Is Splitting Related to Resistance to Proactive Interference? A Process-Oriented Study of Kernberg's Conceptualization of Splitting.

INTRODUCTION: Splitting, as a defense mechanism in Kernberg's theory, plays a significant role in the development and maintenance of polarized and oscillating representations of self/other characteristics of borderline personality disorder (BPD). Although the notion of splitting can be considered from a structural and a functional point of view, almost all empirical studies to date have focused on the former elements to the detriment of related cognitive processes. METHODS: To further investigate the cognitive processes related to splitting, 60 participants were administered the Splitting Index and indexes of resistance to proactive interference (PI) using the interpersonal recent negative task with words that reflect negative or positive interactions compared to neutral words. RESULTS: The use of splitting was uniquely and significantly predicted by a higher capacity to resist PI and a lower capacity to consistently maintain this resistance when presented with negative words, above and beyond BPD traits, primitive defenses, and the presentation of neutral words. Results showed no evidence of a relationship between splitting and resistance to PI with positive words. CONCLUSION: Results appear compatible with Kernberg's conceptualization of splitting as an active defense process that relates to an unstable capacity to inhibit negative representations of the object from entering working memory.

Changes in cardiac vagal tone as measured by heart rate variability during naloxone-induced opioid withdrawal.

BACKGROUND: Heart rate variability (HRV) is of interest to researchers due to its potential utility as a marker for both physiological and psychological stress. Sympatholytics are used to treat opioid withdrawal, but little information about the parasympathetic system's role in mediating withdrawal symptoms exists. The goal of the current study was to evaluate changes in HRV during opioid withdrawal to provide a better understanding of the autonomic effects of opioid withdrawal. METHODS: Ten male participants (mean age = 46.4 years) received intramuscular naloxone (mean dose =0.26 mg) to confirm opioid dependence. The presence and severity of withdrawal symptoms were assessed using subjective and objective measures (Wang et al., 1974). Electrocardiography (ECG) was measured continuously, and HRV was analyzed in 2-minute segments before naloxone injection (at baseline) and after participants were in moderate withdrawal (Wang Test score ≥10). Heart rate, blood pressure, pupil diameter, and respiratory rate were also examined. RESULTS: Pupil diameter significantly increased after naloxone administration relative to baseline (t(9) = 5.562, p = 0.000). Both high frequency (HF) HRV (Z = -2.803, p = 0.005) and root mean square of successive differences (RMSSD) HRV (Z = -2.090, p = 0.037) were significantly lower during withdrawal relative to baseline. Increases in heart rate (Z = -2.090, p = 0.032) and systolic pressure (t(9) = 8.099, p = 0.0000) from baseline to withdrawal also were significant. CONCLUSIONS: These preliminary data indicate that a large reduction in cardiac vagal tone occurs during naloxone-induced withdrawal. This finding underscores the need for further research into the role of the parasympathetic nervous system in opioid withdrawal.

The impact of deep breathing and alternate nostril breathing on heart rate variability: a human physiology laboratory.

An increase in the beat-to-beat variability of heart rate (HRV) is a robust marker of enhanced parasympathetic activity and of a calm and relaxed state. The purpose of this laboratory activity was to introduce the concept of HRV to our students, while having them address a novel question of whether two yogic breathing techniques, namely alternate nostril breathing (ANB) and standard deep breathing (DB), impact the SD of instantaneous heart rate (SDHR), a measure of HRV. Fifty-five undergraduates enrolled in a physiology course designed for nonscience majors were tasked with analyzing HR and SDHR from electrocardiograms recorded during normal breathing, DB, and ANB. A repeated-measures ANOVA showed that HR was significantly, albeit slightly, elevated from normal (74.5 ± 13.4 beats/min; means ± SD) during DB (76.5 ± 11.2 beats/min), but not during ANB (75.7 ± 10.1 beats/min). Analysis of SDHR showed significant differences between conditions (normal: 5.5 ± 2.1, DB: 8.6 ± 3.0, ANB: 7.8 ± 2.8 beats/min). The instructors further analyzed the same data set using more robust measures of HRV (SD of sequential N-N intervals, root mean square of successive differences, and high-frequency domain of HRV) to determine whether SDHR during a 2-min epoch is a sufficient measure for HRV in the undergraduate course setting. Statistical analysis for these measures showed a near identical pattern of magnitude and significance among the groups as SDHR. Our students developed a greater appreciation for the effects of breathing patterns on HRV and HR, using the simple measure of SDHR.

Treatment for Substance Use Disorder With Co-Occurring Mental Illness.

Substance use disorder is a highly prevalent condition, leading to significant morbidity, mortality, and burden on the health care system. Substance use disorders are overrepresented among individuals with a mental illness. The term "dual diagnosis" was introduced by the World Health Organization in the mid-1990s and refers to the co-occurrence of a substance use disorder with mental illness-a more recently used term is "co-occurring disorders." In the past decade, substantial progress has been made toward expanding psychotherapeutic and pharmacotherapeutic treatments for treating co-occurring disorders. Yet management remains a challenge among clinicians and has been a source of confusion and considerable controversy. This review describes the epidemiology and treatment of co-occurring disorders, with a focus on major depressive disorder, anxiety disorders, and attention-deficit hyperactivity disorder. Substance use may make diagnosis of the underlying psychiatric condition difficult, and a period of abstinence may be necessary. Findings from efficacy studies of medications used to treat co-occurring disorders are reviewed, as are results of preliminary studies of newer treatments, such as topiramate, ketamine, noninvasive brain stimulation, and deep brain stimulation. Treatment recommendations that combine medications and psychosocial interventions are summarized.

Watchful Waiting in Continuous-Flow Left Ventricular Assist Device Patients With Ongoing Hemolysis Is Associated With an Increased Risk for Cerebrovascular Accident or Death.

BACKGROUND: Management of hemolysis in the setting of suspected device thrombosis in continuous-flow left ventricular assist device patients varies widely, ranging from watchful waiting with intensified antithrombotic therapy to early surgical device exchange. The aim of this study was to compare the outcomes of hemolysis events treated with surgical interventions versus medical management alone. METHODS AND RESULTS: A retrospective review of Heartmate II continuous-flow left ventricular assist device patients at 2 centers from January 2009 to September 2014 was completed. Patients were categorized as surgical management if hemolysis refractory to intensification of standard antithrombotic therapy was treated surgically. The primary end point was the first occurrence of cerebrovascular accident (CVA) or death. Sixty-four hemolysis events occurred in 49/367 patients implanted with Heartmate II continuous-flow left ventricular assist devices. Of 49 primary hemolysis events, 24 were treated with surgical interventions. After surgical treatment, 1 patient died and 2 experienced CVAs, as compared with 3 deaths and 9 CVAs in the 25 patients who remained on intensified antithrombotic therapy alone. The 1-year freedom from CVA or death was 87.5% and 49.5% in the surgical and medical cohorts, respectively (P=0.027). Resolution of a primary hemolysis event without CVA or death occurred in 21/24 patients treated with surgical interventions and in 13/25 who remained on medical therapy alone. A similar association between treatment and outcome was noted in the 15 recurrent hemolysis events. CONCLUSIONS: Hemolysis refractory to intensification of antithrombotic therapy identifies continuous-flow left ventricular assist device patients at major risk for CVA and death. Early device exchange should be considered to minimize these risks.

Memory reconsolidation, repeating, and working through: Science and culture in psychotherapeutic research and practice.

Hypothesizing that an effective common feature in divergent forms of psychotherapy is a process of memory reconsolidation integrating new emotional experiences, Lane et al. usefully shift the focus away from established and/or specialized techniques to deeper questions about the underlying principles of psychotherapeutic change. More research attention to cultural factors influencing the definition and treatment of psychopathology is also needed.

The mind as a complex internal object: inner estrangement.

The psyche is not a passive container (of emotions, memories, representations, objects, structures, drives, defenses, etc.), and not just an object-seeking organism; it acts on itself as the object of its own scrutiny, which can take many forms. Emphasis on the role of interpersonal object relations has sometimes tended to reduce our working model of the psyche to its internalizations and how these shape personality. This essay uses illustrative clinical vignettes and metapsychological reasoning to explore the mind's relationship to itself and its capacity to act upon itself, arguing that attention to this aspect of clinical material is vital to the psychoanalytic process, fostering what might be described as the growth of internal intersubjectivity.

Coincidence imaging using 2 dual-head gamma-camera systems, with and without attenuation correction.

OBJECTIVE: Coincidence imaging enhances the potential for imaging a greater number of patients with 18F-FDG in centers that do not have dedicated PET systems. The purpose of this study was to compare, in a clinical setting, coincidence imaging for tumor detection using 2 dual-head gamma-camera systems, one equipped with a 5/8-in. (16 mm) detector (CoDe5) and the other equipped with a newly designed 1-in. (25.4 mm) detector (CoDe8) with an x-ray tube installed in its gantry. METHODS: Thirty consecutive patients were studied by both systems during the same visit and had 4 image sets for comparison: CoDe5 without attenuation correction (CoDe5NC), CoDe8 with (CoDe8AC) and without (CoDe8NC) attenuation correction, and fused coincidence-CT images. The target-to-background ratio (T/Bg ratio) and target-to-nontarget ratio (T/NT ratio) were calculated for each tumor site. RESULTS: On visual assessment, 61 tumor sites were detected on CoDe8AC images. Of these, 59 (97%) were detected on CoDe8NC and 54 (88%) were detected on CoDe5NC images. Fused images improved image interpretation in 10 patients (33%) compared with coincidence images alone. Data added by fusion were of clinical relevance in 6 patients (20%). On quantitative assessment, the number of accepted events by the CoDe8 was significantly higher than that by CoDe5 (5.21 +/- 1.46 million vs. 1.27 +/- 0.36 million, P <0.001). When comparing CoDe5 with CoDe8 images without attenuation correction, the T/Bg and T/NT ratios were significantly higher on the CoDe8 images (P <0.0005 and P <0.0005, respectively). When comparing CoDe8 images with and without attenuation correction, the T/Bg ratio was better on the attenuation-corrected images (P <0.0005). CONCLUSION: Coincidence imaging with 1-in. detectors and attenuation correction improve image quality and, to a lesser extent, the tumor detection rate compared with the 5/8-in. detectors and noncorrected images. The data added by fusion of coincidence images to CT findings were clinically relevant in 20% of the patients.