The complexity of treatment-resistant depression: A data-driven approach.

BACKGROUND: Recent systematic reviews highlight great variability in defining and assessing treatment-resistant depression (TRD). A key problem is that definitions are consensus rather than data-led. This study seeks to offer a comprehensive socio-demographic and clinical description of a relevant sample. METHODS: As part of a pragmatic randomized controlled trial, patients (N = 129) were managed in primary care for persistent depression and diagnosed with TRD. Data included previous treatment attempts, characteristics of the depressive illness, functioning, quality of life, co-occurring problems including suicidality, psychiatric and personality disorders, physical health conditions, and adverse events. RESULTS: Findings show a severe and chronic course of depression with a duration of illness of 25+ years. Overall, 82.9 % had at least one other psychiatric diagnosis and 82.2 % at least one personality disorder; 69.8 % had significant musculoskeletal, gastrointestinal, genitourinary, or cardiovascular and respiratory physical health problems. All but 14 had severe difficulties in social and occupational functioning and reported severely impaired quality of life. Suicidal ideation was high: 44.9 % had made at least one serious suicide attempt and several reported multiple attempts with 17.8 % reporting a suicide attempt during childhood or adolescence. Of the patients, 79.8 % reported at least one adverse childhood experience. LIMITATIONS: Potential for recall bias, not examining possible interactions, and absence of a control group. CONCLUSIONS: Our findings reveal a complex and multifaceted condition and call for an urgent reconceptualization of TRD, which encompasses many interdependent variables and experiences. Individuals with TRD may be at a serious disadvantage in terms of receiving adequate treatment.

Violence and Capacity to Hate.

This paper analyses two opposite relational configurations: violence and the capacity to hate. The former results in a psychic impoverishment, the latter in a psychic development. Primarily, the aspects of violence and the inability to hate within modern Western society are introduced. When a psychic fragility is unconsciously supported by an entire society, it becomes even more difficult to alleviate, and transform into a resource promoting psychic development. The second section explores the use of hate by young children in order to show the naturalness of this emotion and its origin. In the third and fourth sections, the unfortunate outcomes of the incapacity to hate, leading to violent antisocial conduct, are explored. To do so, the pioneering contributions by Melanie Klein and Donald Winnicott are commented on, followed by modern contributions by the literature: one of our articles published in 2020, and the review of the literature published by Alessandro Orsini on the topic of radicalisation. Finally, the differences between violence and the capacity to hate are highlighted and summarised. The article also emphasises numerous bibliographic references to further deepen the study on violence from a psycho-social perspective.

How Do Adolescents Use Social Networks and What Are Their Potential Dangers? A Qualitative Study of Gender Differences.

The rapid development of software applications and the increasing use of the Internet have raised many questions about the impact of this technology on the lives of adolescents, especially on "digital natives." The advent of social networks (SNs) restructures their relationships in various ways, affecting both adolescents' development and mental health. The present study aims to investigate uses and dangers of SNs according to a sample of 296 (166 female and 130 male) Italian middle and high schools adolescents (age range 13-18) and build a model of how SNs can turn out to be dangerous. To achieve this, twenty-four audio-recorded focus groups of Italian male and female adolescents were investigated by a Grounded Theory approach, abstracting from the transcripts the main uses and dangers of SNs and proposing a final model for the interpretation of the whole set of categories. The results highlighted two main dangers of SNs: (a) the desperate search for popularity, and (b) the exhibition of violent or offensive behavior facilitated by the sense of protection and anonymity derived from being hidden behind a virtual account. Finally, a psychological model of how SNs can turn out to be dangerous is presented. This study could be useful in developing prevention procedures against the risks of SNs (e.g., cyberbullying, internet addiction) without demonizing the use of social media as such.

Stability and flexibility in psychotherapy process predict outcome.

Ten good outcome and ten poor outcome psychotherapy cases were compared to investigate whether or not the temporal stability and flexibility of their process variables can predict their outcomes. Each participant was monitored daily using the Therapy Process Questionnaire (TPQ), which has 43 items and seven sub-scales, and responses over time were analyzed in terms of correlation robustness and correlation variability across the TPQ sub-scales. "Correlation robustness" and "correlation variability" are two basic characteristics of any correlation matrix: the first is calculated as the sum of the absolute values of Pearson correlation coefficients, the second as the standard deviation of Pearson correlation coefficients. The results demonstrated that the patients within the poor outcome group had lower values on both variables, suggesting lower stability and flexibility. Furthermore, a higher number of cycles of increase and decrease in correlation robustness and variability of the TPQ sub-scales was observed within good outcome psychotherapies, suggesting that, these cycles can be considered as process-markers of good-outcomes. These results provide support for the validity of these quantitative process-parameters, correlation robustness and variability, in predicting psychotherapeutic outcomes. Moreover, the results lend support to the common clinical experience of alternating periods of flexibility and integration being beneficial to good psychotherapeutic processes.

To Work or Not to Work, That Is the Question: The Psychological Impact of the First COVID-19 Lockdown on the Elderly, Healthcare Workers, and Virtual Workers.

The spread of COVID-19 created a state of emergency all over the world and played a big role in the decline of the mental health of citizens. The context of the workplace became an important variable in the impact of the lockdown on individuals. In this study, we deepened the categories of healthcare workers (HWs), virtual workers (VWs), and the elderly, along with their emotional approach to this emergency. A sample of 257 participants (ElderlyN = 62; HWsN = 104; VWsN = 91) completed: a semi-structured interview on their experience during lockdown via telephone; an online survey with a sociodemographic questionnaire; the Difficulties in Emotional Regulation Scale (DERS); and the Post-Traumatic Growth Inventory (PTGI). Linguistic measures of the Referential Process were utilized to code the interviews. An independent ANOVA explored the variability among groups. The results show more affective language in the Elderly (M = 0.0310, SD = 0.0070) and a growth in spirituality (M = 4.16, SD = 3.17). HWs displayed a higher PTGI (M = 56.84, SD = 20.29), while VWs displayed a lower PTGI (M = 50.02, SD = 21.05). Moreover, VWs presented higher scores in Impulse on the DERS (M = 11.67, SD = 5.05) and a more cognitive/abstract narration (Reflection IREF M = 0.0260, SD = 0.0071; Reorganization IWRRL M = 0.5419, SD = 0.0032; Referential Activity IWRAD M = 0.4978, SD = 0.0029). This study aims to take the work context into consideration to create focused interventions.

Preliminary development of a questionnaire to measure the extra-pulmonary symptoms of severe asthma.

BACKGROUND: Research into the effects of asthma treatments on the extra-pulmonary symptoms of severe asthma is limited by the absence of a suitable questionnaire. The aim was to create a questionnaire suitable for intervention studies by selecting symptoms that are statistically associated with asthma pathology and therefore may improve when pathology is reduced. METHODS: Patients attending a specialist asthma clinic completed the 65-item General Symptom Questionnaire (GSQ-65), a questionnaire validated for assessing symptoms of people with multiple medically unexplained symptoms. Lung function (FEV1%) and cumulative oral corticosteroids (OCS) calculated from maintenance dose plus exacerbations were obtained from clinic records. Pathology was represented by the two components of a principal component analysis (PCA) of FEV1% and OCS. LASSO regression was used to select symptoms that had high coefficients with these two principal components and occurred frequently in severe asthma. RESULTS: 100 patients provided data. PCA revealed two components, one where FEV1% and OCS were inversely related and another where they were directly related. LASSO regression revealed 39 symptoms with non-zero coefficients on one or more of the two principal components from which 16 symptoms were selected for the GSQ-A on the basis of magnitude of coefficient and frequency. Asthma symptoms measured by asthma control questionnaires were excluded. The GSQ-A correlated 0.33 and - 0.34 (p = 0.001) with the two principal components. CONCLUSION: The GSQ-A assesses the frequency of 16 heterogenous non-respiratory symptoms that are associated with asthma severity using the statistical combination of FEV1% and OCS.

Convergent Validation of Methods for the Identification of Psychotherapeutic Phase Transitions in Time Series of Empirical and Model Systems.

AIM: In many cases, the dynamics of psychotherapeutic change processes is characterized by sudden and critical transitions. In theoretical terms, these transitions may be "phase transitions" of self-organizing nonlinear systems. Meanwhile, a variety of methods is available to identify phase transitions even in short time series. However, it is still an open question if different methods for timeseries analysis reveal convergent results indicating the moments of critical transitions and related precursors. METHODS AND PROCEDURES: Seven concepts which are commonly used in nonlinear time series analysis were investigated in terms of their ability to identify changes in psychological time series: Recurrence Plots, Change Point Analysis, Dynamic Complexity, Permutation Entropy, Time Frequency Distributions, Instantaneous Frequency, and Synchronization Pattern Analysis, i.e., the dynamic inter-correlation of the system's variables. Phase transitions were simulated by shifting control parameters in the Hénon map dynamics, in a simulation model of psychotherapy processes (one by an external shift of the control parameter and one created by a simulated control parameter shift), and three sets of empirical time series generated by daily self-ratings of patients during the treatment. RESULTS: The applied methods showed converging results indicating the moments of dynamic transitions within an acceptable tolerance. The convergence of change points was confirmed statistically by a comparison to random surrogates. In the three simulated dynamics with known phase transitions, these could be identified, and in the empirical cases, the methods converged indicating one and the same transition (possibly the phase transitions of the cases). Moreover, changes that did not manifest in a shift of mean or variance could be detected. CONCLUSION: Changes can occur in many different ways in the psychotherapeutic process. For instance, there can be very slow and small transitions or very high and sudden ones. The results show the validity and stability of different measures indicating pattern transitions and/or early warning signals of those transitions. This has profound implications for real-time monitoring in psychotherapy, especially in cases where a transition is not obvious to the eye. Reliably identifying points of change is mandatory also for research on precursors, which in turn can help improving treatment.

A Phase Transition of the Unconscious: Automated Text Analysis of Dreams in Psychoanalytic Psychotherapy.

AIM: Psychotherapy could be interpreted as a self-organizing process which reveals discontinuous pattern transitions (so-called phase transitions). Whereas this was shown in the conscious process of awake patients by different measures and at different time scales, dreams came very seldom into the focus of investigation. The present work tests the hypothesis that, by dreaming, the patient gets progressively more access to affective-laden (i.e., emotionally charged) unconscious dimensions. Furthermore, the study investigates if, over the course of psychotherapy, a discontinuous phase transition occurs in the patient's capacity to get in contact with those unconscious dimensions. METHODS AND PROCEDURES: A series of 95 dream narratives reported during a psychoanalytic psychotherapy of a female patient (published as the "dreams of Amalie X") was used for analysis. An automated text analysis procedure based on multiple correspondence analysis was applied to the textual corpus of the dreams, highlighting a 10-factor structure. The factors, interpreted as affective-laden unconscious meaning dimensions, were adopted to define a 10-dimensional phase space, in which the ability of a dream to be associated with one or more local factors representing complex affective-laden meanings is measured by the Euclidean distance (ED) from the origin of this hyperspace. The obtained ED time series has been fitted by an autoregressive integrated moving average (ARIMA) model and by non linear methods like dynamic complexity, recurrence plot, and time frequency distribution. Change point analysis was applied to these non linear methods. RESULTS: The results show an increased frequency and intensity of dreams to get access to affective-laden meanings. Non linear methods identified a phase transition-like jump of the ED dynamics onto a higher complexity level of the dreaming process, suggesting a non linear process in the patient's capacity to get in contact with unconscious dimensions. CONCLUSION: The study corroborates the hypothesis that, by dreaming, the patient gets progressively more access to affective-laden meaning intended as unconscious dimensions. The trajectory of this process has been reproduced by an ARIMA model, and beyond this, non linear methods of time series analysis allowed the identification of a phase transition in the unconscious process of the psychoanalytic therapy under investigation.

What Differentiates Poor- and Good-Outcome Psychotherapy? A Statistical-Mechanics-Inspired Approach to Psychotherapy Research, Part Two: Network Analyses.

Statistical mechanics is the field of physics focusing on the prediction of the behavior of a given system by means of statistical properties of ensembles of its microscopic elements. The authors examined the possibility of applying such an approach to psychotherapy research with the aim of investigating (a) the possibility of predicting good and poor outcomes of psychotherapy on the sole basis of the correlation pattern among their descriptors and (b) the analogies and differences between the processes of good- and poor-outcome cases. This work extends the results reported in a previous paper and is based on higher-order statistics stemming from a complex network approach. Four good-outcome and four poor-outcome brief psychotherapies were recorded, and transcripts of the sessions were coded according to Mergenthaler's Therapeutic Cycle Model (TCM), i.e., in terms of abstract language, positive emotional language, and negative emotional language. The relative frequencies of the three vocabularies in each word-block of 150 words were investigated and compared in order to understand similarities and peculiarities between poor-outcome and good-outcome cases. Network analyses were performed by means of a cluster analysis over the sequence of TCM categories. The network analyses revealed that the linguistic patterns of the four good-outcome and four poor-outcome cases were grounded on a very similar dynamic process substantially dependent on the relative frequency of the states in which the transition started and ended ("random-walk-like behavior", adjusted R 2 = 0.729, p < 0.001). Furthermore, the psychotherapy processes revealed statistically significant changes in the relative occurrence of visited states between the beginning and the end of therapy, thus pointing to the non-stationarity of the analyzed processes. The present study showed not only how to quantitatively describe psychotherapy as a network, but also found out the main principles on which its evolution is based. The mind, from a linguistic perspective, seems to work-through psychotherapy sessions by passing from the most adjacent states and the most occurring ones. This finding can represent a fertile ground to rethink pivotal clinical concepts such as the timing of an interpretation or a comment, the clinical issue to address within a given session, and the general task of a psychotherapist: from someone who delivers a given technique toward a consultant promoting the flexibility of the clinical field and, thus, of the patient's mind.

Monitoring Nonlinear Dynamics of Change in a Single Case of Psychodynamic Play Therapy.

A systematic single case study with a mixed quantitative and qualitative methodology was conducted to investigate the nonlinear dynamics of change in play profiles of a child in psychodynamic play therapy. The first aim of the study was to cluster the different features of play characteristics (i.e., descriptive, cognitive, affective, and social characteristics of play, and the defensive strategies used in play) in order to construct the different play profiles of this child, and secondly to assess the transitions between profiles over the course of treatment. It was expected that there would be an increase in critical fluctuations during the transitions between the profiles and an increase in the variability of play profiles. Results showed that the child's play characteristics clustered into eight states and three attractors. The Markov Transition Matrix showed how play profiles evolved over time. Entropy analyses comparing the first and the second half of therapy showed an increase in variability. Qualitative analyses indicated the importance of expression of the child's underlying fear, and its integration with overt anger in the generation of the new play profiles. The results indicate an increase in variability, and a destabilization of old play profiles that were used towards generating new play profiles.

The Non-linear Trajectory of Change in Play Profiles of Three Children in Psychodynamic Play Therapy.

Aim: Even though there is substantial evidence that play based therapies produce significant change, the specific play processes in treatment remain unexamined. For that purpose, processes of change in long-term psychodynamic play therapy are assessed through a repeated systematic assessment of three children's "play profiles," which reflect patterns of organization among play variables that contribute to play activity in therapy, indicative of the children's coping strategies, and an expression of their internal world. The main aims of the study are to investigate the kinds of play profiles expressed in treatment, and to test whether there is emergence of new and more adaptive play profiles using dynamic systems theory as a methodological framework. Methods and Procedures: Each session from the long-term psychodynamic treatment (mean number of sessions = 55) of three 6-year-old good outcome cases presenting with Separation Anxiety were recorded, transcribed and coded using items from the Children's Play Therapy Instrument (CPTI), created to assess the play activity of children in psychotherapy, generating discrete and measurable units of play activity arranged along a continuum of four play profiles: "Adaptive," "Inhibited," "Impulsive," and "Disorganized." The play profiles were clustered through K-means Algorithm, generating seven discrete states characterizing the course of treatment and the transitions between these states were analyzed by Markov Transition Matrix, Recurrence Quantification Analysis (RQA) and odds ratios comparing the first and second halves of psychotherapy. Results: The Markov Transitions between the states scaled almost perfectly and also showed the ergodicity of the system, meaning that the child can reach any state or shift to another one in play. The RQA and odds ratios showed two trends of change, first concerning the decrease in the use of "less adaptive" strategies, second regarding the reduction of play interruptions. Conclusion: The results support that these children express different psychic states in play, which can be captured through the lens of play profiles, and begin to modify less dysfunctional profiles over the course of treatment. The methodology employed showed the productivity of treating psychodynamic play therapy as a complex system, taking advantage of non-linear methods to study psychotherapeutic play activity.

Synchronization Analysis of Language and Physiology in Human Dyads.

We studied the synchronization dynamics of a therapist and patient during a psychotherapy session. This investigation was developed in order to explore a new possible perspective and methodology for studying the expression of emotions. More specifically, literature concerning synchronization of in-session non-verbal variables emphasises its positive correlation with empathy and therapeutic outcomes. We compared the dynamics of galvanic skin response (GSR) and linguistic prosody, chosen as indicators of emotional expression in different domains. We studied their synchronization through complementary methodologies: Recurrence Quantification Analysis (RQA) and Principal Component Analysis (PCA), Markov Transition Matrix (MTM) and Cross-Recurrence Quantification Analysis (CRQA). We investigated the nonlinearity of GSR in terms of self-similarity and power-law, as emerged in autocorrelation functions and signal variations. We considered time-lagged correlations as a measure of dynamical systems' memory. This article concludes by highlighting the importance of a deeper study of all variables related to the psychotherapeutic process and their synchronization in order to extend our knowledge of general human dynamics.