A psychoanalytic teaching exercise

The paper is a detailed account of a teaching exercise designed for first year candidates in a psychoanalytic training program. The material for the classroom exercise is a selected "specimen" session from the author's practice which clearly demonstrates the appearance, the handling and the dynamic significance of the clinical concept of resistance. The teaching method consists of the instructor reading numbered segments of a few lines each from the session in sequence to the students each of whom is responsible for a written response to a numbered segment; the students rotate in sequence in giving their written answers to whether a particular excerpt from the session is a resistance, a transference reaction, a theme or one of the usual technical interventions. The body of the paper consists of the numbered excerpts from the session, a sampling of students responses and comments by the author. It is seen that the students become involved in the unfolding session and have a "hands on" experience of the analytic process. The method of selecting appropriate (to the topic) sessions allows for a wide variety of clinical topics to be taught this way.     

Differences between patients classified as "recovered" or "improved" and "unchanged" or "deteriorated" in a psychotherapy outcome study

The concepts of statistical and clinical significance of pre-post-changes have been used to class patients into four groups of therapy outcome: "recovered", "improved", "unchanged" and "deteriorated". Aim of this study is to investigate the advantages of this classification in comparison to a simple division into "successful" and "not successful". 43 patients were examined before and after an in-patient psychotherapy and again two years later with several test inventories. Therapy outcome was measured by the changes in the Global Severity Index of the SCL-90-R. "Recovered" and "improved" patients did only differ in regard to their initial symptom severity, but not in regard to the amount of symptom reduction or stability of therapy effect. "Deteriorated" patients could reduce their increase in symptoms until follow-up. Our results do not indicate a general advantage of the classification into four outcome groups over a division into "successful" / "not successful".     

"Depressive pseudodementia" or "Melancholic dementia": a 19th century view.

Nineteenth century views on the interaction between dementia, depressive illness, general paralysis and brain localisation are discussed in the context of a book by A Mairet entitled: Melancholic Dementia. It is shown that by 1883 there was already awareness of the fact that severe affective disorder could lead to cognitive impairment. General paralysis was the commonest diagnosis put forward to account for patients with depression who went on to develop dementia. Patients so diagnosed, however, often recovered and clinical and statistical analysis of Mairet's case histories suggests that some were in fact suffering from depressive pseudodementia. Evidence is marshalled to show that during the 19th century there was wide disagreement concerning the clinical domain, course and even histopathology of general paralysis. This casts doubt on the traditional view that this condition served as "a paradigm" for other psychiatric diseases during this period. It is shown that by the turn of the century these difficulties led to a redefinition of the concept of dementia and to a marked narrowing of the clinical bounds of general paralysis.     

"On hidden madness"--"De amentia occulta" by Ernst Platner in early 19th-century tension of medicine and jurisprudence

During the first half of the 19th century psychiatry became more and more influential in the evaluation of mentally ill offenders. "Doubtful" states of mind gained a particular importance for forensic practice. One of the mental disorders that was heavily disputed was amentia occulta (hidden madness) first described by the well-known Leipzig doctor and philosopher Ernst Platner. This publication (1797) preluded several other diagnoses to refer to non-obvious, "hidden mental derangements". Regardless of the differences in arguments as developed by the experts in question (E. T. A. Hoffmann, Merzdorff, E. Horn, J. C. A. Clarus), two case studies from the early 19 (th) century (D. Schmolling, J. C. Woyzeck) will exemplify the process of medicine, and psychiatry in particular, becoming more and more influential in everyday jurisdictional practice. The above-mentioned Ernst Platner, the author of manifold forensic studies and of "De amentia occulta", was one of the pioneers and promoters of this process. By emphasising the importance of mental states being evaluated by medical professionals he contributed a great deal to the establishment of forensic psychiatry.     

Channelopathies: summary of the hot topic keynotes session

The "Hot Topic Keynotes: Channelopathies" session of the 26th International Neurotoxicology Conference brought together toxicologists studying interactions of environmental toxicants with ion channels, to review the state of the science of channelopathies and to discuss the potential for interactions between environmental exposures and channelopathies. This session presented an overview of chemicals altering ion channel function and background about different channelopathy models. It then explored the available evidence that individuals with channelopathies may or may not be more sensitive to effects of chemicals.     

"Don't tell us--show us": the use of role play in the teaching of psychoanalytic theory

The psychological concepts associated with psychoanalysis are sometimes considered to be precious and somewhat irrelevant by professionals working with disturbed adolescents. Discussions (at a theoretical level) of these ideas may not highlight their usefulness in clinical situations. This paper describes the use of active role play techniques in a staff training group designed to teach about the "Inner World of the Adolescent". The fundamental features of "transference" and "counter-transference" were brought alive during these groups, and several other theoretical contributions of modern psychoanalysis were demonstrated within the setting of a training session. These groups were not intended to train "therapists", but to support and improve existing styles of work with adolescents.     

History of "Epileptic Vertigo": Its Medical, Social, and Forensic Problems

Summary: We traced the history of the association of vertigo with the condition of epilepsy through the ages. In ancient times, vertigo was closely linked with epilepsy; indeed, it was believed to be the harbinger of chronic seizures. With the advent of modern scientific study of epilepsy initiated by the French in the 18th and 19th centuries, vertigo, not yet associated with disease of the inner ear or vestibular connections, assumed a specific role in the clinical gradation of seizure entities. It was believed to be the mildest form of epilepsy. Later, with the establishment of the conceptual linkage of "larval" or "masked" epilepsy with outbursts of violence, "epileptic vertigo" was considered the trigger for potentially lethal behavior and thus assumed a much-feared reputation. Evidence for this abounds in the medical, legal, and even the popular literature at the end of the 19th century. The role of vertigo and its epileptic associations occupied the attention of most of the pioneer workers in epileptology of that era, and it was finally agreed that as a symptom the inner ear rather than epilepsy underlay its causation. Even today, epilepsy and vertigo are conceptually associated, sometimes erroneously.     

<Emphasis Type="Italic">ARHGEF9</Emphasis> mutations in epileptic encephalopathy/intellectual disability: toward understanding the mechanism underlying phenotypic variation

ARHGEF9 resides on Xq11.1 and encodes collybistin, which is crucial in gephyrin clustering and GABA_A receptor localization. ARHGEF9 mutations have been identified in patients with heterogeneous phenotypes, including epilepsy of variable severity and intellectual disability. However, the mechanism underlying phenotype variation is unknown. Using next-generation sequencing, we identified a novel mutation, c.868C > T/p.R290C, which co-segregated with epileptic encephalopathy, and validated its association with epileptic encephalopathy. Further analysis revealed that all ARHGEF9 mutations were associated with intellectual disability, suggesting its critical role in psychomotor development. Three missense mutations in the PH domain were not associated with epilepsy, suggesting that the co-occurrence of epilepsy depends on the affected functional domains. Missense mutations with severe molecular alteration in the DH domain, or located in the DH-gephyrin binding region, or adjacent to the SH3-NL2 binding site were associated with severe epilepsy, implying that the clinical severity was potentially determined by alteration of molecular structure and location of mutations. Male patients with ARHGEF9 mutations presented more severe phenotypes than female patients, which suggests a gene-dose effect and supports the pathogenic role of ARHGEF9 mutations. This study highlights the role of molecular alteration in phenotype expression and facilitates evaluation of the pathogenicity of ARHGEF9 mutations in clinical practice.     

"Back from the future": a powerful age-progression technique.

This paper briefly reviews the benefits of using age-progression techniques in hypnotherapy, followed by a detailed explanation and illustration of the "back-from-the-future" technique with two case examples, including their outcome. The patients presented with feelings of helplessness, hopelessness, and a sense of futurelessness. Following the hypnotherapeutic intervention, patients were instructed to take time to reflect on the session and to write down the specific experiences they had on their voyage into the future focusing on their visual images, auditory sensations, experiences with other senses (touch, smell, and taste), as well as thoughts, emotions, and self-perceptions. Follow-up validated that the patients maintained their therapeutic accomplishments several months after the initial interventions.     

Future Psychiatry: a "think tank" for the Italian psychiatry

The Future Psychiatry Project was founded with the goal to address the critical ratio of research/training/clinic. In a series of regular meetings, each devoted to a specific clinical topic, data and more advanced models for the clinical area in question will be analyzed in an integrated and multidisciplinary approach and the real possibility of extension of development and prospects of scientific advances to the clinic and therapy will be evaluated. The primary methodological objective of the Future Psychiatry meetings is the training method to overcome the common type of teacher/learner classroom teaching, albeit divided into the various possibilities offered by different types of educational meetings. The structure is informal, with features of intensive seminars and suggested modes for better interaction. The objective is the "think tank", a common space for study and exchange of knowledge, experiences, opinions and expectations, aimed at producing an integrated and shared dynamic result, that can provide a real reference point for participants and for all researchers and clinicians engaged in improving their level of updating and best clinical activity. The first Future Psychiatry meeting was held in Sermoneta (Latina) in the halls of the Castello Caetani on September 16th to 18th 2010. The chosen topic was "The Future of Depression: the development of knowledge, the evolution of therapies". The currently most advanced data of research were discussed and developed in their potential to reach a shared model taking into account the etiological complexity of Depression and to be a real reference to the possibility of application to real clinical experience. The main guidelines of the current research and major prospects for development of this in the field Depression have been outlined, also in relation to the ongoing evolution and the future outlook of the models and tools of therapy. Psychiatrists' clinical needs and expectations in front of the development of scientific knowledge were analyzed in relation to the translational prospect of a better application of these in the clinical practice of present and future care of Depression.     

Isolated thoracic syrinx in children with Chiari I malformation

Introduction

Syrinx has been reported in 25–85 % of children with Chiari malformation type I (CMI), and it is most commonly cervical in location. As a result, cervical MRI is routinely included in an evaluation for CMI. Isolated thoracic syrinx without involvement of the cervical cord in this population is uncommon but clinically important because its presence may influence the decision to operate, surgical techniques employed, or interpretation of follow-up imaging. The purpose of this study was to determine the incidence of isolated thoracic syrinx in a large group of children evaluated for CMI.

Methods

We retrospectively reviewed all patients under 21 years of age who were evaluated for CMI at Columbia University/Morgan Stanley Children’s Hospital of New York from 1998 to 2013. All patients underwent MRI of the entire spine as part of the CMI evaluation, regardless of whether surgery was planned. The proportion of patients exhibiting isolated thoracic syrinx was determined. Presenting signs, symptoms, and imaging findings were then studied in an attempt to identify any clinical features associated with isolated thoracic syrinx.

Results

We identified 266 patients evaluated over the study period. One-hundred thirty-two patients (50 %) presented with a syrinx, and 12 patients (4.5 % of all patients evaluated and 9.1 % of all patients with a syrinx) had an isolated thoracic syrinx. Demographic variables, clinical presentation, and extent of tonsillar ectopia showed great heterogeneity in this group, and no factor was consistently associated with isolated thoracic syrinx.

Conclusions

Isolated thoracic syrinx is an uncommon but clinically significant finding in children with CMI. Our data demonstrate that the presence of a CMI-related thoracic syrinx cannot be reliably predicted clinically and is therefore likely to be missed in patients who do not undergo complete spinal cord imaging. MRI of the entire spinal cord should be considered for all children undergoing initial evaluation for CMI.

     

Acute and chronic effects of electroconvulsive treatment on oxidative parameters in schizophrenia patients

Electroconvulsive therapy (ECT) is an effective treatment alternative for schizophrenia. Previous studies have already indicated the possible effects of oxidative stress in this disorder. However, there have been no previous studies evaluating the effects of ECT on the oxidative stress in these patients. We therefore aimed to investigate the acute and chronic effects of ECT on serum levels of oxidant and antioxidant molecules in schizophrenia patients (n = 28). The serum MDA and CAT levels of the patients with schizophrenia were higher than that of the controls before ECT (n = 20) but there was no significant difference in the serum NO and GSH levels of the patient groups compared to the controls. We found that the NO levels of the patients were higher than the controls in the group experiencing their first episode but not in the chronic group. There was a significant clinical improvement in the patients in terms of BPRS, SANS and SAPS reduction after the 9th ECT, but not the 1st ECT. Serum MDA levels were significantly reduced compared to the baseline after the 9th ECT session although there was no significant difference after the 1st session. Separate evaluation of the patient groups revealed that the significant MDA decrease following ECT was in the patients experiencing their first episode and not in the chronic group. No significant difference was noted in the serum levels of other oxidant and antioxidant molecules after either the 1st or 9th ECT session. These results suggest that ECT does not produce any negative effect on oxidative stress in patients with schizophrenia.     

正确把握精神卫生临床试验设计三要素的要领（I）--受试对象

明确阐释在进行精神卫生临床试验设计时,应正确把握"受试对象"的意义和要领。从基本常识出发,并基于精神卫生科研的特点,寻找和发现在此研究领域中,怎样做才能被称为正确把握了"受试对象"。通过结合本专业的特点及实例,获得如下结果,即在进行精神卫生临床试验设计时,必须把握好以下三个方面:1正确确定受试对象的种类;2制订出合理的受试对象的质量标准;3有根据地确定合适的样本含量。在如何确定受试对象的问题上,正确把握好前述提及的三个方面,就是抓住了问题的本质,是提高临床试验研究质量的一个重要环节。     

Operationalizing "trance". I: Rationale and research using a psychophenomenological approach

Despite the popularity of the term "trance" among clinicians to describe the subjective effects associated with being hypnotized, heretofore there has been no means to operationalize that definition. The authors present a rationale and psychophenomenological method to operationalize the term "trance" in terms of (a) hypnotic depth, a quantitative measure of subjective trance assessed via a pHGS (predicted Harvard Group Scale) score, derived from regression analysis, and (b) "trance typology profiles," a qualitative differentiation of empirically derived (via cluster and discriminant analyses) categories of subjective trance experiences. The authors then discuss theoretical and clinical implications of this psychophenomenological approach for developing an operational definition of the concept of trance.     

Challenges in the clinical diagnosis of Alzheimer's disease: influence of "family coaching" on the mini-mental state examination

The Mini-Mental State Examination (MMSE) is a commonly used clinical tool for evaluating the cognitive aspects of mental function. In this study, 40 consecutive patients presenting to a memory disorder clinic and their caregivers were evaluated for coaching of the patient with respect to MMSE content over the 24 hours prior to clinical evaluation. Caregivers completed a questionnaire concerning MMSE practice sessions with the patient prior to the physician encounter; then, the patients were asked to spell the word "WORM" backwards instead of "WORLD" during the MMSE test. Some or all of the MMSE content was reviewed with the patient prior to the interview by 42.5 percent of the caregivers; 17.5 percent of patients spelled or attempted to spell "WORLD" backwards instead of "WORM". These results demonstrate that coaching of patients prior to administration of the MMSE is not uncommon, and that this needs to be taken into consideration when forming therapeutic decisions based on MMSE results.     

d-cycloserine enhancement of exposure therapy for social anxiety disorder depends on the success of exposure sessions

Objective

The evidence for the efficacy of d-cycloserine (DCS) for augmenting cognitive behavioral therapy (CBT) for anxiety disorders has been mixed. Guided by preclinical research and initial findings from a small-scale study involving humans, we tested the hypothesis that DCS enhancement of exposure therapy would be specific to successful exposure sessions.

Method

Medication-free adults with generalized social anxiety disorder (N = 145) received 50 mg of DCS or placebo 1 h before each of 5 exposure sessions that were part of a standardized 12-session group CBT protocol. Participants provided fear ratings at the beginning and just before the end of exposure exercises. Independent raters, blind to group assignment, administered the clinical global impression improvement and severity scales at each session and at posttreatment.

Results

Mixed-effects analyses revealed that, among patients who reported low fear at the end of an exposure session, those who had received DCS evidenced significantly greater clinical improvement at the next session, relative to those who had received placebo. In contrast, when exposure end fear was high, patients receiving DCS exhibited less clinical improvement at the following session than patients receiving placebo. Similarly, patients who had received DCS evidenced lower clinical severity at posttreatment, relative to patients who had received placebo, only when their average end fear for medication-augmented sessions had been in the low to moderate range. Finally, these moderating effects of exposure success as indexed by end fear were not better accounted for by within-session extinction.

Conclusions

The efficacy of DCS for augmenting exposure-based CBT depends on the success of exposure sessions. These findings may help guide the development of an algorithm for the effective use of DCS for augmenting exposure-based CBT.

Trial registry

http://www.ClinicalTrials.gov, ID# NCT00633984, http://www.clinicaltrials.gov/ct2/show/NCT00633984.     

"Postpsychotic depression" and residual schizophrenia in a mental health hospital

Forty three patients, mean age 55.20 +/- 9.27 SD, affected by Schizophrenia Residual Type (DSM IV, RDC criteria) and treated with neuroleptic drugs for a mean of 25.42 years (+/- 4.12 SD) were included into the study. Clinical evaluation was cross-sectional assessed by BPRScale, SAPS, SANS, HRS-D, EPSE. ACS and MMSE. Seventy percent of patients presented a "postpsychotic depression" (42%, mild; 16%, moderate and 12% serious). "Postpsychotic depression" does not seem to be influenced by neuroleptics, but it seems to be a component of residual schizophrenia in patients with a long lasting permanence in a mental hospital.     

Validation of a new diagnostic procedure for DSM IV axis I disorders

Despite the fact that, in today's psychiatric research and especially in epidemiological studies, diagnostic assessments are made with reliable standardized clinical interviews, recent articles have shown discrepancies in prevalence rates of DSM IV axis I disorders assessed with different, yet reliable, clinical standardized interviews, raising the problem of the clinical relevance of some of these instruments. Within an epidemiological study, we developed a simple method for evaluating DSM IV axis I disorders with the aim of improving the clinical relevance of assessed diagnoses. This method is based on an evaluation performed by two clinicians. The first one used a short structured clinical interview (MINI v 5.0) and the second one completed the procedure with an open clinical interview, intended to be more clinically relevant. Finally, a consensus diagnosis is given by the two investigators. We conducted a survey in order to validate this method by measuring the agreement of diagnoses reported by two pairs of clinicians on a population of 20 inpatients. Results show that this double evaluation led to a high agreement (kappa ranging between 0.76 and 1.00) suggesting that the proposed evaluation procedure, which is intended to be more clinically relevant, is also highly reliable.     

<Emphasis Type="Italic">FMR1</Emphasis> Premutation: Basic Mechanisms and Clinical Involvement

The wide spectrum of clinical phenotypes associated with the FMR1 premutation affect more than two million people worldwide. The clinical implications have only been recognized recently despite this disorder constitutes a relevant health problem. The present issue of The Cerebellum is focused on the “2^nd International Conference on the FMR1 Premutation: Basic Mechanisms and Clinical Involvement” held in Sitges, Barcelona (Spain), from September 30th to October 2nd, 2015. The conference was attended by professionals from different countries in Europe, the USA, Chile, Israel, Australia, and Indonesia and covered the latest clinical and molecular findings resulting from FMR1 premutation studies. Although the pathologies associated with the FMR1 premutation are considered as rare diseases, seventy abstracts were presented. This reflects the relevance of this topic in the medical community and the growing interest among professionals from other disciplines. The major topics discussed included why and how the mRNA toxicity due to a gain of function and non-canonical RAN are responsible for disorders associated with the premutation. Several presentations addressed the impact of these mechanisms in FXTAS and FXPOI, two clinical presentations caused by the FMR1 premutation. Interestingly, a deterioration of the DNA repair machinery was first proposed as the pathogenicity cause of premutation alleles. Communications related to FXTAS and FXPOI animal models were also presented. These models facilitate studies aimed to understand disease progression and early treatment interventions. Finally, there were presentations related to psychiatric, psychological, neurological, and radiological aspects. Interesting discussion on intermediate alleles and their involvement in clinical and reproductive aspects was generated. In this regards, genetic counselling is improved by taking into account the AGG interruptions and including information about the FMR1 premutation associated pathologies although there are still some uncertainties linked to the spectrum of these pathologies. Overall, the meeting covered all aspects of the different pathologies associated with the premutation of the FMR1 gene.     

合并园艺治疗对慢性精神分裂症住院患者随机对照研究

背景：园艺疗法作为一种新兴的精神分裂症康复治疗手段逐渐引起重视,但目前研究很少,也缺乏相应的规范化治疗方案。
　　目标：探讨园艺疗法对慢性精神分裂症住院患者的疗效,探索园艺疗法在精神卫生中心规范化实施的可能性。
　　方法：选择2015年9月—2015年12月在本院康复病房符合入组标准并签署知情同意书的精神分裂症患者共110例,用随机数字法分为试验组和对照组,两组均进行常规的药物治疗,试验组合并园艺治疗,在具有国家二级心理咨询师资格的康复治疗师的带领下进行园艺治疗,每周3次,每次90min,共12周。具体内容包括对花卉进行配土、栽植、浇水、施肥及修剪;对田园进行泥土翻耕、播种、浇水、施肥、拔草及捉虫以及花草的观赏、蔬菜的采摘、烹饪、品尝。每次课程结束前10min由患者互相交流心得体会治疗师总结并点评。两组在基线、治疗4周末、治疗12周末予以阳性和阴性症状量表(PANSS)的评估。
　　结果：两组性别、年龄、病程、婚姻、文化、使用的抗精神病药物平均剂量、在治疗前PANSS得分均无显著差异,具有可比性。试验组PANSS得分在治疗4周末、治疗12周末随访时较对照组得分低,差别均有统计学意义（t=-4.03,p<0.001; t=-5.57,p<0.001）;自身前后比较差异均有统计学意义(试验组F=253.03, p<0.001;对照组F=67.66,p均<0.001),两组阳性症状量表和一般精神病理量表得分在治疗4周和治疗12周随访时差异均有统计学意义（4周随访t=-3.69, p<0.001;t=-3.67, p<0.001;12周随访t=-3.55, p=0.001;t=-3.34, p<0.001）,自身前后比较差异也有统计学意义（阳性量表试验组F=13.76 p<0.001;对照组F=5.12, p=0.02;一般精神病理量表试验组F=156.40, p<0.001,对照组F=56.72, p<0.001）。两组之间阴性量表得分在治疗12周末时差异有统计学意义(t=-2.76, p=0.007),自身前后比较差异均有统计学意义(试验组F=103.94, p<0.001;对照组F=34.03, p<0.001)。
　　结论：药物治疗可改善慢性精神分裂症住院患者的症状,但药物治疗合并园艺治疗的效果更加明显;其中对于阳性症状、阴性症状均有改善。