[The own and the foreign. Philosophical and clinical aspects]. / Das Eigene und das Fremde. Philosophische und klinische Aspekte.

INTRODUCTION: The own and the foreign are not actually philosophical basic concepts, but rather topoi, since they always relate to each other relationally and this always in relation to the perspective in which we experience something as foreign or own. Strangeness concerns us, irritates, unsettles, does not leave us alone, but at the same time, as strangeness, it eludes determination or cannot be determined, since it would then lose its strangeness. It has the character of a relapse, is paradoxically determined by presence in withdrawal, cannot be completely classified, is thus "extraordinary" and singular. It is incomparable and yet related to one's own. The article attempts a philosophical approach to the particularity of the foreign - also in ourselves - in order to clarify the theoretical considerations for the understanding of a concrete clinical case from a psychiatric-transcultural consultation. This case deals with the question of non-understanding in the face of a behavior of the patient that is alienating for the therapist as well as for the patient. This leads to the question whether and how this non-understanding could still be understandable.

Exclusion-Proneness in Borderline Personality Disorder Inpatients Impairs Alliance in Mentalization-Based Group Therapy.

Interpersonal sensitivity, particularly threat of potential exclusion, is a critical condition in borderline personality disorder (BPD) which impairs patients' social adjustment. Current evidence-based treatments include group components, such as mentalization-based group therapy (MBT-G), in order to improve interpersonal functioning. These treatments additionally focus on the therapeutic alliance since it was discovered to be a robust predictor of treatment outcome. However, alliance is a multidimensional factor of group therapy, which includes the fellow patients, and may thus be negatively affected by the exclusion-proneness of BPD patients. The aim of this pilot study was to examine the predictive value of threat of social exclusion for the therapeutic alliance in MBT-G. In the first part of the study, social exclusion was experimentally induced in 23 BPD inpatients and 28 healthy subjects using the Cyberball paradigm, a virtual ball tossing game. The evoked level of threat was measured with the Need-Threat Scale (NTS) which captures four dimensions of fundamental human needs, i.e., the need for belongingness, for self-esteem, for control, and for a meaningful existence. In the second part of the study, therapeutic alliance was measured on three dimensions, the therapists, the fellow patients and the group as a whole, using the Group-Questionnaire (GQ-D). BPD patients scored higher in their level of threat according to the NTS in both, the inclusion and the exclusion condition. The level of threat after exclusion predicted impairments of the therapeutic alliance in MBT-G. It was associated with more negative relationships, lower positive bonding and a lower positive working alliance with the fellow patients and lower positive bonding to the group as a whole whilst no negative prediction of the alliance to the therapists was found. Consequently, our translational study design has shown that Cyberball is an appropriate tool to use as an approach for clinical questions. We further conclude that exclusion-proneness in BPD is a critical feature with respect to alliance in group treatments. In order to neutralize BPD patients' exclusion bias, therapists may be advised to provide an "inclusive stance," especially in initial sessions. It is also recommendable to strengthen patient to patient relations.

Impact of Interpersonal Problems in Borderline Personality Disorder Inpatients on Treatment Outcome and Psychopathology.

BACKGROUND: Borderline personality disorder (BPD) is a very common illness; interpersonal problems are one of the core features. The purpose of this study was to investigate the changes in interpersonal problems after transference-focused psychotherapy (TFP)-based disorder-specific treatment and to explore whether the severity of interpersonal problems could serve as a predictor for other variables. SAMPLING AND METHODS: A sample of 37 inpatients with BPD was assessed with the Structured Clinical Interviews for DSM-IV Axis I and II Disorders (SCID I and II) and had to complete a questionnaire including the Inventory of Interpersonal Problems (IIP-C), Inventory of Personality Organization (IPO), Beck Depression Inventory (BDI), Spielberger State and Trait Inventory (STAI), Spielberger State and Trait Anger Inventory (STAXI), and Symptom Checklist-90 (SCL-90-R). After 12 weeks of TFP-based disorder-specific treatment, the patients repeated the same questionnaire; 7 patients had to be excluded from the study, and thus calculations were conducted with 30 patients. RESULTS: After treatment, the patients showed a significant decrease in the IIP total item score and all 8 subscales except the domineering, intrusive, and cold scales. The IIP total item baseline score was correlated with borderline symptomatic and psychopathology [e.g. anxiety, Global Severity Index (GSI)] after 12 weeks as well as with most IIP postsubscales. CONCLUSIONS: Although interpersonal problems are considered one of the more stable features of BPD, our results showed a significant improvement after 12 weeks of TFP-based disorder-specific inpatient treatment, especially in the total score and the subscales on the friendly submissive level. The severity of interpersonal problems at baseline was connected to outcome values of other borderline features as well as general psychiatric complaints. It therefore seems important to consider the treatment of interpersonal problems in therapy to be of greater significance.

Role of calcium, glutamate and NMDA in major depression and therapeutic application.

Major depression is a common, recurrent mental illness that affects millions of people worldwide. Recently, a unique fast neuroprotective and antidepressant treatment effect has been observed by ketamine, which acts via the glutamatergic system. Hence, a steady accumulation of evidence supporting a role for the excitatory amino acid neurotransmitter (EAA) glutamate in the treatment of depression has been observed in the last years. Emerging evidence indicates that N-methyl-D-aspartate (NMDA), group 1 metabotropic glutamate receptor antagonists and α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) agonists have antidepressant properties. Indeed, treatment with NMDA receptor antagonists has shown the ability to sprout new synaptic connections and reverse stress-induced neuronal changes. Based on glutamatergic signaling, a number of therapeutic drugs might gain interest in the future. Several compounds such as ketamine, memantine, amantadine, tianeptine, pioglitazone, riluzole, lamotrigine, AZD6765, magnesium, zinc, guanosine, adenosine aniracetam, traxoprodil (CP-101,606), MK-0657, GLYX-13, NRX-1047, Ro25-6981, LY392098, LY341495, D-cycloserine, D-serine, dextromethorphan, sarcosine, scopolamine, pomaglumetad methionil, LY2140023, LY404039, MGS0039, MPEP, 1-aminocyclopropanecarboxylic acid, all of which target this system, have already been brought up, some of them recently. Drugs targeting the glutamatergic system might open up a promising new territory for the development of drugs to meet the needs of patients with major depression.

Change in Identity Diffusion and Psychopathology in a Specialized Inpatient Treatment for Borderline Personality Disorder.

OBJECTIVES: Patients with borderline personality disorder (BPD) show various psychopathological symptoms and suffer especially from disturbance in their identity. The purpose of the study was to investigate changes-particularly in affective BPD symptoms and identity diffusion-during a structured, disorder-specific inpatient treatment (DST) that combined a psychodynamic transference-focused psychotherapy approach with modules of dialectical behavioural skills training. METHOD: In a prospective, two-group comparison trial, 44 patients with BPD were assessed with questionnaires addressing identity diffusion and state, as well as trait affective psychopathology, before and after 12 weeks of inpatient treatment. Thirty-two patients received DST, whereas 12 patients were given inpatient treatment-as-usual (TAU). The patients were allocated in a non-random procedure for two groups, in order of admission and availability of treatment options in the DST unit. RESULTS: In the pre-post-comparison, the DST group showed a significant decrease in identity diffusion (p < 0.001) and improvements in instability of the image of self and others (p < 0.008), as well as in pathological (trait and state) symptoms. However, there was no significant improvement in the TAU group. CONCLUSIONS: After a 12-week inpatient treatment, the findings indicate significant improvements in the DST group in typical affective borderline symptomatology and in the personality structure feature of identity diffusion. This highlights the significance of a short-term specific inpatient therapy for BPD. KEY PRACTITIONER MESSAGE: A structured, disorder-specific inpatient treatment of patients diagnosed with borderline personality disorder (BPD) combined a psychodynamic transference-focused psychotherapy treatment approach (focusing on pathological features in personality organization, particularly on non-integrated images of self and others) with modules of dialectical behavioural skills training. This treatment is associated with a decrease in identity diffusion of these patients after 12 weeks of treatment. The treatment is also related to a significant decrease in borderline typical psychopathological symptoms such as depressive symptoms, as well as an improvement in state anger. The outcomes of this structured, disorder-specific inpatient treatment of severely ill BPD patients indicated the relevance of intensive short-term inpatient psychotherapy in terms of psychopathological improvements as well as initial changes in structural personality organization.

Comorbid atypical depression in borderline personality disorder is common and correlated with anxiety-related psychopathology.

BACKGROUND: The core features of borderline personality disorder (BPD) are affective instability, unstable relationships and identity disturbance. Axis I comorbidities are frequent, in particular affective disorders. The concept of atypical depression is complex and often underestimated. The purpose of the study was to investigate the comorbidity of atypical depression in borderline patients regarding anxiety-related psychopathology and interpersonal problems. METHODS: Sixty patients with BPD were assessed with the Structured Clinical Interviews for DSM-IV Axis I and II Disorders (SCID I, SCID II) as well as the Atypical Depression Diagnostic Scale (ADDS). Additionally, patients completed a questionnaire (SCL-90-R, BDI, STAI, STAXI, IIP-C). RESULTS: Forty-five BPD patients (81.8%) had a comorbid affective disorder of which 15 (27.3%) were diagnosed with an atypical depression. In comparison to patients with major depressive disorder or no comorbid depression, patients with atypical depression showed significant higher scores in psychopathological symptoms regarding anxiety and global severity as well as interpersonal problems. CONCLUSIONS: The presence of atypical depression in borderline patients is correlated with psychopathology, anxiety, and interpersonal problems and seems to be of clinical importance for personalized treatment decisions.

The inversion of the fall: on identity construction in anorexia nervosa.

Anorexia nervosa can be comprehended as an illness in the broader context of Western culture. The myth of the Fall, narrating a forbidden act of eating, provides a symbolic background of a philosophical-anthropological comprehension of the identity of man, which frames a clinically relevant point of view of anorexia nervosa. The formation of identity in its broader anthropological sense and particularly with people suffering from anorexia nervosa is subjected to a philosophical and psychological analysis consulting the relevant philosophical, sociological and psychodynamic literature. The order of eating in terms of interdiction and disobedience anthropologically constitutes the identity of men: by ignoring the divine taboo, men can reach consciousness and culture. Philosophy and psychoanalytical theory have focused on this process regarding an emerging capacity to symbolize and on its relation to emancipation and the pursuit of autonomy. Under postmodern conditions with a decline of stable cultural value systems and traditional structures the process of an emancipatory identity construction becomes critical. Surrogates replace missing values; thus, injunctions such as to enjoy substitute interdictions. This paper sheds light on the impact of these cultural conditions and their postmodern changes on the identity construction of anorexia nervosa. Moreover, implications for psychotherapeutic treatment are outlined. Besides the medico-scientific models, a multifaceted understanding of anorexia nervosa has to consider cultural contexts and symbolic processes that matter in the disorder in order to provide a broader background for the treatment approach of the anorectic patient.

On identity: from a philosophical point of view.

BACKGROUND: The term "identity" has a much longer tradition in Western philosophy than in psychology. However, the philosophical discourse addresses very different meanings of the term, which should be distinguished to avoid misunderstandings, but also to sharpen the key meanings of the term in psychological contexts. These crucial points in the philosophical concepts of identity in the sense of singularity, individuality, or self-sameness may structure the ongoing discussion on identity in psychiatric diagnoses (as in DSM-5, Child Adolesc Psychiatry Ment, this issue, 2013), in psychology, psychoanalysis, but also neuroscience and neurophilosophy (Child Adolesc Psychiatry Ment, this issue, 2013). METHOD: The concept of identity is subjected to a systematic philosophical analysis following some milestones in its history to provide a background for recent discussions on identity in psychiatry and psychology. RESULTS: The article focuses first on the philosophical core distinctions of identity in the different meanings to be addressed, second, briefly on some of the diverse psychological histories of the concept in the second half of the 20th century. Finally some reflections are presented on borderline personality disorder, considered as a mental disorder with a disturbance or diffusion of identity as core feature, and briefly on a newly developed instrument assessing identity development and identity diffusion in adolescence, the AIDA that is also presented in the special issue of this journal (Child Adolesc Psychiatry Ment, this issue, 2013). CONCLUSION: As a conclusion, different points of view concerning identity are summarized in respect to treatment planning, and different levels of description of identity in phenomenology, philosophy of mind, cognitive science, and social science and personality psychology are outlined.

Associations between identity diffusion, Axis II disorder, and psychopathology in inpatients with borderline personality disorder.

BACKGROUND: Patients with borderline personality disorder (BPD) suffer from instability in their relationships, their affectivity, and their identity. However, the associations between these dimensions are not clear. The purpose of the present study was to investigate the relation between identity diffusion and psychopathology in BPD. METHODS: In the second week of inpatient treatment, 52 patients with BPD were assessed with the Inventory of Personality Organization (IPO) and questionnaires measuring general psychiatric symptoms, mood states, and negative affects (SCL-90-R, BDI, STAI, and STAXI). A median split was examined to differentiate BPD patients with high identity diffusion from those with low identity diffusion. RESULTS: BPD patients with high identity diffusion did not differ in their social data from BPD patients with low identity diffusion. However, BPD patients with high identity diffusion showed significantly higher levels of psychiatric symptoms, as well as higher anxiety, anger, and depression scores (p < 0.01). Moreover, they suffered more frequently from concurrent personality disorders (p < 0.05). CONCLUSIONS: These findings indicate an association of identity diffusion with psychopathological symptoms and features of personality disorder and emphasize the clinical significance of identity diffusion for patients with BPD.

The self-image in borderline personality disorder: an in-depth qualitative research study.

Patients with borderline personality disorder (BPD) suffer from affective instability, impulsivity, and identity disturbance which particularly manifest in an unstable or insecure self-image. One main problem for studies of core psychopathology in BPD is the complex subject of identity disturbance and self-image. The purpose of this study was to investigate the self-image of BPD patients with a qualitative research approach. Twelve patients with BPD were compared to 12 patients with remitted major depressive disorder (MDD) without personality disorder, using the Structured Interview of Personality Organization (STIPO). The transcribed interviews were analyzed using a combination of content analysis and grounded theory. BPD patients described themselves predominantly as helpful and sensitive; reported typical emotions were sadness, anger, and anxiety. MDD patients on the other hand reported numerous and various characteristics and emotions, including happiness, as well as sadness and anxiety. Other persons were characterized by the BPD group as egoistic and satisfied, while the MDD group described others as being balanced and secretive. BPD patients displayed an altruistic, superficial, and suffering self-image. Aggressive tendencies were only seen in other persons. Our findings support the concept of a self and relationship disturbance in BPD which is highly relevant for psychotherapy treatment.

[Antidementia drugs]. / Antidementiva.

The pharmacological treatment of dementias aims to improve cognitive deficits, activities of daily living and behavioural and psychiatric symptoms. The weighting of theses therapeutic aims varies with disease progression. Behavioural symptoms may dominate especially in the more severe stages of the disease and may further deteriorate global functional level of the patient. Today there is no causal therapy for Alzheimer's disease (AD). Based on preclinical disease models novel therapeutic approaches are under development that target the beta-amyloid and tau protein metabolism. Some of them aim to inhibit the formation, aggregation and toxicity of beta-amyloid peptides or promote their clearance from the brain. Others inhibit the formation of neurofibrillary tangles or have neuroprotective effects. Active or passive immunisation against beta-amyloid may be a very specific and effective approach. The efficacy of acetylcholine esterase inhibitors (AchEI) in the treatment of mild to moderate AD is well documented. They are first line therapeutics in the treatment of the disease and lead to a delay of symptomatic progression. Memantine is effective in the treatment of moderate to severe stages of AD. The evidence for the treatment of vascular dementia is comparatively weak. However, positive effects have been shown for all available AchEI and memantine. Non pharmacological therapy is an indispensable part of the treatment of dementia patients and should be adapted to the individual needs of the patient in the respective stage of the disease. The efficacy of antipsychotics in the treatment of behavioural and psychiatric symptoms of dementia is limited. These drugs are associated with increased morbidity and mortality in dementia patients. Therefore, their application should be based on a critical and individual evaluation of risks and benefits.

[Children of psychotic parents]. / Kinder psychosekranker Eltern - Qualitative Biografieforschung als Forschungsdesiderat -

OBJECTIVE: A focused review of a selected part of research on psychotic parents' children is being provided. The paper presents a general survey of high-risk-studies followed by a critical discussion of some of the research being done about the relatives of psychotic people. This discussion is inspired and guided by a crucial interest in the subjective dimension of biography. RESULTS: It will be shown that there is only very little research being done on the perspective of the involved people themselves. The tradition of Bleuler and Anthony, demanding a strong shift to questions of resilience and coping, is being considered only hesitatively. On the other hand, qualitative research drawing on hermeneutic methods seems to be restricted to case studies mainly. CONCLUSIONS: Children's capacity to integrate their experiences with a psychotic parent into their own lives very often shows up in biographic narratives. Thus it is accessible to a methodologically elaborated qualitative analysis. Considering the growing interest in children being affected by their parents' psychosis - especially in their ability to cope with their specific situation - the paper pleads for more extensive research on the biographies of these people and the narratives shaping them.