalytic thinking, psychiatry and neuroscience. [ABSTRACT FROM AUTHOR]

This paper introduces a Relational Affective Formulation of severe narcissistic and borderline disorders. The formulation is grounded in psychoanalytic and neuroscientific theory, clinical observation and therapeutic work with hospitalised patients. It provides a conceptual framework for psychodynamic psychiatrists, therapists and psychosocial practitioners working in teams. Paying particular attention to the central place of affect, projective and introjective processes, claustro-agoraphobic phenomena, regression and the place of both deficits and dynamic defences in the failure of symbolisation, the case is made that this framework is suited to therapeutic work with patients who are highly suicidal and complex. The application of this formulation to service design and treatment pathways is described along with a summary of the body of psychoanalytic thinking which contributed to its development. The formulation is the cornerstone of a practice guide currently under development. [ABSTRACT FROM AUTHOR]