Revisiting Anna O.: a case of chemical dependence

The famous clinical case of Anna O./Bertha Pappenheim, who was treated by Breuer from 1880 to 1882 and whose pathology was discussed by him and Freud in an 1895 article (J. Breuer & S. Freud, 1895/1955), is reviewed based on biographical information regarding the patient, which appeared from 1953 onward. The objective of this article is to show that, in order to better understand the case, the diagnosis of chloral hydrate and morphine dependence, as well as that of mood disorder (primary or drug induced), has to be taken into account. The method used is a careful literature review. The conclusion is that, based on all available data disclosed in recent years, these 3 diagnoses should be considered in this case, which is the most studied one in the history of psychoanalysis.     

Changes in the level and quality of object relations in psychoanalysis: followup of a longitudinal, prospective study

As part of a prospective, longitudinal study of suitability for and outcome of psychoanalysis, 22 patients were evaluated for changes in the level and quality of their object relations. These patients had been accepted for supervised analysis with candidates in training by senior analysts who had diagnosed them as neurotic. The majority of these patients reported difficulties in relationships as at least one of their reasons for originally seeking psychoanalytic treatment. Prior to beginning analysis, each patient was given a battery of psychological tests. One year after the termination of analysis, the test battery was readministered and a followup interview was conducted separately with each patient and analyst. Ratings of change based on patient and analyst interviews and comparisons of psychological tests before and after treatment all showed statistically significant improvement in the level and quality of object relations for this patient group. The results of this study support what is often observed in clinical practice, that psychoanalysis has a positive effect on the level and quality of a patient's object relations.     

Short-term psychodynamic intervention in an urban health clinic: A case report

This paper describes the application of short-term dynamic therapeutic techniques to treat both symptom disturbance and character pathology in an urban mental health clinic. Short-Term dynamic psychotherapy focuses extensively on the subjectivity and inner life of the patient with emphasis on repressed anger, sadness and desire. Methods to overcome patient ambivalence and resistance to psychotherapy are presented. The clinical psychodynamics associated with early life trauma are illustrated with a case of an African-American patient.Acknowledgments for support & critical feedback are expressed to Christine Baker, Ph.D., John Swanson, ACSW, Duncan Walton, Ph.D., and Isabelle Beveridge (Graphics).     

The shattered mirror: Treatment of a group of narcissistic patients

Increasingly, group psychotherapy takes its place as a valid treatment model for patients with severe character pathology. This paper explores the impact of group treatment on a homogeneous group of patients with narcissistic character problems. The clinical example serves to illustrate the particular dynamics of this patient population; addresses the challenges inherent in treating these patients in a homogeneous, long-term therapy group; and, finally, underscores the countertransference pitfalls in such a clinical situation. Nonetheless, the successful working through of some of these patients' terrifying pathology supports the important of continuing experience and research into this arena.The author wishes to acknowledge with gratitude the invaluable assistance of J. Scott Rutan, Ph.D., in the planning and preparation of this clinical report.     

Relationship between patient characteristics and treatment allocation for patients with personality disorders

Within a large multi-center study in patients with personality disorders, we investigated the relationship between patient characteristics and treatment allocation. Personality pathology, symptom distress, treatment history, motivational factors, and sociodemographics were measured at intake in 923 patients, who subsequently enrolled in short-term or long-term outpatient, day hospital, or inpatient psychotherapy for personality pathology. Logistic regressions were used to examine the predictors of allocation decisions. We found a moderate relationship (R(2) = 0.36) between patient characteristics and treatment setting, and a weak relationship (R(2) = 0.18) between patient characteristics and treatment duration. The most prominent predictors for setting were: symptom distress, cluster C personality pathology, level of identity integration, treatment history, motivation, and parental responsibility. For duration the most prominent predictor was age. We conclude from this study that, in addition to pathology and motivation factors, sociodemographics and treatment history are related to treatment allocation in clinical practice.     

Conservation Withdrawal vs. Depression in Medically Ill Patients: Rorschach Case Study

The psychological consultant in a general hospital may be asked to evaluate physically ill patients who present ambiguous clinical symptomatology. The differential diagnoses of depression from the normal (conservation-withdrawal) reaction to stress is particularly difficult. A case study is presented illustrating the Rorschach test findings of a patient who appeared depressed upon initial clinical examination, but who illustrates conservation-withdrawal, an adaptive nonpathological stress reaction.     

The effects of dropping in‐situation safety behaviors in the treatment of social phobia

Over the past years, important advances in the cognitive–behavioral treatment of social phobia have taken place. There is wide evidence that demonstrates exposure is an effective treatment for social phobia. However, some research has noticed that exposure has limitations in treating this disorder. In clinical practice we find patients who do not achieve marked reductions in anxiety using this technique. One of the mechanisms that can be involved is the use of in‐situation safety behaviors, which patients use to prevent the feared consequences in social situations. The aim of this study is to present a single case study where we compare the improvement achieved using exposure alone versus exposure dropping in‐situation safety behaviors. The social phobic patient improved significantly when exposure was combined with the drop of in‐situation safety behaviors. Copyright © 2003 John Wiley & Sons, Ltd.     

The name of the Piggle: Reconsidering Winnicott's classic case in light of some conversations with the adult ‘Gabrielle’

On the 40th anniversary of its publication, the author re‐reads Winnicott's The Piggle – a case of ‘on demand analysis’ with a child suffering from psychotic night terrors – in light of new information about the patient. Conversations between the author and ‘Gabrielle’ explore two areas not regarded as priorities by Winnicott: the transgenerational transmission of pathology/trauma, and the ways that language, in general – and given names, in particular – organize individual subjectivity. The question raised is to what degree Winnicott – who described the treatment as “psychoanalysis partagé [shared]” due to the parents’ involvement – thought of the pathology itself as ‘shared.’ The goal is not to supplant but to expand Winnicott's understanding of the case, borrowing insights from the work of Lacan and others.     

Supervision, transference and countertransference

The author discusses supervision, transference and countertransference as seen in the context of the clinical case of a patient who had been first seen as a training analysis case and who later, in a fortuitous way, was treated by the supervisor of the training analysis. The supervisor, who in the first instance did not recognize the patient, discusses the reasons for this unusual experience in terms of the presence and absence of transference during the analysis of this patient as a training case and the problems inherent in the task of supervising. The patient's feelings towards the first and the second analyst and the vicissitudes of transference and countertransference during the supervision of the training analysis and its influence on the presentation of the analytical sessions by the student are also detailed and discussed. The question of recorded supervision presentations and their possible influence on the dynamics of supervision is raised.     

The analyst's excitement in the analysis of perversion

The author believes that unconscious sexual excitement in the transference and countertransference is an especially problematic aspect of the analysis of perverse character pathology and that perverse sexual gratifi cation deserves a more prominent position in the clinical theory of analyzing perversion than that which has been assigned tacitly through analysts' routine focus on the defensive and destructive dynamics of perversion. He presents clinical material from the analysis of a perverse patient that illustrates the role of excitement in the transference perversion established in this analysis; and he asserts that gratifying perverse enactments occurring in the transference perversion can appear not only as conscious or unconscious excitement in the transference but also, at times most clearly, as the analyst's excitement. The author suggests that using a clinical theory that supports the analyst in understanding his excited responses as perverse countertransferences-i.e. evoked excitement complementary to the sexual component of a perverse transference-will assist him in locating and thinking about gratifying, perverse excitement in the transference where it is most usefully analyzed. Finally, he discusses some of the reasons why analysts might deny, suppress or otherwise avoid perverse countertransferences and in so doing contribute to sustaining perverse resistances.     

内隐学习策略的存在及其外显转化

该研究采用＂乘法算式答案正误判断的实验室任务＂,以＂奇偶检查策略＂为具体策略研究对象,探查内隐奇偶检查策略的存在及其自动性特征。实验结果表明：（1）奇偶检查策略可以以内隐方式存在,但经过不断练习可最终上升到意识层面;（2）奇偶检查策略的外显和内隐使用表现出各自独立的优势效应。外显学习策略的优势效应主要表现在正确算式判断任务中,而内隐学习策略则在错误算式判断任务中表现出＂内隐优势效应＂的趋势;（3）内隐奇偶检查策略的人为外显化并不能促使个体增加使用该策略的频率,也不能有效提高策略的执行效率。     

Change after long-term psychoanalytic psychotherapy

Psychoanalytic psychotherapy in clinical practice is traditionally a long-term treatment conducted by well-trained psychotherapists. However, very few studies have been published that evaluate the effects of such treatment. To redress this lack of studies, 55 individuals selected for long-term psychoanalytic psychotherapy (average, 3 years) were invited to participate in a naturalistic study. The psychotherapists had a mean of 15 years of professional experience. The 36 patients who completed psychotherapy manifested a substantial reduction in symptomatic suffering and decreased levels of character pathology, as measured by the Karolinska Psychodynamic Profile (KAPP) and the Karolinska Scales of Personality. Generally, such changes were not found in the individuals who did not engage in treatment. In the therapy group, improvements were found on eight KAPP subscales defining different aspects of character: Intimacy and Reciprocity, Frustration Tolerance, Regression in the Service of the Ego, Coping with Aggressive Affects, Conceptions of Bodily Appearance and their Significance for Self-esteem, Sexual Function, Sexual Satisfaction, and Personality Organization. The results indicate that individuals who engaged in psychotherapy improved their capacity to handle crucial aspects of life and reduced their symptomatic suffering.     

Idiopathic orthostatic hypotension]

The disease picture of idiopathic orthostatic hypotonia is described from a clinical and histological point of view with reference to a case treated by the present authors. The independent character of this particular ailment may be considered as resulting from the virtually uncontrollable orthostatic decreases in blood pressure in connection with the progressive disorders especially of the motor system. Also, the etiology is not yet fully understood.     

Changes in personality pathology after pharmacotherapy and combined therapy for depressed patients

The central question addressed by this article is whether courses of treatment consisting of pharmacotherapy or pharmacotherapy combined with psychotherapy (combined therapy) produce different changes in personality pathology at follow-up after 40 weeks. We also examined whether recovery from depression has an influence on outcome. The study population consisted of 128 outpatients in whom personality pathology and severity of depression were determined at the start of the study. For 72 patients, personality pathology and severity of depression were determined again after 40 weeks. Of the group of 72 patients, 25 patients received only pharmacotherapy for 6 months, and 47 patients received combined treatment (pharmacotherapy and psychodynamic supportive psychotherapy). The antidepressant protocol provides for three successive steps in case of intolerance or inefficacy: fluoxetine, amitriptyline, and moclobemide. The combined therapy condition consisted of 16 sessions of Short Psychodynamic Supportive Psychotherapy in addition to pharmacotherapy. In the combined therapy condition there was a significant reduction in personality pathology in patients who recovered from depression but also in patients who had not. In the pharmacotherapy condition the significant decrease was restricted to patients who recovered from depression. The results were most striking for Cluster C psychopatology. Patients with cluster B pathology changed the least. Depressed patients with comorbid personality pathology appear to benefit most from a combination of pharmacotherapy and a form of short, psychodynamic, supportive psychotherapy.     

Transference Focused Psychotherapy for Patients with Comorbid Narcissistic and Borderline Personality Disorder

Clinical experience involving the treatment of patients with comorbid borderline and narcissistic personality disorders suggests that this patient population is among the more difficult to treat within the personality disorder spectrum. In this article, we present refinements of Transference Focused Psychotherapy (TFP) based on our clinical experience with and research data on patients with comorbid narcissistic personality disorder/borderline personality disorder (NPD/BPD). We briefly review object relations formulations of severe narcissistic pathology, as well as recent research in attachment and the allied concept of mentalization, which have provided a new lens through which to view narcissistic disorders. The research findings from two randomized clinical trials demonstrating the efficacy and effectiveness of TFP are presented. The data from the two Randomized Clinical Trials (RCT) allowed for the study of the characteristics of the subgroup of borderline personality disorder patients who have comorbid NPD/BPD. Findings on comorbidity, attachment status, capacity for mentalization, and level of personality organization of borderline patients with comorbid NPD/BPD, compared with borderline patients without comorbid narcissistic pathology (BPD), are presented. Clinical implications of the observed group differences are discussed, with a focus on refinements in the technique of TFP. Clinical case material is presented to illustrate the specific challenges posed by narcissistic patients to carrying out TFP in each phase of treatment.     

Informed Consent Revisited: Japan and the U.S.

Informed consent, decision-making styles and the role of patient–physician relationships are imperative aspects of clinical medicine worldwide. We present the case of a 74-year-old woman afflicted with advanced liver cancer whose attending physician, per request of the family, did not inform her of her true diagnosis. In our analysis, we explore the differences in informed-consent styles between patients who hold an “independent” and “interdependent” construal of the self and then highlight the possible implications maintained by this position in the context of international clinical ethics. Finally, we discuss the need to reassess informed-consent styles suitable to the needs of each patient regardless of whether he or she resides in the United States or in Japan.     

Counseling Disruptive Black Elementary School Boys

The assignment was to counsel the 10 worst behaved boys at an inner-city elementary school. This case study illuminates the interplay between theory, practice, and values by describing effective techniques of intervention in a situation that reflects social pathology. Traditional African values and certain principles of character provide a set of reliable standards for improving behavior.     

Psychoanalytic identity and the external world: Interaction between psychoanalysis and health service systems in Sweden

Abstract

This paper continues the exploration of the clinical phenomenon of analytic contact. The author demonstrates, through case material, the essential ingredients of psychoanalysis to be not frequency or use of the couch, but rather the moment-to-moment analysis of the patient's transference state and phantasies of what it means to establish relational contact with their objects and with themselves. The nature of the treatment can be shaped, prevented, perverted, or fostered by the patient's phantasies and unconscious conflicts into something more analytic or less analytic. Interpretation needs to include the exploration of the patient's attempts to change the treatment into something that is often a replica or a repetition of archaic object relations. The typical patient in psychoanalytic treatment is struggling with rather profound pathology and as such tends to create a significant stand-off with the analyst when analytic contact is forming. Analytic contact is often threatening to these patients in very primitive and alarming ways that must be gradually understood and interpreted if the treatment is to survive and remain a primarily analytic journey rather than be transformed into a more supportive counseling or a pathological re-enactment of conflictual phantasy states.     

It only takes one psychologist to demonstrate the impact of psychological assessment

Evidence is needed in the field of psychological assessment of psychiatric patients to verify if test findings actually influence the clinical processes of diagnosis, treatment, case disposition, and outcome. Those who perform many assessments can conduct limited experiments to measure these effects. One such study is presented. It is a quasi-experiment in which the value of the psychologist's diagnostic recommendations to treating psychiatrists was measured. Diagnoses at admission, at subsequent psychological evaluation, and at discharge were compared among 70 patients referred to a clinical diplomate from the American Board of Professional Psychology (ABPP) for assessment. The psychiatrists who had referred the patient agreed with the psychologist's diagnosis in 94% of the cases. Agreement was high even when the psychologist had disagreed with the admitting psychiatrists' diagnoses. Despite imperfections in research design, the study demonstrates that solo practitioners can evaluate the impact of assessment. Other possibilities for study are presented, as are reasons for the significant findings of this study.