Introduction to Jacques Lacan "Some Reflections on the Ego".

This is a brief introduction to Jacques Lacan's paper "Some Reflections on the Ego" which summarizes his main ideas.

Receptivity is not passivity: A comparison between psychoanalysis and phenomenology concerning experience, judgement and the analytic attitude.

Starting from Edmund Husserl's last book Experience and Judgement, this paper explores the notions of "passivity" and "receptivity" in phenomenology and psychoanalysis. Both sciences agree that receptivity differs from passivity, but they have developed different conceptualizations about the very nature of the rudimentary "ego-activity" which is the source of receptivity. In phenomenological terms, "pre-predicative" experience roots in a primary presence and openness of the ego towards the world, whilst psychoanalysis has emphasized the role of projective and introjective processes which are close to bodily experiences and unconscious phantasy. The second part of the paper draws some conclusions concerning the analytic situation, in particular the shift among receptivity, empathy, curiosity and creative imagination as central features of the analytic attitude from a mainly Kleinian point of view. The paper argues that receptivity is a field where phenomenological and psychoanalytic approaches can mutually enrich and learn from each other.

The enigma of transference. Freud's discovery and its repercussions.

This brief introduction gives an historical outline of the development of the concept of transference in the different psychoanalytic traditions. It goes back to the various meanings of the German term "Übertragung" - transference, transcription, transmission, transposition and assignment - and how they were accentuated by the different psychoanalytic schools. The paper depicts the transition from a mainly intrapsychic understanding of transference as repetition to a more bipersonal and intersubjective approach exploring the different meanings of "intersubjectivity" and the forces that operate within the analytic field. Major developments arose from a new understanding of the role of the analyst's countertransference and the detection of transference mechanisms in narcissistic, borderline and psychotic states. The exploration of different forms of splitting and projective and introjective identification deepened the understanding of the analytic communication and led to concepts like "acting in", role-responsiveness, "actualization" and "enactment". As the author tries to show, all these approaches can find a legitimization in Freud's original writings, but the main differences concern technical issues, i.e. the interpretation of transference.

Typical disease courses of patients with unipolar depressive disorder after in-patient treatments-results of a cluster analysis of the INDDEP project.

Introduction: Previously established categories for the classification of disease courses of unipolar depressive disorder (relapse, remission, recovery, recurrence) are helpful, but insufficient in describing the naturalistic disease courses over time. The intention of the present study was to identify frequent disease courses of depression by means of a cluster analysis. Methods: For the longitudinal cluster analysis, 555 datasets of patients who participated in the INDDEP (INpatient and Day clinic treatment of DEPression) study, were used. The present study uses data of patients with at least moderate depressive symptoms (major depression) over a follow-up period of 1 year after their in-patient or day-care treatments using the LIFE (Longitudinal Interval Follow-Up Evaluation)-interview. Eight German psychosomatic hospitals participated in this naturalistic observational study. Results: Considering only the Calinski-Harabatz index, a 2-cluster solution gives the best statistical results. In combination with other indices and clinical interpretations, the 5-cluster solution seems to be the most interesting. The cluster sizes are large enough and numerically balanced. The KML-cluster analyses revealed five well interpretable disease course clusters over the follow-up period: "sustained treatment response" (N = 202, 36.4% of the patients), "recurrence" (N = 80, 14.4%), "persisting relapse" (N = 115, 20.7%), "temporary relapse" (N = 95, 17.1%), and remission (N = 63, 11.4%). Conclusion: The disease courses of many patients diagnosed with a unipolar depression do not match with the historically developed categories such as relapse, remission, and recovery. Given this context, the introduction of disease course trajectories seems helpful. These findings may promote the implementation of new therapy options, adapted to the disease courses.

Roger Money-Kyrle's 1934 paper on war: the context and personal background.

This brief introduction summarizes and gives the biographical context of Roger Money-Kyrle's 1934 paper "A psychological analysis of the causes of war". It also contextualizes his interest in the interplay between the psychological mechanisms operating within the individual, the society and groups and his personal experience with Germany in between and after two catastrophic wars.

The conceptualization of trauma in psychoanalysis: an introduction.

This paper highlights some aspects of the conceptualization of trauma in psychoanalysis and introduces the three subsequent papers by Bernard Chervet, Jan Abrams and Howard Levine. It focuses on the interchange between external and internal reality, the construction of traumatic defensive organizations and the role of reparation and guilt in overcoming the repetition compulsion.

Follow-Up Treatment After Inpatient Therapy of Patients With Unipolar Depression-Compliance With the Guidelines?

OBJECTIVE: To date, there is only a limited number of studies evaluating the implementation and effects of treatment guidelines. Therefore, this study aimed to determine how many patients diagnosed with a major depression were treated in compliance with the German treatment guideline after hospital treatment, and whether a deviation from the guideline resulted in a less favorable development. METHODS: Five hundred two patients, which originally participated in the INDDEP-study, were included. Data were collected at admission and discharge from eight different psychosomatic (psychotherapeutic) hospitals in Germany as well as 3 months and 1 year after hospital treatment. Data on depressive symptomatology were assessed by QIDS-C (clinical interviews). By phone interviews, the clinical course and the outpatient treatments were assessed. Statistical analyses compared patients who were treated in compliance with the German treatment guideline with those who were not. RESULTS: Seventy-nine point one percent of the outpatient treatments complied with the treatment guideline. Eleven point eight percent of the patients were treated with medication only, 60.2% with psychotherapy only, and 28.0% with a combination. There was no difference in the clinical outcome (depression) with regard to guideline compliance. Cases in which deviation from the guideline occurred (20.9%) were younger and had a less severe depressive symptomatology at admission and after hospital treatment. CONCLUSION: After treatment in a psychosomatic hospital or day hospital, the majority of patients with a depressive disorder received adjacent treatment in accordance with the German guideline and with a clear focus on psychotherapy. Deviations from the guideline did not result in a less favorable course of the illness. CLINICAL TRIAL REGISTRATION: ISRCTN20317064, retrospectively registered 31.07.2012.

Self-Criticism and Personality Functioning Predict Patterns of Symptom Change in Major Depressive Disorder.

Aim of the study was to identify patient variables that predict specific patterns of symptom course during and after hospital treatment for major depressive disorder (MDD). In a sample of 518 patients, four pairs of clinically relevant patterns of symptom change were contrasted. The time points of measurement were admission, discharge, 3 and 12 month after discharge. CATREG was used to identify the best sets of predictors from 28 variables. A greater reduction in self-criticism during hospital treatment was the strongest predictor of rapid and sustained improvement. Traumatic childhood experiences and lower abilities for communication with others predicted a transient relapse after discharge, while a co-morbid personality disorder and higher level of anxiety differentiated between those with a persistent relapse and those with only a transient relapse in depressive symptoms following discharge. Overall, patients with less severe depression at admission, better abilities in self-perception, and less self-criticism (baseline and/or greater reduction during treatment) showed a better outcome after 1 year. There is limited generalizability to other countries and treatment settings. Data on personality functioning were not available for all patients and findings are correlational in nature. However, findings are in support of a psychotherapeutic focus on a reduction of self-criticism in MDD. Patient with traumatization, a co-morbid personality disorder and lower abilities to communicate their emotional needs should get specific attention and support after discharge from hospital treatment.

A brief history of the super-ego with an introduction to three papers.

The paper gives a survey of the origin of the concept of the super-ego in Freud's work and its further elaboration within the different psychoanalytic traditions. It introduces three papers on the perverse and psychotic super-ego, the development of the concept in Bion's work and its significance for psychoanalytic social psychology.

A river with several different tributary streams: Reflections on the repetition compulsion.

This paper examines the repetition compulsion as a composite structure and explores the elements that are involved in it. After examining the difference between playful repetition, which promotes psychic development, and the repetition compulsion, which obstructs psychic change, the author discusses Freud's models of the repetition compulsion (as the return of the repressed vs an expression of the death drive). Further elements that contribute to the repetition compulsion include the role of a primitive, punitive superego, the persistence of raw, unsymbolized elements, obsessional doubt, the retreat into timeless states of mind as well as a re-entry mechanism in certain psychotic patients. Finally, the failure of reparative processes seems to be a central mechanism in sustaining the repetition compulsion. Brief clinical vignettes illustrate the author's arguments.

[Therapeutic Effort in Inpatient or Day Patient Treatments and Therapy Success in Patients with Depressive Disorders]. / Therapeutischer Aufwand in stationärer oder tagesklinischer Behandlung und Therapieerfolg bei Patienten mit depressiven Störungen.

Several therapeutic treatments like individual psychotherapy, group therapy, creative therapies and talks with the nursing staff are components in an inpatient psychosomatic (psychotherapeutic) treatment or a psychosomatic day hospital treatment. In Germany, these therapies have to be documented by the administration with so called OPS-Codes. These codes are reported to the Institute for Reimbursement in Hospitals (InEK). With the data of the INDDEP-study it should be investigated how the therapies of 7 hospitals and 8 day-hospitals compare to each other. In addition, it should be studied, if the amount of the documented therapies is connected to the outcome in these hospitals. In the INDDEP-study, data of patients with major depression were assessed at 4 measurement points (admission, discharge, 3 months and 12 months follow up). In addition, the OPS codes of the treatments were documented. The results show that it is possible to get a rough estimation of the psychotherapeutic doses by the OPS-codes. The results show significant differences between the hospitals in terms of the intensity and professional group composition of the treatments. This result is confirmed for in-patient and day hospital treatments. Correlation analyses showed no significant correlation between the total amount of therapy and the improvement in depressive symptoms. It is assumed that there are moderating variables (patient-, therapy and process-related) which moderate the relation between doses and outcome. This should be identified in further studies.

Strong Associations Between Inflammation, Pruritus and Mental Health in Dialysis Patients.

Pruritus, impaired mental health and inflammation contribute to morbidity in end-stage renal disease. There are no studies on all 3 conditions. We therefore obtained inflammatory parameter data (C-reactive protein and interleukin-6), pruritus data and psychological test data (36-Item Short-Form Health Survey, "Allgemeine Depressionsskala" and Toronto Alexithymia Scale-20) for 19 dialysis patients with pruritus, 20 dialysis patients without pruritus and 15 healthy controls. Non-parametric hierarchical clustering revealed 3 clusters of parameters: one mainly driven by pruritus scores (chronic kidney disease-associated pruritus cluster), one by mental health scores (mental health cluster) and one by inflammatory parameters (inflammatory cluster). Factor analysis showed strong associations (mental health cluster/chronic kidney disease-associated pruritus cluster, r=-0.49; mental health cluster/inflammatory cluster, r=-0.52; inflammatory cluster/chronic kidney disease-associated pruritus cluster, r=0.48). For the first time, complete correlations between inflammation, mental health and pruritus in dialysis patients have been established. As all 3 conditions are associated with mortality, knowledge about their interdependence helps to understand end-stage renal disease pathophysiology.

Patterns of symptom change in major depression: Classification and clustering of long term courses.

To evaluate treatment effects in depression, it is important to monitor change during treatment and also to follow up for a reasonably long time. Describing the variability of symptom change trajectories is useful to better predict long-term status and to improve interventions. Outcome data (N_complete = 518, 4 time points, 1 year of observation time) from a large naturalistic multi-center study on the effects of inpatient and day hospital treatment of unipolar depression were used to identify clusters of symptom trajectories. Common outcome classifications and statistical methods of longitudinal cluster analysis were applied. However, common outcome classifications (in terms of e.g. remission, relapse or recurrence) were not exhaustive, as 49.3% of the trajectories could not be allocated to its classes. Longitudinal cluster analysis reveals 7 clusters (fast response, slow response, retarded response, temporary or persistent relapse, recurrence, and nonresponse). Nonresponse at the end of treatment was a predictor of poor outcome at long term follow up. The classification of patterns of symptom change in depression should be extended. Longitudinal cluster analysis seems a valid option to analyze outcome trajectories over time if a limited number of time points of measurement are available.

The effects of social exclusion on response inhibition in borderline personality disorder and major depression.

It is a prevalent notion that borderline personality disorder (BPD) is characterized by deficits in executive functions (EF) like inhibition. Yet experimental studies yield inconsistent results. However, despite emotional dysregulation being a core feature of BPD, most paradigms did not control for emotional state or comorbid mental disorders. In the present study, subjects with BPD and comorbid MDD (BPD+MDD), with major depression (MDD) and healthy controls (HC) partook in a social exclusion paradigm combined with an inhibition task. We expected inhibition to be more strongly impaired in BPD+MDD than in depression and HC when experiencing negative emotions. Respecting inhibition, depressed patients performed best while (BPD+MDD) patients performed worst. Surprisingly, MDD & HC participants' performance improved during social exclusion, but this was not the case for BPD+MDD. Inhibition deficits were correlated with childhood trauma. These results challenge the hypothesis that an induction of negative emotion results in inferior inhibition in (BPD+MDD). Instead, patients with (BPD+MDD) seem to suffer from a more general inhibitory dysfunction. Importantly, (BPD+MDD) patients were not able to improve their performance during social exclusion like HC and MDD patients did. These findings need to be investigated further, particularly regarding the efficiency of neural networks regulating inhibition and effects of trauma.

The surprising modernity of Klein's Lectures on Technique and Clinical Seminars: Putting them in context.

Focusing on the vividness and modernity of Klein's 1936 lectures the author argues that Klein was very aware of the complexity of the transference-situation and the analyst's involvement in it. The Clinical Seminars of 1958 show that the concept of projective identification helped to further clarify her ideas and to anticipate later developments. Nevertheless she remaines sceptical about the counter-transference simply seen as a response to the patient's projections and warned against re-projecting it back into the patient.

Unconscious phantasy as a structural principle and organizer of mental life: The evolution of a concept from Freud to Klein and some of her successors.

Starting with Freud's discovery of unconscious phantasy as a means of accessing his patients' internal world, the author discusses the evolution of the concept in the work of Melanie Klein and some of her successors. Whereas Freud sees phantasy as a wish fulfilling imagination, dominated by primary process functioning and kept apart from reality testing, Klein understands phantasies as a structural function and organizer of mental life. From their very beginnings they involve object relations and gradually evolve from primitive body-near experiences to images and symbolic representations. With her concept of projective identification in particular, Klein anticipates the communicative function of unconscious phantasies. They are at the basis of processes of symbolization, but may also be put into the service of complex defensive operations. The author traces the further evolution of the concept from the contributions of S. Isaacs, the theories of thinking proposed by W.R. Bion and R. Money-Kyrle, Hanna Segal's ideas on symbolization and reparation all the way to the latest approaches by R. Britton, J. Steiner and others, including the understanding of transference and counter-transference as a 'total situation'. Points of contact with Freud are to be found particularly in connection with his concept of 'primal phantasies'. In the author's view, the idea of the transmission and communicative potential of unconscious phantasies enabled these authors to overcome the solipsistic origins of drive theory in favour of a notion in which unconscious phantasies both set down the coordinates of the inner world and form and reflect the matrix of inter-subjective relations.

Prognostic and prescriptive predictors of improvement in a naturalistic study on inpatient and day hospital treatment of depression.

BACKGROUND: The study aimed to identify prognostic (associated with general outcome) and prescriptive (associated with differential outcome in two different settings) predictors of improvement in a naturalistic multi-center study on inpatient and day hospital treatment in major depressive disorder (MDD). METHODS: 250 inpatients and 250 day hospital patients of eight psychosomatic hospitals were assessed at admission, discharge and a 3-months follow-up. Primary outcome was defined as a reduction of depressive symptomatology from admission to discharge and from discharge to follow-up (QIDS-C, total score). Percent improvement scores at discharge and at follow-up were entered as dependent variables into two General Linear Models with a set of predictor variables and the respective interaction terms with treatment setting. The selection of predictor sets was guided by statistical methods of variable preselection (LASSO). RESULTS: Three variables were associated with less improvement from admission to discharge: the number of additional axis-I diagnoses, axis-II co-morbidity (SCID) and lower motivation (expert assessment). Social support (F-SozU) predicted symptom course between discharge and 3-month follow-up. Patients with no absent / sick days prior to admission showed a less favorable symptom course after discharge when treated as inpatients. CONCLUSIONS: Patients with co-morbidity show less improvement during the active treatment phase. Motivation can be considered a prerequisite for symptom reduction, whereas social support seems to be an important factor for the maintenance of treatment gains. The lack in prescriptive predictors found may point to the fact that inpatient and day hospital treatment have comparable effects for most subgroups of patients with MDD.