Affect regulation in psychoanalytic treatments of patients with a borderline personality disorder–psychoanalysis and psychodynamic psychotherapy–a comparison

BACKGROUND A recent meta-analysis has confirmed that the effects of psychotherapy on patients with borderline personality disorders(BPD)are still insufficiently understood.Evidence of differences between different types of therapies has been questioned.AIM To study repetitive interaction patterns in patients with BPD undergoing either psychoanalysis or psychodynamic therapy.METHODS Psychoanalysis(PSA)or psychodynamic psychotherapy(PDT)was administered to 10 patients each,the two groups were matched.Therapy regimens were applied according to care as usual/manualized including quality control and supervision as usual.Randomization to one of the groups was done after baseline assessment.During classical PSA(n=10)and PDT(n=10),semiannually,recordings(audio or video)of five consecutive therapy sessions were taken over three years for an ex-post analysis.The patients'characteristics,such as affect parameters[Affect regulation and experience Q-sort(AREQ)],quality of object relations(quality of object relations scale)and personality traits[Shedler-Westen Assessment Procedure(SWAP-200)]were analyzed retrospectively by independent raters.Therapeutic action(psychotherapy process Q-sort)and affective(re)actions of the patients(AREQ)were then analyzed in relation to changes found in the patients'characteristics.RESULTS During the first year of therapy(PSA:n=10;PDT:n=9),the therapeutic method PSA was associated with significant improvements in the variable"SWAP Borderline",while in PDT change was not significantly different to baseline(PSA:P=0.04;PDT:P=0.33).Long-term results and follow up was available for seven participants in PSA and for five in PDT after three years;change in SWAP borderline for the whole sample was not significant at this time point when confronting to baseline(P=0.545).However,differences between PSA and PDT were significant when analyzing the“mean change”in the SWAP Borderline variable after one year of therapy(P=0.024):PSA led to slightly increased BPD symptoms,while PDT to a decrease;for the long run,variance of observed change was higher in PSA than in PDT(SDPSA±9.29 vs SDPDT±7.94).Our assumption that transference interpretations,closely followed by affective changes in the patient,could be useful modes of interaction was reproducible in our findings,especially when looking at the descriptive findings in the long-term data.The analysis of repetitive interaction structures demonstrated a very specific"time-lag"between therapeutic intervention and a corresponding increase in positive affect in successful therapy cases.CONCLUSION Exploring the change processes in the patients'characteristics and linking these changes to specific treatment strategies is of clinical importance when starting treatment and for its long-term progress.

Clinical, scientific and stakeholders’ caring about identity perturbations

In this editorial we comment on the article by Zhang et al published in the recent issue of the World Journal of Psychiatry.We focus on identity diffusion,identity perturbations,their origin and developmental pathways.This is an upcoming problem in the society as not only school children are affected.Adolescents and young people suffer from uncertainty in gender identity,in self-image,migration effects due to chronic crises caused by war,pandemic disruptions or climate change.We show how such chronic uncertainty can be cared for,treated,and contained.The key is affective holding,reflection and to provide adequate affective mentalizing in a close concomitant way.These key features also depend on ambient conditions,such as psychotherapeutic care.In a qualitative interview study carried out in a cyclical research design with a comparative analysis on the basis of thematic coding using Grounded Theory Methodology we found institu-tionalized defenses in health policies.Professionals request better training and adequat academic knowledge as well as research into unresolved areas for improvement of the ambient conditions for adequat development of the self.Practice points for further clinical and scientific development are given and discussed.

Cognitive dissonance and mindset perturbations during crisis:“ecosocio-psycho-somatic”perspectives

Mandatory and restrictive health regulations during the corona pandemic caused psychic disorders in many people,which even led to clinically relevant mental disorders.At the same time,there was gradually a polarization of opinions among the population.In order to improve future pandemic management,an integrative understanding of these psychosocial processes therefore seems useful.Here we start theoretically with the mental effects of inconsistencies of the information environment by referring to concepts such as the theory of cognitive dissonance.In a next step,we use the psychodynamic theory to understand the affective-motivational defense mechanisms underlying these cognitive states and processes.However,a broader theoretical framework of psychoanalysis seems to make sense,because self-referential processing also influences the style of thinking.For this reason,we use a more comprehensive psychological systems theoretical framework model to integrate these different perspectives.This integrative view refers in part to basic knowledge of health psychology regarding the resistance of unhealthy ways of thinking and behaviors and the possibilities for interventions for change.We then extend this model to a broader picture that also covers the relationship between men and their environment.This results in the perspective of a multidimensional socioecological theoretical framework,which as a heuristic reference model and related to other ecological approaches could also be helpful for various theoretical questions for public health,and could provide a better public understanding of health issues.In line with this perspective,we hypothesize that with regard to the coronavirus disease 2019 pandemic,the acceptance of public health narratives could be increased if a more consistent picture of the scientific descriptions and explanations of the pandemic-similar to the model proposed-could be provided,which would enable the understanding of the origin,course and countermeasures,and thus could have positive collective psycho-hygienic effects.

How does the‘environment’come to the person?The‘ecology of the person’and addiction

Currently,psychiatry lacks a field that can be called“theoretical psychiatry”,which uses theoretical concepts and explanatory models:The main stream of research is to collect data of all kinds in the hope that the computational Big Data approach will shed a bright light on the black box of mental disorders.Accordingly,the biology-based Research Domain Criteria of the National Institute of Mental Health have been established.However,as philosophical analyses of concepts and methods have shown,several epistemological gaps stand in the way of a consistent multilevel understanding of mental disorders.Also,the implicit ontological problems in the biological reduction of the psychosocial level and in the integration of so-called hard and soft disciplines are mostly left out.As a consequence,a non-reductive psychological theory of mental disorders is sought that also integrates correlating biological and sociological issues.In this context,one example of promising nonreductive psychiatric research is the option of systems/network psychopathology.The possibilities for integrating different psychological perspectives are highlighted for the field of addiction research and treatment,where pragmatic behaviorist approaches dominate over the theorybased practice of psychoanalysis.In comparing the theoretical constructs of these two approaches,the relevance of the concept of“(social)environment”as the wealth of influential sociocultural factors is discussed at levels superior to the interpersonal micro-level,namely the organizational meso-and societal macro level,which is not sufficiently considered in current biopsychiatry.On this basis of argumentation,the usefulness of grounding and framing psychiatry through the field of ecological sciences,especially human ecology,is demonstrated.Finally,to this end,an outline of an ecological model of mental health and illness is presented.

Importance of communication in medical practice and medical education:An emphasis on empathy and attitudes and their possible influences

BACKGROUND Healthcare professionals need to be prepared to promote healthy lifestyles and care for patients.By focusing on what students should be able to perform one day as clinicians,we can bridge the gap between mere theoretical knowledge and its practical application.Gender aspects in clinical medicine also have to be considered when speaking of personalized medicine and learning curricula.AIM To determine sets of intellectual,personal,social,and emotional abilities that comprise core qualifications in medicine for performing well in anamnesis-taking,in order to identify training needs.METHODS An analysis of training clinicians’conceptions with respect to optimal medical history taking was performed.The chosen study design also aimed to assess gender effects.Structured interviews with supervising clinicians were carried out in a descriptive study at the Medical University of Vienna.Results were analyzed by conducting a qualitative computer-assisted content analysis of the interviews.Inductive category formation was applied.The main questions posed to the supervisors dealt with(1)Observed competencies of students in medical history taking;and(2)The supervisor’s own conceptions of"ideal medical history taking".RESULTS A total of 33 training clinicians(n=33),engaged in supervising medical students according to the MedUni Vienna’s curriculum standards,agreed to be enrolled in the study and met inclusion criteria.The qualitative content analysis revealed the following themes relevant to taking an anamnesis:(1)Knowledge;(2)Soft skills(relationship-building abilities,trust,and attitude);(3)Methodical skills(structuring,precision,and completeness of information gathering);and(4)Environmental/contextual factors(language barrier,time pressure,interruptions).Overall,health care professionals consider empathy and attitude as critical features concerning the quality of medical history taking.When looking at physicians’theoretical conceptions,more general practitioners and psychiatrists mentioned attitude and empathy in the context of"ideal medical history taking",with a higher percentage of females.With respect to observations of students’history taking,a positive impact from attitude and empathy was mainly described by male health care professionals,whereas no predominance of specialty was found.Representatives of general medicine and internal medicine,when observing medical students,more often emphasized a negative impact on history taking when students lacked attitude or showed non-empathetic behavior;no gender-specific difference was detected for this finding.CONCLUSION The analysis reveals that for clinicians engaged in medical student education,only a combination of skills,including adequate knowledge and methodical implementations,is supposed to guarantee acceptable performance.This study’s findings support the importance of concepts like relationship building,attitude,and empathy.However,there may be contextual factors in play as well,and transference of theoretical concepts into the clinical setting might prove challenging.

Future of processing and facilitating change and learning

The field of the sciences of the mind is evolving fast.With the diversification of knowledge and accumulation of data,often lacking integration and reproducibility,questions arise.The role of critical thinking and research is evident.As the science of the unconscious,psychoanalysis provides a method and theory to understand human minds and mentalities,helping the patient know his mind and transform action into reflection.Mental activities,including social skills,develop in the social context,depending on the social environment’s demands and resources put onto the individual.Encoding emotional signals,markers of meaning for the individual,is ontogenetically necessary and has influences on memory encoding.Beyond theoretical understanding,implicit relational knowledge is actualized in the therapeutic setting.With a strong focus on experiencing emotional reconsolidation of memories,previous relationships’repercussions are enriched with broadening viewpoints in the analytic environment.The long-term effects of psychotherapeutic treatments have been examined.A sufficient explanation of the specific factors contributing to success or an answer when an impact is lacking is still under investigation.When investigating subliminal and implicit mechanisms leading to memory reconsolidation and the formation of functional object relations and interaction patterns,the focus is set on affective interplay and processing prior/during and after social interactions.The present paper discusses which parameters might contribute to the reshaping of memories and the linkage of memory with the emotional load of experience.Providing insights into such dynamic mental phenomena could enhance process research by investigating moment by moment interactions in psychoanalysis,treatment,and learning processes.Due to the research subject’s complexity,different research methods and integration of associated research fields are required.

Learning and competence development via clinical cases-what elements should be investigated to best train good medical doctors?

In European higher education,application of information technology,concentration on the learning-processes,consistent implementation,transfer learning,case-based learning,autonomous learning has been extensively studied in the last decade.Educational sciences based on neuroscientific findings use brain-based learning and teaching,including integrated thematic instructions and emotion-theory.Elements essential to this strategy,such as theory and methods for learning,competencies,attitudes,social reality,and a metadiscourse are described herein.Research on learning tends to focus on declarative knowledge,associative learning with conditional stimuli,and procedural knowledge with polythematic/crosslinking thinking.Research on competencies:In research on competencies(e.g.,for clinical reasoning,decision-making),intuitive and analytical components are studied.As repeated presentation and exercising of clinical cases is crucial for an efficient learning process,the implementation of interactive scenarios including affectively involving didactics is considered.For competence-development observational methods,questionnaires/item sets or factors have to be targeted and empirically validated.Attitudes and social reality:Clinical decision-making,identification processes and attitudes(“Hidden curriculum”),as well as secondary socialization processes(integration of social norms,values,preparation of role-acquisition,occupational role)are studied via process research,conceptual research,and observational methods.With respect to social reality research,conscious and unconscious bargaining processes have to be taken into account.Methodology:Neuroscience-memory,neuronal,molecular biology,and computer science(Neurocircuits)are integrated into observational process research(e.g.,affective-cognitive interface,identification processes)and conceptual research is added and studied on the meta-level,including discussion of research paradigms.This discussion provides ongoing feedback to projects in a hermeneutic circle.

Case studies in psychotherapy training using Austria as an example

BACKGROUND Case studies(CS)are relevant for the development of theoretical and practical competencies in psychotherapy.Despite rapid progress in the development of methods and principles for establishing CS in the last three decades,research into the aims of CS,especially in training,or how CS are to be conducted is rare.AIM To elucidate the form and methodology of CS,the objectives of CS used in training institutions(TI),and if/how TIs handle therapist allegiance.Also,this preliminary investigation will suggest avenues for further research and attempt to establish certain guidelines.METHODS In order to counteract researcher bias and enlarge the question-pool,a focus group was established.The recorded and transcribed text was analyzed with Mayring’s method of qualitative content analysis,and the generated categories were formulated as questions.The resulting questionnaire with both qualitative and quantitative queries was sent out(after pre-testing)to all 39 Austrian TIs that provide professional psychotherapy training.The answers and text passages received were then also categorized with qualitative content analysis.Data analysis was discussed by a peer group consisting of three psychotherapists trained in differing schools of psychotherapeutic methods.RESULTS 94%of Austrian institutes use CS as part of their psychotherapeutic training.Understanding of the term“case study”is inconsistent and has a wide variety of interpretations.CS serve mainly:(1)For observation of training/progress in therapeutic practice and knowledge/acquisition of the theory specific to each psychotherapeutic school;(2)To improve(self-)reflection capabilities;and(3)To expand theoretical knowledge.Most of the CS written are not accessible for students nor for the research community.More than two thirds of the CS take only the position of the author into account(the client’s position is not described).15.5%of the TIs do not consider researcher or therapist allegiance at all.CONCLUSION A more precise formulation of the term case study is needed in psychotherapeutic training.The training therapists play a key function,as they exemplify and teach how to deal with distorting factors.General guidelines as to how to conduct CS in training institutions would provide more direction to students,increase scientific rigor,and enhance synergistic effects.

COVID-19 survivors:Multi-disciplinary efforts in psychiatry and medical humanities for long-term realignment

The coronavirus disease 2019 pandemic represents an enduring transformation in health care and education with the advancement of smart universities,telehealth,adaptive research protocols,personalized medicine,and self-controlled or artificial intelligence-controlled learning.These changes,of course,also cover mental health and long-term realignment of coronavirus disease 2019 survivors.Fatigue or anxiety,as the most prominent psychiatric“long coronavirus disease 2019”symptoms,need a theory-based and empirically-sound procedure that would help us grasp the complexity of the condition in research and treatment.Considering the systemic character of the condition,such strategies have to take the whole individual and their sociocultural context into consideration.Still,at the moment,attempts to build an integrative framework for providing meaning and understanding for the patients of how to cope with anxiety when they are confronted with empirically reduced parameters(e.g.,severe acute respiratory syndrome coronavirus type 2)or biomarkers(e.g.,the FK506 binding protein 5)are rare.In this context,multidisciplinary efforts are necessary.We therefore join in a plea for an establishment of‘translational medical humanities’that would allow a more straightforward intervention of humanities(e.g.,the importance of the therapist variable,continuity,the social environment,etc)into the disciplinary,medial,political,and popular cultural debates around health,health-care provision,research(e.g.,computer scientists for simulation studies),and wellbeing.

Simulating the mind and applications-a theory-based chance for understanding psychic transformations in somatic symptom disorders

With the new category of somatic symptom disorder/bodily distress disorder in ICD-11,research into pathogenetic and therapeutic pathways is stimulated.By turning away from the definition of somatoform disorders as“the lack of something physical explaining everything”,this new classification might offer a way to put the focus on the individual patient’s psychodynamic balance and conflicts and their condensation in the symptom.Modelling and simulation have a long history in science to gain insight also into complex phenomena.Considering the evolution of precision medicine many different parameters are meanwhile operationalised and ready for consequent process research.Calculation models have to fit to the complexity of this disorder category.In an interdisciplinary discourse between computer and medical/psychoanalytic scientists a multilayer,fine grained calculation model is elaborated.Starting from a clinical case history,within iterative discussion,by acknowledging the demand for interdisciplinary synergy and cooperation in science,psychoanalytic theory served as the basis for computer-scientific information technique.A parallelisation with the Mealy model helped to establish a meaningful calculation possibility for further process research.How psychic transformations can be understood properly in order to provide meaningful treatments,the respective training,and to conduct appropriate process-and outcome-research is established in simulating the mind and applications.

Personalized treatment-which interaction ingredients should be focused to capture the unconscious

A recent meta-analysis revealed that mental health and baseline psychological impairment affect the quality of life and outcomes in different chronic conditions.Implementing mental health care in physical care services is still insufficient.Thus,interdisciplinary communication across treatment providers is essential.The standardized language provided by the diagnostic statistical manual favors a clear conceptualization.However,this approach might not focus on the individual,as thinking in categories might impede recognizing the continuum from healthy to diseased.Psychoanalytic theory is concerned with an individual’s unconscious conflictual wishes and motivations,manifested through enactments like psychic symptoms or(maladaptive)behavior with long-term consequences if not considered.Such modifiable internal and external factors often are inadequately treated.However,together with the physical chronic condition constraints,these factors determine degrees of freedom for a self-determined existence.The effect of therapeutic interventions,and especially therapy adherence,relies on a solid therapeutic relationship.Outcome and process research still investigates the mechanism of change in psychotherapeutic treatments with psychanalysis’s focus on attachment problems.This article examines existing knowledge about the mechanism of change in psychoanalysis under the consideration of current trends emerging from psychotherapy research.A clinical example is discussed.Additionally,further directions for research are given.The theoretical frame in psychoanalytic therapies is the affect-cognitive interface.Subliminal affect-perception is enabled via awareness of subjective meanings in oneself and the other;shaping this awareness is the main intervention point.The interactional ingredients,the patient’s inherent bioenvironmental history meeting the clinician,are relevant variables.Several intrinsic,subliminal parameters relevant for changing behavior are observed.Therapeutic interventions aim at supporting the internalization of the superego’s functions and at making this ability available in moments of self-reflection.By supporting mentalization abilities,a better understanding of oneself and higher selfregulation(including emotional regulation)can lead to better judgments(application of formal logic and abstract thinking).Thus,this facilitates enduring behavior change with presumably positive effects on mental and physical health.