There is room for even more doublethink: the perilous status of psychoanalytic research

The opposition between psychoanalysis and systematic interdisciplinary research is to be regretted. The target article attempts to bridge the intellectual divide and for this aim as well as the intellectual adroitness shown it is to be celebrated. Much harder to understand is the high level of affect generated by the debate. Accusations of “doublethink” are helpful. The present paper, like the target paper it follows, attempts to develop an understanding of the position of those who are categorically opposed to interdisciplinary systematic research linked to psychoanalysis. Appreciating the perspective of those deeply opposed to such work could help to create a shared agenda from which our troubled discipline could benefit. This is predicated on the possibility of an open collegial dialogue which this journal was founded to create

Practitioner review: Borderline personality disorder in adolescence: Recent conceptualization, intervention, and implications for clinical practice

The past decade has seen an unprecedented increase in research activity on personality disorders in adolescents. The increase in research activity, in addition to major nosological systems legitimizing the diagnosis of borderline personality disorder (BPD) in adolescents, highlights the need to communicate new research on adolescent personality problems to practitioners. In this review, we provide up-to-date information on the phenomenology, prevalence, associated clinical problems, etiology, and intervention for BPD in adolescents. Our aim is to provide a clinically useful practitioner review and to dispel long-held myths about the validity, diagnostic utility, and treatability of personality disorders in adolescents

Clinical Associations of Deliberate Self-Injury and Its Impact on the Outcome of Community-Based and Long-Term Inpatient Treatment for Personality Disorder

Background: Deliberate self-injury (DSI) is significantly associated with personality disorder (PD). There are gaps in our knowledge of DSI as an indicator of severity of psychopathology, as moderator of outcome and with regard to its response to different treatment programs and settings. Methods: We compare 2 samples of PD with (n = 59) and without (n = 64) DSI in terms of clinical presentation, response to psychosocial treatment and relative outcome when treated with specialist long-term residential and community-based programs. We test the assumption that DSI is an appropriate indicator for long-term inpatient care by contrasting the outcomes (symptom severity and DSI recidivism) of the 2 DSI sub-groups treated in the 2 different approaches. Results: PD with DSI had greater severity of presentation on a number of variables (early maternal separation, sexual abuse, axis-I comorbidities, suicidality and inpatient episodes) than PD without DSI. With regard to treatment response, we found a significant 3-way interaction between DSI, treatment model and outcome at 24-month follow-up. PD with DSI treated in a community-based program have significantly greater chances of improving on symptom severity and recidivism of self-injurious behaviour compared to PD with DSI treated in a long-term residential program. Conclusions: Although limitations in the study design invite caution in interpreting the results, the poor outcome of the inpatient DSI group suggests that explicit protocols for the management of DSI in inpatient settings may be beneficial and that the clinical indications for long-term inpatient treatment for severe and non-severe PD may require updating. Copyright (C) 2010 S. Karger AG, Base

Foreword: Consciousness, mentalization and attachment

The notion of the unrepressed unconscious has been a major psychoanalytic puzzle since the inception of the discipline. Psychoanalytic thinking about the nature of consciousness has always implicitly distinguished between a non-conscious and a dynamically unconscious mental content, whether marked by distinctions such as repressed versus unrepressed, preconscious versus unconscious or, using Sandler’s three-box model, past versus present unconscious. Where the line is drawn, how the distinctions are made, may depend more on the subject matter on which the scholar is focused, which in turn calls for particular metapsychological models. This excellent book attempts to map this somewhat controversial field and addresses the dichotomy from six distinct perspectives that share the wish to integrate contemporary neuroscience with psychoanalytic perspectives, using the clinical setting as the primary constraint on theory-building. In this foreword to a unique and outstanding contribution by the major scholars in this field, I can do no more than set out the distinction between the Freudian and current approaches to the dichotomy and introduce our own rather limited perspective (Fonagy & Allison, in press), which has the advantage of drawing on the past work of many of the contributors to this volume

A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder

The precise nature and etiopathogenesis of borderline personality disorder (BPD) Continues to elude researchers and clinicians. Yet, increasing evidence from various strands of research converges to suggest that affect dysregulation, impulsivity, and unstable relationships constitute the core feature,,, of BPD. Over the last two decades, the mentalization-based approach to BPD has attempted to provide a theoretically consistent way of conceptualizing the interrelationship between these core features of BPD. with the aim of providing clinicians with a conceptually sound and empirically supported approach to BPD and its treatment. This paper presents an extended version of this approach to BPD based oil recently accumulated data. In Particular, We Suggest that the core features of BPD reflect impairments in different facets of mentalization, each related to impairments in relatively distinct neural circuits underlying these facets. Hence, we provide a comprehensive account of BPD by showing how its core features are related to each other in theoretically meaningful ways. More specifically, we argue that BPD is primarily associated with a low threshold for the activation of the attachment system and deactivation of controlled mentalization. linked to impairments in the ability to differentiate mental states of self and other, which lead to hypersensitivity and increased susceptibility to contagion by other people's mental states, and poor integration of cognitive and affective aspects of mentalization. The combination of these impairments may explain BPD patients' propensity for vicious interpersonal cycles, and their high levels of affect dysregulation and impulsivity. Finally, the implications of this expanded mentalization-based approach to BPD for mentalization-based treatment and treatment of BPD more generally are discussed

Attachment, mentalization, and the self

Mentalizing is often simplistically understood as synonymous with the capacity of empathy toward other people. In fact, mentalizing comprises a spectrum of capacities that critically involve the ability to see one’s own behavior as coherently organized by mental states, and to differentiate oneself psychologically from others. It is these capacities that tend to be noticeably absent in individuals with a personality disorder (PD), particularly at moments of interpersonal stress. In this chapter, we will attempt to demonstrate that such impairments in mentalizing are at the heart of our explanatory framework for conceptualizing PDs. The foundations of our thinking lie in attachment theory, but, according to our most recent formulation, the heart of the relationship between mentalizing and personality pathology lies in the capacity of engaging productively in communication, and more specifically, in the quality of epistemic trust the individual possesses in relationships and, formatively, in the relationship between the child and his/her primary caregivers. Epistemic trust is defined in terms of an individual’s experience of communication from others, specifically, the ability to receive and treat new knowledge from others as personally relevant and therefore capable of modifying durable representational structures pertaining to self, others, and interpersonal relationships. Underpinning this capability is the consideration of the informant as a “trustworthy” source likely to communicate information that is generalizable and relevant to the self

The stress–reward–mentalizing model of depression: An integrative developmental cascade approach to child and adolescent depressive disorder based on the research domain criteria (RDoC) approach

The Research Domain Criteria (RDoC) propose a much-needed change in approach to the study of vulnerability factors implicated in mental disorders, shifting away from a categorical, disease-oriented model to a dimensional approach that focuses on underlying systems implicated in psychopathology. In this paper we illustrate this approach with a focus on the emergence of depression in childhood and adolescence. Based on evolutionary biological and developmental psychopathology considerations, we present an integrative developmental cascade model of depression that essentially suggests that depression emerges out of a three-pronged series of interacting impairments in the domains of stress regulation, reward, and mentalizing. We discuss the relation of these impairments to the five domains proposed by RDoC. We also focus on how this model may explain in large part the marked comorbidity of depression with other psychiatric disorders, as well as with functional somatic and somatic disorders. Limitations of this theoretical approach are discussed, as well as implications for the development, evaluation, and dissemination of interventions aimed at preventing or treating depression

Integrating and differentiating personality and psychopathology: a psychodynamic perspective

Several strands of research converge to suggest that personality and psychopathology can be integrated in the form of a hierarchical model of individual differences. The notion that personality and psychopathology are intrinsically linked has a long tradition within psychodynamic approaches. In this article, we first summarize empirical evidence supporting two related key assumptions of psychodynamic approaches to personality and psychology: that a developmental, person-centered approach is needed to complement a static, disorder-centered approach in the conceptualization and treatment of psychopathology; and that personality and psychopathology are best conceptualized as dynamic attempts at adaptation. Research in each of these areas supports the notion that personality and psychopathology are difficult to separate and may be moderated by severity (i.e., general psychopathology) such that increasing levels of severity result in increased intrinsic coupling between the two. We then discuss these findings in the context of a newly emerging social-communicative approach to human development that suggests that personality and psychopathology are better conceptualized in terms of a disorder of social communication, and that the purported rigidity and stability typically attributed to them are largely explained by the stability of the environmental mechanisms that underpin them, rather than by stable intrapersonal traits. The implications of these new views for the future of the science of personality and psychopathology, and for treatment strategies, are discussed