Commentary by a Psycho-Analyst

The therapist writes about a 16-year-old adolescent boy who has been in twice-weekly psychotherapy for a year. We are told that Paul presented with somatic symptoms: headaches and high blood pressure, for which no organic cause was found. These are relatively unusual psychosomatic symptoms in an adolescent, and suggest the possibility of early problems in affect regulation and the psychic representation of primitive affects. This links with what we are told about Paul's long-standing problems in controlling his aggression and rage; he is described as having very little internal control. He has also used drugs and alcohol to deal with unbearable affects. Though we know little about his infancy and early childhood, and so have little knowledge of his developmental history, the theme of expulsion, being pushed out too soon, a fundamental lack of a sense of containment, seems to be important in making sense of Paul's experience. I gained the impression that there was a lot of anxiety, overt and unacknowledged, in the family, due partly to the older sister's severe mental illness, and possibly the effects of father's immigration experience. Paul presents his parents as relatively unreliable and unpredictable; mother as over-indulgent and