The almost untreatable narcissistic patient

Clinical experience in the Personality Disorders Institute at Weill Cornell Medical College suggests that patients with borderline personality organization and a narcissistic personality disorder have a more serious prognosis than all other personality disorders functioning at the borderline level, and that those who in addition present significant antisocial behavior have an even worse prognosis (Clarkin, Yeomans, and Kernberg 1999; Stone 1990). This negative trend culminates in a group of practically untreatable patients with antisocial personality disorder, who represent the most severe cases of pathological narcissism. There are also patients with severe narcissistic personality disorder, functioning at an overt borderline level with significant antisocial features, but not presenting an antisocial personality disorder proper, who at times respond to treatment, while others do not. These patients are explored here, with a focus on particular psychotherapeutic techniques that have proven helpful, as well as on the limits of these technical approaches.     

Memento ... life imitates art: the request for an ethics consultation

This was a troublesome case, without complete consensus about the right thing to do. It seemed there were arguments on both sides: those who thought that the goal of comfort care without treatment was most consistent with his wishes, versus those who thought the additional testing and treatment might have produced a net benefit in spite of the burdens. Ultimately, the patient was placed in a facility with a do-not-resuscitate (DNR) order in effect and a plan for comfort care. He may live a few months or more. We all hope that whatever time he has is spent free of pain and symptoms, and that he is able to live a life of quality consistent with his wishes. The main story line is consistent with actual events; however, there have been changes in terms of gender, disease, and relationships that have been included to protect the anonymity of the patient.     

Clinical perspectives on the combination of D-cycloserine and cognitive-behavioral therapy for the treatment of anxiety disorders

In a particular success for translational research agendas, characterization of the neuronal circuits underlying fear extinction, and basic research in animal extinction paradigms, has led to intervention studies examining the use of D-cycloserine (DCS) to enhance therapeutic learning from exposure-based cognitive-behavioral therapy (CBT). In this article, we review these intervention studies, and discuss DCS augmentation of CBT relative to more traditional combination-treatment strategies in the treatment of anxiety disorders. We offer an accounting, based on evidence for internal context effects, of current limitations in the combination of antidepressant or benzodiazepine medications with CBT and discuss the advantages of isolated-dosing strategies with DCS relative to these limitations. This strategy is contrasted with the chronic-dosing applications of DCS for schizophrenia and Alzheimer's disease, and future directions for isolated-dosing strategies are discussed.     

Navigating through abstract decision spaces: Evaluating the role of state generalization in a dynamic decision-making task

Research on dynamic decision-making tasks, in which the payoffs associated with each choice vary with participants’ recent choice history, shows that humans have difficulty making long-term optimal choices in the presence of attractive immediate rewards. However, a number of recent studies have shown that simple cues providing information about the underlying state of the task environment may facilitate optimal responding. In this study, we examined the mechanism by which this state knowledge influences choice behavior. We examined the possibility that participants use state information in conjunction with changing payoffs to extrapolate payoffs in future states. We found support for this hypothesis in an experiment in which generalizations based on this state information worked to the benefit or detriment of task performance, depending on the task’s payoff structure.     

The encounter with God in myth and madness

Background

It is well known how often psychiatric patients report religious experiences. These are especially frequent in schizophrenic and epileptic patients as the subject of their delusions. The question we pose is: are there differences between this kind of religious experiences and those we find in religious texts or in the mythological tradition?

Results

An overview on famous mythological narratives, such as The Aeneid, allows us to establish that the divinities become recognizable to the human being at the moment of their departure. Thus, Aeneas does not recognise his mother, Venus, when she appears to him in the middle of the forest at the coast of Africa. A dialogue between the two takes place, and only at the end of the encounter, when she is going away and already with her back to Aeneas, she shows her son the signs of her divinity: the rose-flush emanating from her neck, her hair perfume and the majesty of her gait. Something analogous can be observed in the encounter of Moses with Yahweh on Mount Sinai. Moses asks God: "Show me your glory, I beg you". And God replies, among other things: "you shall see the back of me, but my face is not to be seen". In the same sense, the Emmaus disciples do not recognise Jesus till the moment of his disappearance ("but he had vanished from their sight"), and Saul of Tars falls off his horse just in the moment when he feels the divine presence. In short, the direct encounter with the divinity seems not to occur in the realm of myth or in religious tradition. The realm of madness is exactly the opposite. Our research on religious experiences in schizophrenic and epileptic patients leads us to conclude that God appears to them face to face, and the patient describes God the father, Jesus or the Virgin Mary in intimate detail, always in an everyday setting. So, the divinity is seen in the garden, or in the bedroom, or maybe above the wardrobe, without any of its majesty. The nearness to God also tends to be so extreme that even an identification of patient and God can occur. That light emanating from the world of the divine ceases to be perceived by them.

Conclusion

While in mythological narratives God appears to the human being at the moment of His departure or showing His back, psychiatric patients with religious delusions experience the divinity in a direct way, face to face. Given the deformation of the divine occurring on the edge of madness we can better understand the mysterious words from Yahweh to Moses in Exodus: "for man cannot see me and live".     

Memory deficits in young schizophrenics with normal general intellectual function

The aim of the present study was to examine different dimensions of memory functioning in young schizophrenics with normal general intellectual abilities. Thirty-three patients with schizophrenia and 33 healthy controls were included in the study. The results suggest that immediate short-term memory is intact, though there emerged a working memory deficit in the schizophrenia group. Deficient encoding of verbal material was observed in some, but not in other, testing conditions. There also seemed to be a retrieval deficit for verbal material in schizophrenia, though no storage deficit was indicated. Impaired memory for non-verbal material was also revealed. These results occurred in a context of intact executive functioning as measured by the Wisconsin Card Sorting Test. The results indicate that temporal and frontal structures, as well as their interconnections, may be compromised in schizophrenia.     

Abuse History, World Assumptions, and Religious Problem Solving

At a Christian university, 167 subjects completed questionnaires measuring worldview assumptions, religious problem solving, physical and emotional abuse, and subjects' beliefs about whether they had been "abused." Results indicated that worldview assumptions were not related to actual abuse histories. Instead, such assumptions were related to the subjects' beliefs that they had been abused. Subjects who believed that they had been abused had more negative views of the impersonal world, people, and themselves; they were also more likely to see events as random. Both actual abuse history and subjects' beliefs that they had been abused were related to religious problem-solving styles. Finally, problem-solving styles were related to various worldview assumptions. Results are discussed in terms of previous research on abuse and in the psychology of religion.     

Scientific Meetings of the Association for the Advancement of Psychoanalysis

The American Journal of Psychoanalysis -     

An empirical evaluation of a scale to measure occupational aspiration level

Data from 34,118 American high school students are used to evaluate the Occupational Aspiration Scale (OAS). The OAS is successively reevaluated for each of 16 subsamples (cells) generated by cross-classifying respondents by grade in school (9–12), sex, and socioeconomic status (SES). In each cell the OAS is found to be essentially unifactorial, and that factor is identified as level of occupational aspiration (LOA). The reliability of the OAS is slightly lower among females ($\text{r}$_kk = .681) than among males ($\text{r}$_kk = .756); it does not vary appreciably by grade or SES. The mean scores are lower for youth from low SES families than for those from high SES families, in accord with previous research. Mean OAS differences due to sex and grade are small. No important differences by age, sex, or SES are found in the standard deviations of the test scores. This and previously published data from small, local samples indicate that the reliability and validity of the OAS are sufficient for research on high school youth of both sexes and from both higher and lower SES levels.