Kok Han Ang

Institute of Mental Health, Singapore

A Psychodynamic Case Formulation: An Object-Relational and Trauma-Focused Perspective on Disorganised Attachment

---

Biography

Dr. Ang Kok Han is a Senior Resident in Psychiatry at the Institute of Mental Health, Singapore. He graduated from Barts & the London School of Medicine and Dentistry in London, and has presented at multiple international conferences in the field of consultation liaison psychiatry. He is currently developing his interest in forensic psychiatry at IMH and is serving as the Chief Resident for the National Healthcare Group Psychiatry Residency Programme. 

Abstract

Objective: This case report illustrates the use of psychodynamic formulation, grounded in object relations theory, to understand and guide treatment of an adult presenting with pervasive emptiness and relational instability rooted in complex developmental trauma.

Methods: A single case study of “S,” a woman in her mid-twenties, was developed from twelve weekly sessions of outpatient psychodynamic psychotherapy. Formulation was derived from clinical interview material, with attention to history, defences, and the transference-countertransference field. Informed consent was obtained and identifying details anonymised.

Results: S presented with depressed mood, emotional numbness, disordered eating, and a chronic sense of “emptiness,” against a background of inconsistent and abusive parenting, sibling differential treatment, maternal disappearance in infancy, and three episodes of non-consensual sexual contact. Her presentation was consistent with disorganised attachment, characterised by identification with the aggressor, splitting, projective identification, and humour as an immature defence against affect. Tattoos emerged as symbolic markers of permanence and longed-for constancy. Within the therapeutic relationship, a “push-pull” dynamic re-enacted her early relational patterns, complicated by transference related to her history of disappointment with male figures. Green’s “dead mother complex” offered a useful lens for her chronic emptiness. Therapy ended abruptly due to a change in S’s employment, before deeper trauma material could be fully processed.

Conclusion: This case demonstrates how object-relational and trauma-focused formulation can illuminate the origins and function of disorganised attachment patterns, even within a brief and prematurely terminated treatment. It underscores the clinical importance of a consistent, containing therapeutic frame and patience in building trust with trauma-exposed, avoidantly attached patients.