Mentalization Psychotherapy for Patients Presenting with a Psychotic Personality Structure: A Contemporary Approach.

Overt psychotic symptoms, currently understood as resulting from both neurobiological and developmental etiological factors, are also associated with deficits in mentalization in a subgroup of patients presenting with psychotic personality structure. Neurodevelopmental and traumatic impairments seen in this subtype of psychotic disorders create a pressure or need for what has been called a transformational mentalizing process. This specific form of mental elaboration focuses explicitly on finding words and images that help patients to grasp their emotional and mental states. It thus differs from mainstream mentalization treatment, which puts a greater emphasis on reflective functioning. A psychodynamically informed mentalization-based individual and group psychotherapy for this subgroup of patients was developed, aiming at augmenting the patient's psychological resources through explicit transformational mentalization, rather than primarily targeting symptom reduction. This program stimulates curiosity about one's mental states, progressively aiming to give shape to and explore affectively charged mental states, and is integrated with other treatment modalities. This article presents a psychological model of psychotic personality structure and its psychotherapeutic implications, as well as clinical illustrations. Preliminary findings from a pilot study provide encouraging support for the model, including emerging reflective capacities and symptom reduction, as well as overall improvement of social and occupational functioning.

Assessing Psychodynamic Conflict.

Psychodynamic psychotherapies suggest that symptomatic relief is provided, in part, with the resolution of psychic conflicts. Clinical researchers have used innovative methods to investigate such phenomenon. This article aims to review the literature on quantitative psychodynamic conflict rating scales. An electronic search of the literature was conducted to retrieve quantitative observer-rated scales used to assess conflict noting each measure's theoretical model, information source, and training and clinical experience required. Scales were also examined for levels of reliability and validity. Five quantitative observer-rated conflict scales were identified. Reliability varied from poor to excellent with each measure demonstrating good validity. However a small number of studies and limited links to current conflict theory suggest further clinical research is needed.

Toward developing a scale to empirically measure psychotic defense mechanisms.

In recent years, research on psychological processes has greatly advanced our understanding of various psychopathologies. Defense mechanisms, for example, have been described as observable phenomena, and studies have shown meaningful relationships among these processes and other measurable dimensions of health and illness. Despite some notable exceptions, one area that has been overlooked is the empirical study of defenses in psychotic disorders. This is in part due to the lack of valid instruments measuring psychotic-level defenses. Propadeutic to creating an empirical scale for measuring psychotic defenses, the psychoanalytic and empirical literature on psychotic defenses is reviewed, after which the concept of psychotic defenses as measured by the P-DMRS (Psychotic-Defense Mechanism Rating Scales)--which can be used independently or in combination with the current DMRS (Defense Mechanism Rating Scales)--is operationalized. Finally, current research directions applying the P-DMRS to the clinical setting are presented, as well as its implications for guiding current clinical practice.

Chronic gamma-hydroxybutyric-acid use followed by gamma-hydroxybutyric-acid withdrawal mimic schizophrenia: a case report.

INTRODUCTION: Gamma-hydroxybutyric-acid is a potentially addictive drug known for its use in "rave" parties. Users have described heightened sexual drive, sensuality and emotional warmth. Its euphoric, sedative and anxiolytic-like properties are also sought by frequent users. Abrupt gamma-hydroxybutyric-acid withdrawal can rapidly cause tremor, autonomic dysfunction and anxiety, and may later culminate in severe confusion, delirium, auditory, visual or tactile hallucinations, or even death. CASE PRESENTATION: A 23-year-old woman presented to the emergency room with paranoid delusions and auditory hallucinations. Her psychiatric history included two brief psychotic episodes induced by amphetamines and marijuana. In the last six months, she had demonstrated bizarre behaviour, had been more isolated and apathetic, and unable to take care of daily chores. The patient reported occasional use of gamma-hydroxybutyric-acid, but her initial accounts of drug use were contradictory. Since the toxicology urine screen was negative, a schizophrenic disorder was initially suspected and an antipsychotic medication was prescribed. A few hours after her admission, signs of autonomic dysfunction (tachycardia and hypertension) appeared, lasting 24 hours. Severe agitation and confusion were also present. Restraints and a cumulative dose of 7 mg lorazepam were used to stabilize her. The confusion resolved in less than 72 hours. The patient then revealed that she had been using gamma-hydroxybutyric-acid daily for the last six months as self-medication to treat insomnia and anxiety, before stopping it abruptly 24 hours prior to her visit. CONCLUSIONS: In our opinion, this original case illustrates the importance of considering gamma-hydroxybutyric-acid withdrawal delirium in the differential diagnosis of a first-break psychosis. In this case, the effects of chronic GHB use were incorrectly identified as the negative symptoms of schizophrenia prodrome. Likewise, severe gamma-hydroxybutyric-acid withdrawal syndrome was initially mistaken for acute positive symptoms of schizophrenia, until autonomic dysfunction manifested itself more clearly.