Abh?ngigkeitserkrankungen und Pers?nlichkeitsst?rungen

Substance use disorders and personality disorders often co-occur in clinical treatment. In this review the association between substance use disorders and personality disorders is described and discussed. Clinical and neurobiological data as well as psychodynamic concepts are included to focus on the therapeutic implications for patients with these comorbidities. The consumption of substances often begins as a kind of self-medication. Patients suffering from severe personality disorders need these substance effects to avoid severe destructive affects and to regulate their self-esteem. Patients with chronic substance dependence often show changes in brain structure. In the dependency stage of addiction clinical symptoms can make the diagnosis of a specific personality disorder very difficult. The treatments can be classified by the severity of substance use disorders and personality disorders. Substance misuse can be treated with psychotherapy. In substance dependence, specific forms of addiction therapy should be included. In patients with the frequent comorbidity of substance use disorders and severe personality disorders, disorder-specific treatment can be used with good results.     

Thought suppression and psychopathology.

Wegner's seminal investigations of effects of thought suppression on later thought frequency have had a significant impact on recent approaches to understanding emotional disorders characterized by the occurrence of persistent, repetitive, unwanted thoughts. Thought suppression has now been implicated as a etiological and/or maintaining factor in depression, generalized anxiety disorder, specific phobia, posttraumatic stress disorder and obsessive-compulsive disorder. These developments are fairly new, and it has not been until recently that studies have investigated the effects of suppressing thoughts that are actually analogous to problematic thoughts characteristic of emotional disorder. This paper provides a review of this body of work, including the findings and their relevance for existing models of specific disorders. Directions for future research are suggested.     

Posttraumatische Belastungsstörung

There are some problems concerning the concepts of trauma-related disorders and especially the category of posttraumatic stress disorder (PTSD) with respect to classification, diagnosis and epidemiological findings, which can only be understood within the historical framework of the development. Even current diagnostic systems, such as the diagnostic and statistical manual of mental disorders version 4 (DSM-IV) and the international classification of diseases version 10 (ICD-10) differ in the classification of these disorders which led to higher prevalence rates being achieved with ICD-10. The diagnostic algorithms have been opened to included subsyndromal PTSD as well as complex PTSD including more severe psychiatric disorders.     

Heavenly Bodies: Religious Issues in Cognitive Behavioral Treatment of Eating Disorders

Minimal attention has been given to the role that religion may play in the development, maintenance, and treatment of eating disorders. Many religions espouse specific doctrines about the nature and purpose of the body as well as prescribe particular body grooming and eating practices. These doctrines and practices influence individuals' schemas and experiences of the body and eating, which can either contribute to or provide protection from eating disorders. This paper describes pathways through which religious beliefs and practices may impact risk for and maintenance of eating disorders. Methods for integrating religious concepts, practices, and resources into standard cognitive-behavioral treatment for eating disorders are discussed, including interventions that address purported religiously oriented contributory and protective factors. Treatment of a religious client with an eating disorder is described to illustrate the incorporation of religiously oriented interventions in practice.     

Specificity of autonomic arousal to DSM-IV panic disorder and posttraumatic stress disorder

Although research on the hierarchical model of anxiety and depression has confirmed that autonomic arousability (AA) is more germane to panic disorder with or without agoraphobia (PD/A) than other DSM-IV anxiety and mood disorders, studies have not evaluated the differential relevance of AA to posttraumatic stress disorder (PTSD). This issue was addressed in multivariate analytic models using 295 outpatients with anxiety and mood disorders. Consistent with prediction, the presence of current DSM-IV PTSD and PD/A was significantly predictive of AA, even when other forms of anxiety disorder comorbidity were held constant. Moreover, latent structural analyses indicated that PTSD and PD/A were the only DSM-IV anxiety disorder constructs to have significant direct effects on AA (in accord with previous findings, the DSM-IV constructs of generalized anxiety disorder, social phobia, and obsessive-compulsive disorder did not have significant structural relationships with AA). The current findings, which attest to the specificity of AA to PTSD and PD/A, are discussed in context of other clinically salient shared features of these disorders and their relevance to treatment and diagnostic classification.     

The role of defeat and entrapment in depression, anxiety, and suicide

Defeat and entrapment are psychological constructs that have played a central role in evolutionary accounts of depression. These concepts have since been implicated in theoretical accounts of anxiety disorders and suicidality. The current article reports on a systematic review of the existing research investigating the links among defeat, entrapment, and psychopathology in the domains of depression, suicidality, posttraumatic stress disorder (PTSD), and other anxiety syndromes. Fifty-one original research articles were identified and critically reviewed. There was strong convergent evidence for a link with depressive symptoms, across a variety of clinical and nonclinical samples. Preliminary support for an association with suicidality was also observed, with effects not readily explainable in terms of comorbid depression. There was strong evidence for an association between defeat and PTSD, although this may have been partly accounted for by comorbid depression. The findings for other anxiety disorders were less consistent. There was, however, evidence that social anxiety in individuals with psychosis may be related to perceptions of entrapment. Overall, there was evidence that perceptions of defeat and entrapment were closely associated with various forms of human psychopathology. These effects were often in the moderate to large range and superseded the impact of other environmental and psychological stressors on psychopathology. We provide a unified theoretical model of how defeat and entrapment may contribute to these different psychopathological conditions. Clinical implications and avenues for future research are discussed.     

Therapiekonzeption für traumatisierte Patienten mit schweren Persönlichkeitsstörungen

Comorbidity between severe personality disorder and posttraumatic stress disorder is a frequent clinical problem. Severe personality disorders are characterized by an impaired regulation of emotions, a low mentalization capacity and deficits in personality integration. For severe personality disorders and posttraumatic stress disorder, a variety of evidence-based treatment approaches of psychodynamic and cognitive-behavioral origin are available. However, a closer inspection of these treatment concepts shows that they do not sufficiently take the respective comorbid condition into account. No single concept is able to cover all problem areas presented by patients with this comorbidity. Therefore, an attempt is made to present an integrative psychodynamically oriented therapy concept for traumatized patients with personality disorders which contains elements from psychodynamic, cognitive-behavioral and other concepts. The phase structure of the concept clarifies the sequence hierarchy of the therapeutic interventions. The content of the five phases are: (1) safety, holding and strengthening of coping capacities, (2) emotion regulation and self-care, (3) mentalization and development of stable representations, (4) gentle trauma processing and (5) conflict-oriented psychotherapy and treatment of maladaptive relationship patterns.     

Neuropsychological Sequelae of PTSD and TBI Following War Deployment among OEF/OIF Veterans

Posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) are highly prevalent among Veterans of the conflicts in Iraq and Afghanistan. These conditions are associated with common and unique neuropsychological and neuroanatomical changes. This review synthesizes neuropsychological and neuroimaging studies for both of these disorders and studies examining their co-occurrence. Recommendations for future research, including use of combined neuropsychological and advanced neuroimaging techniques to study these disorders alone and in concert, are presented. It is clear from the dearth of literature that addiitonal studies are required to examine and understand the impact of specific factors on neurocognitive outcome. Of particular relevance are temporal relationships between PTSD and mTBI, risk and resilience factors associated with both disorders and their co-occurrence, and mTBI-specific factors such as time since injury and severity of injury, utilizing comprehensive, yet targeted cognitive tasks.     

Adolescents with learning disabilities: Psychic structures that are not conducive to learning

In this paper, I attempt to make links between theoretical concepts derived from the work of Bion (in particular, the 'ego-destructive super-ego', and the function he termed '-K' in thinking disorders) and the nature of the transference relationship that became evident in my clinical work with some adolescents with learning disabilities. I use three clinical examples to illustrate these ideas and suggest that learning can be facilitated for this patient group by addressing difficulties which arise in the therapist's countertransference related to the theoretical concepts cited above.     

The role of glutamate in anxiety and related disorders

Anxiety, stress, and trauma-related disorders are a major public health concern in the United States. Drugs that target the gamma-aminobutyric acid or serotonergic system, such as benzodiazepines and selective serotonin reuptake inhibitors, respectively, are the most widely prescribed treatments for these disorders. However, the role of glutamate in anxiety disorders is becoming more recognized with the belief that drugs that modulate glutamatergic function through either ionotropic or metabotropic glutamate receptors have the potential to improve the current treatment of these severe and disabling illnesses. Animal models of fear and anxiety have provided a method to study the role of glutamate in anxiety. This research has demonstrated that drugs that alter glutamate transmission have potential anxiolytic action for many different paradigms including fear-potentiated startle, punished responding, and the elevated plus maze. Human clinical drug trials have demonstrated the efficacy of glutamatergic drugs for the treatment of obsessive-compulsive disorder, posttraumatic stress disorder, generalized anxiety disorder, and social phobia. Recent data from magnetic resonance imaging studies provide an additional link between the glutamate system and anxiety. Collectively, the data suggest that future studies on the mechanism of and clinical efficacy of glutamatergic agents in anxiety disorders are appropriately warranted.     

Personality disorder and antisocial deviance: comments on the debate on the structure of the psychopathy checklist-revised

The recent debate on the structure of the Psychopathy Checklist-Revised (PCL-R: Hare, 1991; 2003) has been presented primarily as a statistical issue, but underlying it are longstanding conceptual issues about the relationship of personality concepts to deviant behavior and of psychopathy to criminality and personality disorder. I discuss these issues in this paper. The antisocial items of the PCL-R seem to reflect a propensity to commit crimes that has long been of interest to criminology. This disposition overlaps with, but differs conceptually from personality dispositions, but these surface dispositions do not provide a causal account of criminality. I present data that indicate that the core personality characteristics of psychopathy are more closely related to narcissistic and histrionic personality disorders than to antisocial personality disorder. Overemphasis on involvement in crime has obscured the nature of psychopathy as a disorder of personality characterised by interpersonally harmful behavior that need not necessarily take criminal form.     

Are psychodynamic and psychoanalytic therapies effective?: A review of empirical data

There is a need for empirical outcome research in psychodynamic and psychoanalytic therapy. However, both the approach of empirically supported therapies (EST) and the procedures of evidence‐based medicine (EBM) have severe limitations making randomised controlled trials (RCTs) an absolute standard. After a critical discussion of this approach, the author reviews the empirical evidence for the efficacy of psychodynamic psychotherapy in specific psychiatric disorders. The review aims to identify for which psychiatric disorders RCTs of specific models of psychodynamic psychotherapy are available and for which they are lacking, thus providing a basis for planning further research. In addition, results of process research of psychodynamic psychotherapy are presented. As the methodology of RCTs is not appropriate for psychoanalytic therapy, effectiveness studies of psychoanalytic therapy are reviewed as well. Studies of psychodynamic psychotherapy published between 1960 and 2004 were identifed by a computerised search using Medline, PsycINFO and Current Contents. In addition, textbooks and journal articles were used. Twenty‐two RCTs were identifed of which 64% had not been included in the 1998 report by Chambless and Hollon. According to the results, for the following psychiatric disorders at least one RCT providing evidence for the efficacy of psychodynamic psychotherapy was identifed: depressive disorders (4 RCTs), anxiety disorders (1 RCT), post‐traumatic stress disorder (1 RCT), somatoform disorder (4 RCTs), bulimia nervosa (3 RCTs), anorexia nervosa (2 RCTs), borderline personality disorder (2 RCTs), Cluster C personality disorder (1 RCT), and substance‐related disorders (4 RCTs). According to results of process research, outcome in psychodynamic psychotherapy is related to the competent delivery of therapeutic techniques and to the development of a therapeutic alliance. With regard to psychoanalytic therapy, controlled quasi‐experimental effectiveness studies provide evidence that psychoanalytic therapy is (1) more effective than no treatment or treatment as usual, and (2) more effective than shorter forms of psychodynamic therapy. Conclusions are drawn for future research.     

Anxiety disorders in African-American and white children

There are little available data on African-American children with anxiety disorders. Treatment-seeking African-American (n=30) and white children (n=139), with a current DSM-III-R anxiety disorder, were compared on sociodemographic background variables, clinical characteristics, and lifetime rates of specific DSM-III-R anxiety disorders. Overall, results suggested that the anxiety-disordered African-American and white children who sought treatment from an outpatient mental health facility were more similar than different. The two groups did, however, differ somewhat on several variables (trend only), including rates of school refusal, severity of primary anxiety disorder, lifetime prevalence of posttraumatic stress disorder, and total scores on the Fear Survey Schedule for Children-Revised. More specifically, white children were more likely to present with school refusal and higher severity ratings, while African American children were more likely to have a history of posttraumatic stress disorder and score higher on the FSSC-R. The impact of these findings and the need for additional research are discussed.This study was supported in part by MH grant 40021 from the National Institute of Mental Health.     

Diagnosing PTSD: Lessons From Neuropsychology

Problematic diagnostic issues related to neurocognitive conditions have been well documented in research using neuropsychological instruments. However, due to the nature of differing assessment methods, these issues have not been as clearly established in the diagnostic assessment of psychiatric disorders that rely on self-report. Nonetheless, they appear relevant. This article summarizes diagnostic-related lessons learned based on clinical neuropsychological research and how they are applicable to the practice of diagnosing psychiatric conditions, post-traumatic stress disorder (PTSD) in particular. Ignoring these lessons raises serious risk for misdiagnosis, inappropriate treatment and services, and iatrogenic illness.     

The core elements of neurosis: mixed anxiety-depression (cothymia) and personality disorder

Although there has been great diagnostic activity within the conditions formally included under the general rubric of neurosis in the last 20 years, there is little evidence that the many new diagnoses (i.e., generalized anxiety disorder, panic disorder, social anxiety disorder, and dysthymic disorder) have helped clinicians and improved the health of those diagnosed. This is largely because of the extensive comorbidity between these disorders negates much of their attempted separation and it is argued that the core of neurosis is a mixed anxiety-depressive disorder, or cothymia, combined with significant personality disorder of any type. The specific association of the anxious-fearful personality cluster (cluster C) and neurosis, called the general neurotic syndrome, is also relevant but appears to have lesser significance as the personality elements are not stable. Data are presented that justify these conclusions from a long-term follow-up study of anxiety and depressive disorders.     

Using DSM axis II information to predict outcome in short-term individual psychotherapy

The present study considered three methods of using DSM Axis II information to examine the effect of personality disorder on outcome in two forms of short-term, individual psychotherapy (interpretive and supportive). The first method involved examining whether the presence of any personality disorder influenced treatment outcome. The second method involved examining the effect of the number of personality disorders on outcome. The third involved examining outcome for specific personality disorders. The study found that a diagnosis of any personality disorder did not influence the outcome of therapy. In contrast, the number of personality disorders was significantly related to outcome at post-therapy and at 12-month follow-up. The findings indicated that a greater number of personality disorders was associated with less favorable outcome across both forms of therapy. This supports the notion that personality pathology is more severe when it involves a greater number of personality disorders. In an exploratory set of analyses, the study also found some evidence of differences in outcome for specific personality disorders.     

Longitudinal studies of PTSD: overview of findings and methods

Posttraumatic stress disorder (PTSD) has a discernible starting point and typical course, hence the particular appropriateness of longitudinal research in this disorder. This review outlines the salient findings of longitudinal studies published between 1988 and 2004. Studies have evaluated risk factors and risk indicators of PTSD, the disorder's trajectory, comorbid disorders and the predictive role of acute stress disorder. More recent studies used advanced data analytic methods to explore the sequence of causation that leads to chronic PTSD. Advantages and limitations of longitudinal methods are discussed.     

The Comorbidity of Conduct Problems and Depression in Childhood and Adolescence

An extensive body of research documents the high prevalence of comorbidity among child and adolescent disorders in general and between conduct problems and depression in particular. These problems co-occur at significantly higher rates than would be expected by chance and their comorbidity may have significant implications for nosology, treatment, and prognosis. Four main hypotheses have been put forth to account for these high rates of comorbidity. First, comorbidity may be a result of shortcomings associated with referral or informant biases. Second, comorbidity may be an artifact of overlapping definitional criteria. Third, one disorder may cause the other disorder by influencing the developmental trajectory and placing an individual at increased risk for further difficulties. Finally, comorbidity between two disorders may be explained by shared underlying causal or risk factors. The purpose of this review is to explore these possibilities, concentrating primarily on the common risk factors of parent psychopathology, emotion regulation, and cognitive biases that may underlie the co-occurrence of these two disorders. Based on our review, we propose a model for the development of comorbidity between these two disorders.