Psychoanalytic theory and its relation to clinical work.

Freud's shift to the fantasy theory of neurosogenesis defined the investigation of intrapsychic life as our fundamental theoretical purview. In assigning to inner experience a data base for scientific exploration, there is reflected a central epistemological innovation which must profoundly alter the way we view what is real. This paper considers some of the continuing clinical challenges and far-reaching implications posed by this shift to "psychic reality" as our core psychoanalytic theory.     

Harmful dysfunction, disorder, disease, illness, and evolution.

Can psychiatric disorders be conceptualized as "harmful dysfunctions" (J. C. Wakefield, 1992a, 1992b, 1999; S. O. Lilienfeld & L. Marino, 1995)? Wakefield's (1992a) central concept of disorder as "harmful dysfunction" is discussed by placing it in the context of a complementary discussion of disease, illness, the sick role, and evolution (D. F. Klein, 1978). S. O. Lilienfeld and L. Marino (1995) contended that proper biological function cannot be determined. This argument obscures the key significance of involuntary impairment of evolved functions. The claim that the Roschian concept has no counterpart in reality is incorrect and does not support the conclusion that dysfunctions are irreducibly evaluative and therefore arbitrary. J. C. Wakefield's (1999) views in this area are supplemented. The role of monothetic and polythetic categorization, extremal terms, and the concept of normality in nosology is considered. This analysis refutes the implication that deviance and illness are equivalent. The resolution of this debate is practically relevant to emphasizing areas of research investment, such as therapeutics.     

Anxiety: the importunate companion. Psychoanalytic theory of castration and separation anxieties and implications for clinical technique

In this article I consider the implications of our differing psychoanalytic theories of anxiety on clinical technique. Drawing on differentiations between the focus on separation or castration anxiety and the relative neglect of the latter in contemporary writing, I look in detail at two clinical examples of psychoanalysis in borderline young adults to exemplify the issue. 1     

Assumptions in borderline personality disorder: specificity, stability and relationship with etiological factors.

The specificity and stability of a set of assumptions hypothesized to be characteristic of Borderline Personality Disorder (BPD) was investigated. BPD patients (n = 16) were compared to cluster-C personality disorder patients (n = 12) and to normal controls (n = 15). All subjects were female and diagnosed with SCID-I and -II. Subjects rated a short version of the Personality Disorder Beliefs Questionnaire (PDBQ), with six sets of 20 assumptions each, hypothesized to be characteristic of avoidant, dependent, obsessive-compulsive, paranoid, histrionic and borderline personality disorder. The BPD assumptions (Cronbach alpha = 0.95) proved to be the most specific to BPD patients. Subjects rated the shortened PDBQ again after viewing an emotional video fragment one week later. Despite increased negative emotions, the PDBQ ratings remained relatively stable. Confirming the cognitive hypothesis, regression analyses indicated that the BPD assumptions mediate the relationship between self-reported etiological factors from childhood (sexual abuse and emotional/physical abuse) and BPD pathology assessed with the SCID-II. It is suggested that a set of assumptions is characteristic of BPD, and is relatively stable despite the instability of the behaviour of people diagnosed as having BPD.     

Psychoanalytic ethics: Edoardo Weiss, Freud, and Mussolini.

This paper examines Edoardo Weiss's correspondence with S. Freud regarding Concetta Forzano's analysis and Forzano's efforts to intercede with Mussolini on Freud's behalf after the Nazis invaded Austria in 1938. Freud's reliance on Mussolini can be explained by traditional Viennese attitudes toward Italy, the Duce's protectiveness about Austrian independence, and the relatively benign attitude of the Fascist regime towards Jews.     

Essentialism revisited: evolutionary theory and the concept of mental disorder.

J. C. Wakefield's (1999) elaboration of his harmful dysfunction analysis (HDA) of mental disorder does little to address previous criticisms (S. O. Lilienfeld & L. Marino, 1995) and instead reveals further conceptual weaknesses in his position. The authors demonstrate that (a) a Roschian analysis can account for the results of all of Wakefield's conceptual experiments and predicts a number of judgments of disorder not predicted by the HDA, (b) the HDA is incapable in many cases of providing a scientifically nonarbitrary distinction between disorder and nondisorder, and (c) the HDA cannot account for failures of cultural ex adaptations, mismatches between evolutionary design and novel environments, or defenses against threat. The authors argue that the HDA has been convincingly falsified and discuss the failure of essentialistic concepts to resolve controversies in other domains of biological science.     

Nationalism, hatred of foreigners and antisemitism. Psychoanalytic considerations]

Widespread social crisis phenomena such as unemployment, shortage of housing or lack of prospects are not sufficient to explain aggressive nationalism and the revival of xenophobia in present-day Germany. While from a psychoanalytic viewpoint xenophobia and anti-Semitism have been extensively examined, the same can by no means be said of the phantasm of the "nation". With reference to a case study, the author demonstrates that the adoption of nationalist ideologies (which in Germany specifically are very much bound up with the traditional notion of the nation as a biological organism) can serve both to prevent the outbreak of neurosis at the individual level and to effect what Freud called the "spurious" healing of existing neuroses. Psychologically speaking, the phantasm of the "nation" provides scope for the realization of the desire for pre-ambivalent fusion with an object that has rid itself of everything heterogeneous, alien and autonomous.     

Commonality and specificity of personality disorder profiles in subjects with trauma histories.

Recently, attention has been drawn to a range of disturbances in personality functioning that commonly characterize individuals with a history of severe or prolonged trauma. Many of these features overlap with criteria for some of the Axis II personality disorders. The current study investigated the similarity of personality disorder features in different samples of patients with trauma histories, and specificity of such features compared to other psychiatric samples. Profiles of Axis II features, based on relative frequencies of individual disorder "diagnoses" derived from a common measure (Personality Diagnostic Questionnaire-Revised), were compared in three trauma samples: male Vietnam combat veterans with PTSD, female inpatients with a history of childhood sexual abuse, and female outpatients with a history of childhood sexual abuse. The PDQ-R derived profiles in each of the three trauma samples were then compared with similar PDQ-R derived profiles in published reports of psychiatric samples selected for other diagnoses. Each of the three Spearman rank correlations among the three trauma samples were significant, ranging from .72 to .94. There was a clear pattern of higher correlations within the trauma samples (average correlation of .81) than between the trauma and nontrauma samples (average correlations of .11, .36, and .25 between the nontrauma samples and the combat sample, inpatient sexual abuse sample, and outpatient sexual abuse sample, respectively). The findings suggest that a pattern of personality disorder features may be distinctly associated with individuals with trauma histories, at least of the type examined here. Future studies using more clinically valid measures of personality features and including other types of trauma samples are needed to determine the generalizability of the current findings. Also needed are studies with longitudinal designs to address questions of causal pathways that may underlie such associations.     

Hypervigilance in patients with borderline personality disorder: specificity, automaticity, and predictors

According to cognitive theory, an important factor in borderline personality disorder (BPD) is hypervigilance. The aim of the present study was to test whether BPD patients show schema-related biases, and to explore relations with childhood trauma, schemas, and BPD symptoms. Sixteen BPD patients were compared with 18 patients with a cluster C personality disorder, 16 patients with an axis I disorder, and 16 normal controls. An emotional Stroop task was applied with schema-related and unrelated, negative and positive, supra- and subliminal person-related stimuli. BPD patients showed hypervigilance for both negative and positive cues, but were specifically biased towards schema-related negative cues. Predictors were BPD schemas, childhood sexual traumas, and BPD anxiety symptoms. Both BPD and axis I disorder patients showed a trend for a bias for negative schema-related subliminal stimuli. More attention to hypervigilance in BPD is recommended for clinical practice.     

Psychoanalytic goals,therapeutic action,and the analyst's tension

The author draws a distinction between the goals of psychoanalysis and its therapeutic action. Goals are consciously (or at least preconsciously) held by the analyst, and can be clearly articulated. Ideas about the mechanism of therapeutic action, in contrast, are hypothetical constructs, and cannot be completely spelled out. This is bound to leave analysts in a state of tension; we are certain about what we are trying to do, but what we are actually accomplishing is elusive. This tension may be optimal for the analyst, because attention must be paid simultaneously to the idiosyncratic relationship in the dyad and to the broader purposes of the analytic engagement.