The Quest for Greatness in the Race to Not Be Forgotten.

Details from a brief psychoanalytic treatment with a disturbed and desperate patient in acute emotional crisis are used to consider the internal dread some patients have regarding separation from the object and their phantasy of eternal damnation as a result of self-differentiation. One patient's loyalty to her object as the only way to prevent abandonment is examined in depth, but also considered as a severe psychic struggle found in other disturbed patients. The nature of this pathological loyalty has to do with the internalized and projected demand for perfection as the only currency for love and acceptance. Theoretical considerations are offered from a Kleinian perspective.

Exploring a patient's shift from relative silence to verbal expressiveness: observations on an element of the analyst's participation.

By tracing a portion of close process of a patient's shifts from a relatively silent and inhibited stance to one in which he is beginning to verbalize more about his experience and fantasy, I will illustrate some tensions between the analyst's role as facilitating expressiveness and as occupying a place in the patient's internalized world. Since the analyst's functions as facilitator and as internal object (often an obstacle to the patient's expressiveness) are sometimes in conflict with one another, it is important for the analyst to be able to work internally with this conflict as he works with his patient. Splitting processes between these two functions may provide the analyst with cues related to the patient's and the analyst's resistance to understanding the patient's communication of unconscious conflict and the patient's recruitment of the analyst into the patient's internalized world.

Patients with cluster a personality disorders in psychotherapy: an effectiveness study.

BACKGROUND: While psychopharmacological studies are common in patients with cluster A personality disorders, the effects of psychotherapy have received little attention. The aim of this study is to explore whether psychotherapeutic treatment yields health gains for these patients. METHODS: The study was conducted between March 2003 and June 2008 in 6 mental health care centres in the Netherlands, with a sample of 57 patients with a DSM-IV-TR axis II cluster A diagnosis. Patients were assigned to 3 settings of psychotherapeutic treatment (outpatient, day hospital, inpatient), and effectiveness was assessed at 18 months after baseline. An intention-to-treat analysis was conducted for psychiatric symptoms (Brief Symptom Inventory), psychosocial functioning (Outcome Questionnaire-45) and quality of life (EQ-5D), using multilevel statistical modelling. As the study was non-randomised, the propensity score method was used to control for initial differences. RESULTS: Patients in the day hospital and inpatient group improved substantially in terms of psychiatric symptoms, social and interpersonal functioning, and quality of life. Patients in the outpatient group showed less improvement. Direct comparison of the improvement of psychiatric symptoms showed significant results in favour of day hospital (p = 0.046) and inpatient (p = 0.01) treatment, as compared to outpatient treatment. However, due to substantial baseline differences, this direct comparison should be judged carefully. CONCLUSIONS: Cluster A psychopathology is not a contraindication to benefit from psychotherapy. This is especially true for more intensive forms like inpatient and day hospital treatment. Future research should focus more on psychotherapeutic treatment to gain further insight into effective treatment options for this patient group.

After hours: temporal developments at the edge of the analytic session.

The author presents case material of a rigid, schizoid patient who at some point during his treatment began to come late for sessions. He once missed an entire session only to appear at the door after the scheduled hour had passed; this "timing" was evidently intentional. Discussion centers upon the meaning of this kind of phenomenon; it seemed that this particular patient was trying to remold the analytic frame, and the analyst's temporal experience, in accordance with a deeply primitive experience of the "shape" of time, and thereby carve out a sanctuary into which he could sequester his idiosyncratic sense of nontime until circumstances enabled further progress toward more mature symbolization of time.

"I am not complaining"--ambivalence construct in schizoid personality disorder.

Patients with schizoid personality disorders (SPD) often challenge clinicians because of their seemingly detached and restricted affective behaviour, which may be interpreted as lack of motivation for treatment and lifestyle changes. However, Bleuler indicated the intrapsychic dynamics of ambivalence in schizoid disorder, and it has been discussed in later literature on psychopathology. Schizoid ambivalence refers to contrasting feelings in patients of a seemingly emotionally detached appearance that may curtain an inner, heightened sensitivity and longing for closeness. This article introduces different diagnostic and theoretical descriptions of the ambivalence construct in the schizoid personality disorder. The discussion is elaborated by means of a case example, presenting both the patient's and professionals' points of view on the treatment process. We use the concepts of treatment alliance and countertransference as explanatory models in the discussion of how the schizoid ambivalence may affect the treatment relationship.

Immersion in the surface.

In order to treat patients with a narcissistic structure showing a rigid shell of defence together with a lack of inner differentiation - insufficient subject/object constitution - one has to deal with a split kind of transference. Their compelling need for distance corresponds to their fragile self-esteem. They feel threatened by the analysis and the analytic relationship. Because the seeming normality of these patients' thinking and language is deceptive, a variation of psychoanalytic technique to facilitate the work with them is described and explained in detail. To transform their two-dimensional 'inner' world, which functions in a PS modus, it is helpful to show them, with changing viewpoints step by step, their own manoeuvres, misconceptions and manipulative use of language within the analytic relationship. The gratifying extension of their self-awareness leads to the introjection of the analyst's alpha-function. This makes possible a more distinct separation of subject and object representations and a transformation to a three-dimensional, oedipally structured world with a strengthened capacity to symbolize. This method of working is grounded in Bion's theory of thinking. A case vignette illustrates a development of this kind.

Equipos comunitarios de salud mental (ECSM) para personas con enfermedades mentales graves y trastornos de personalidad

Antecedentes: El cierre de asilos e instituciones para pacientes con enfermedades mentales, acompañado de las políticas gubernamentales que se centran en la reducción del número de camas hospitalarias para los pacientes con enfermedades mentales graves y que están a favor de la prestación de asistencia en una variedad de ámbitos extrahospitalarios, respalda el fundamento para la atención comunitaria. Un paso importante hacia la atención comunitaria ha sido el desarrollo de equipos comunitarios de salud mental (ECSM). Objetivos: Evaluar la efectividad de los Equipos Comunitarios de Salud Mental (ECSM) en el tratamiento de cualquier tipo de enfermedad mental grave en comparación con el tratamiento estándar de estas enfermedades sin estos equipos. (AU)

Cluster A personality disorders: considering the 'odd-eccentric' in psychiatric nursing.

Psychiatric nurses are familiar with the concept of personality disorder because of their contact with persons with the most common personality disorder in clinical settings - borderline type, who frequently engage mental health services. Perhaps it is this familiarity that has focused research and clinical attention on borderline personality disorder compared with the other personality disorders. The significance of cluster A personality disorders for nursing is multifaceted because of their severity, prevalence, inaccurate diagnosis, poor response to treatment, and similarities to axis I diagnoses. Despite this, literature reviews have established that relatively few studies have focused on the treatment of the cluster A personality disorders - paranoid, schizotypal, and schizoid - resulting in a dearth of evidence-based interventions for this group of clients. A discussion of these disorders in the context of personality disorder and their individual characteristics demonstrates the distinctive and challenging engagement techniques required by psychiatric nurses to provide effective treatment and care. It is also strongly indicated that the discipline of psychiatric nursing has not yet begun to address the care of persons with cluster A personality disorders.

[Links between burden of care in parents of patients with schizophrenia or personality disorders and family interactions]. / Zwiazki miedzy brzemieniem rodziców osób z rozpoznaniem schizofrenii lub zaburzen osobowosci a ksztaltowaniem sie relacji w rodzinie.

AIM: The aim of this study is to explore relationships between burden of care in parents of patients with schizophrenia or personality disorders and family interactions. Two main types of family interactions were distinguished according to Stierlin's theory: binding and expelling. Whereas binding leads to an increase in mutual dependency, expelling leads to a rise of mutual independence. METHOD: Families were divided into three groups according to the ICD-10 diagnosis of the index offspring (18-35 years old): (1) schizophrenia (N=33), (2) personality disorder (N=35), (3) control group (N=35). There were no significant differences in the mean age of adult children and mean age of parents, occupational patterns of parents, number of children in families and length of marriage between three groups. Subjects (mother, father and young adult) completed the originally designed questionnaires in which psychometric properties had been analyzed in earlier pilot research. RESULTS: In families with schizophrenic young adults, the levels of burden were elevated. However there was no statistical significance between the mean scores of parental burden in the families of schizophrenic patients and young adults with diagnosis of personality disorders. Parental burden was positively correlated with parents' expelling in families with young adults with schizophrenia or personality disorders. Father's burden was positively correlated with mother's expelling in all groups of families. CONCLUSIONS: This study suggests that the degree of parental burden may have an impact on family interactions.

How to play with patients who would rather remain remote.

Playful technique with negativistic, schizoid patients is described and further explained. They are seen as closing their mind, imagination, needs, and feelings to protect themselves against the terrifying dangers of human relatedness (vulnerability, need, hurt, loss, fusion, destruction). The analyst, while respecting the schizoid patient's need for protection, affirmation, and validation, seeks creative ways of engaging the patient more closely. Playful technique with schizoid patients combines the analyst's sensitive, playful attitude with an invitation to playful action as an experiment with new feelings, longings, hopes, and expectations. Playful engagement is one technique for attempting to engage patients not now open to verbal interpretation. To succeed with such patients, the analyst needs to connect with the core of their protectiveness and thereby come to enjoy their defensive powers, tolerate their need of the analyst, and not feel insulted. The analyst's light, playful approach to these patients' life-and-death terrors of hating and loving aims to show them that they have grossly exaggerated the powers of their hatred and their love.

Belief, hope and faith.

A case of hysteria is presented in order to create a frame of reference for the author's approach to the concepts of hope, belief and faith. A difference between hope as a 'sad passion' (which is here called regressive hope) and hope as a principle of mental functioning is established. The concept of hope will at first always be based on beliefs--either beliefs organised in the paranoid-schizoid position (called here fragmented and delusional beliefs)--or those organised from the depressive position (complex systems of beliefs, which end up being dogmatic); the latter typically occur in neurotics. It is suggested here that there is another possibility for hope, which is based on faith. The meaning of faith is considered here externally to the religious sense. The solid establishment of hope as a principle--based on faith--can be viewed as responsible for the opening up of creative potentials and as one of the main aims of analysis. Such an aim, however requires the establishment of a deep relationship, both in theory and in clinical practice, between the Kleinian question of the depressive position and the Freudian question of the Oedipus complex.

Assessing progress in analysis interminable.

A case study is provided of a schizoid patient in her mid-sixties who in a lengthy analysis had made significant clinical improvement. The treating analyst's impression of clinical improvement was independently verified through systematic analysis of transcripts of audiotapes of thirty-six sessions over a four-year period of treatment. The patient showed significant improvement on measures of character pathology, object relations, mentalization, and superego anxiety. The results suggest that some patients with entrenched character pathology who seem to be in analysis interminable may still make clinically significant improvement. It is suggested that the scientific status of psychoanalysis would be greatly enhanced if the anecdotal evidence generated in private practice were supported by independent verification. The current study illustrates one methodology, "case study plus," for providing independent verification while retaining the richness of the traditional case study.

Fragmented attachments: the paranoid-schizoid experience of loss and persecution.

The author discusses paranoid-schizoid patients who have yet to deal with whole-object depressive fears of harming one's object. Their paranoid-schizoid anxiety is more a combination of dread, paranoia, and fear of destroying one's object with neediness, envy, and other oral desires. In this part-self and part-object world, destruction is absolute. Ego functions and object relational capacities such as guilt and grief are not yet fully consolidated. The part-object is not only destroyed but is also equally capable of magically resurrecting itself to seek revenge. Fear of annihilation of the self and object, as well as desperate attempts at keeping each other alive, are the primary focus of this early anxiety state. These infantile fears are at the root of certain difficult treatment situations. Within the transition from paranoid-schizoid to depressive, the ego struggles with highly exaggerated and distorted fantasies of persecution, loss, and primitive guilt by resorting to crude and often self-destructive mechanisms. These include splitting, projective identification, and idealization. During the course of analytic treatment, three overlapping phases are distinguishable. Acting out is the main theme of early treatment. As this externalization of internal conflict is analyzed and contained, a second phase of intrapsychic struggle emerges. The patient exhibits a paralyzing battle between certain ego-object ties and the striving of a defensive death instinct. If the analytic relationship is able to withstand passage through these difficult phases, the patient begins to work through more core issues of persecutory loss and annihilation. Case material is used for illustration.

[Etiological and therapeutic aspects of schizoid and schizotypal personality disorder]. / Zur ätiologischen Stellung und Therapie der schizoiden und schizotypischen Persönlichkeitsstörung.

Following the introduction to the history of the concepts of abnormal personality, with regard to the schizoid and schizotypal forms, we present their systematic assessment in the modern classification systems.Both, the schizoid and schizotypal forms, are usually considered as schizophrenia-spectrum disorders. Biological and clinical data indicate relations to other axis-I disorders as well. However there are few systematic and strictly controlled studies on the psychotherapeutic and pharmacological treatment of schizotypal and schizoid personality disorders. Basic theoretic assumptions concerning both treatment concepts - for personality disorders in general, and especially in schizoid and schizotypal personality disorder - are given. Finally the role of neuroleptics and antidepressants for schizophrenia-spectrum disorders is discussed. New possibilities may emerge from the use of the recently developed atypical drugs, but further research in randomised studies is needed. Current prospective studies on early detected schizophrenia-spectrum disorders will broaden our knowledge about prevention and therapy.

[The population treated in the general psychiatric sector in 1993 and 1998. Clinical and demographic evolution]. / Caractéristiques de la population prise en charge en secteur de psychiatrie générale en 1993 et 1998. Evolution clinique et démographique.

BACKGROUND: The French information system in public psychiatry sectors does not collect morbidity data for the population being treated, estimated as more than a million persons in 1997. Consequently, two surveys were financed by the "Direction Générale de la Santé" and carried out in 1993 and 1998 in order to specify clinical, social and demographic characteristics of the patients. These surveys allowed a follow-up of evolutions according to the pathology and mode of treatment in a context where outpatient treatments are becoming increasingly frequent. METHODS: A census of the patients was made at a given moment, between one and fifteen days according to the mode of treatment. One sector out of two was surveyed, using a systematic selection process. The ICD-10 was used for diagnosis reference. The same methodology was applied in 1993 and 1998. Comparisons were made with the data supplied by the sectors annually and with the data concerning the general population in order to calculate rates per age groups. RESULTS: Between 1993 and 1998, the number of patients increased by +37% in outpatient care, and in part time care, and decreased by -12% in full time care. Rates for patients increased for all age groups in outpatient and part time care, more particularly for the 35 to 49 years old. Conversely, rates decreased in full time care, above all for patients over seventy. In each mode of treatment, the number of patients presenting mood disorders and neurotic disorders increased more than the average, and the proportion of patients with organic mental disorders and mental retardation decreased. Evolutions were different according to the mode of treatment schizophrenia, schizotypal and delusional disorders, and disorders of adult personality and behaviour. CONCLUSIONS: Recourse to outpatient care and part time care increased considerably over five years but evolutions were markedly different from one diagnosis to another. In full time care, the decrease more particularly concerned certain pathologies and age groups. Three phenomena, with possible interactions, could explain the evolutions observed: the population liable to have recourse to psychiatric care is increasing, health policies have changed and care supply has become diversified, and recourse to psychiatric care is now increasingly accepted.