Actual Neurosis as the Underlying Psychic Structure of Panic Disorder, Somatization, and Somatoform Disorder: an Integration of Freudian and Attachment Perspectives

Panic Disorder as Unthinkable Emotions: Alexithymia in Panic Disorder, a Croatian Cross-Sectional Study

OBJECTIVES

Previous research on alexithymia has led to controversy over its prevalence in panic disorder. The aim of this study was to assess the difference in the prevalence of alexithymia in panic disorder and other anxiety disorders.

DESIGN AND METHODS

We performed a cross-sectional study on a sample of 71 patients diagnosed with panic disorder and 113 patients diagnosed with other anxiety disorders; both groups were 18-50 years old. Primary outcome was the 20-item Toronto Alexithymia Scale (TAS) score. Secondary outcome was the prevalence of alexithymia defined as a TAS score ≥61.

RESULTS

Patients diagnosed with panic disorder had a 25% higher score on the TAS subscale of difficulty identifying feelings than patients diagnosed with other anxiety disorders. The prevalence of alexithymia was 27% in patients with panic disorder and 13% in patients with other anxiety disorders. Patients diagnosed with panic disorder had significantly higher odds for alexithymia.

CONCLUSIONS

The results of our study support the hypothesis of higher prevalence of alexithymia in individuals with panic disorder than in individuals with other anxiety disorders. In addition, difficulty identifying feelings as a salient feature of alexithymia is higher in panic disorder than in other anxiety disorders.

A MODEL FOR INTEGRATING ACTUAL NEUROTIC OR UNREPRESENTED STATES AND SYMBOLIZED ASPECTS OF INTRAPSYCHIC CONFLICT

In psychoanalytic theory, the importance of actual neuroses-considered to be devoid of psychic content-diminished as Freud and subsequent analysts focused on unconscious intrapsychic conflict. This paper explores the relationship between actual neurotic and unrepresented states, which are believed to be best addressed through attention to countertransference, intersubjectivity, and enactments rather than interpretation of intrapsychic conflict. Models suggesting how actual neurotic states and symbolized intrapsychic conflict may interact with each other and environmental stressors are described. Symbolizing actual neurotic states and establishing meaningful linkages between somatic/affective experiences and intrapsychic conflict are viewed as necessary for effective treatment of many disorders.

Clinical Considerations Regarding Regression in Psychotherapy with Patients with Conversion Disorder

Regression is a ubiquitous phenomenon in psychodynamic psychotherapy and psychoanalysis, typically part of a reorganization that leads to progression, at least with respect to recruiting elements in the unconscious to consciousness. Regression in patients with conversion disorder (i.e., pseudo-neurological symptoms without an organic basis) is often itself somatic/physical rather than psychic in nature. Psychotherapists working with these patients must be prepared for confusing or frightening forms of regression that should be expected as part of the therapeutic process. In conversion disorder patients with adequate character structure, this regression, when handled effectively by the psychotherapist, ultimately leads to verbalized thoughts and feelings and a gradually strengthening alternative to physically experienced psychic conflict.

A psychodynamic perspective on treatment of patients with conversion and other somatoform disorders

Conversion disorder, the development of symptoms of neurological disease with no organic basis, is a challenge for mental health professionals to diagnose and treat effectively. There are well-established predisposing factors, such as female sex, childhood trauma, and alexithymia, but less clear is how to approach the subjective suffering that is symbolized with the symptom rather than consciously recognized. While there are overlapping comorbidities such as depression and anxiety that may be treated with medication, psychotherapy is the primary effective treatment for patients with adequate capacity to engage in the process. This article addresses means of identifying patients who might benefit from psychotherapy (along with medication in some instances) as well as some guidelines for conducting psychotherapy, with case examples.

Unmentalized aspects of panic and anxiety disorders

Somatic or emotional experience that has not been symbolically represented, referred to as unmentalized experience, has been given an increasingly prominent role in understanding psychopathology. Panic and anxiety disorders provide a useful model for exploring these factors, as the affective and bodily symptoms can be understood in part as unmentalized experience. The authors explore models of Freud's actual neurosis, Marty and DeM'uzan's pensee operatoire, Klein's unconscious fantasy, Bion's alpha function, Bucci's multiple code system, and relational models to describe how somatic and affective experiences can be translated into symbolic representations, and what factors can interfere with these processes. Approaches to unmentalized aspects of panic and anxiety include symbolizing somatic symptoms, identifying emotional states, and identifying contextual and traumatic links to symptoms.

The subject in an uproar: a Lacanian perspective on panic disorder

From Jacques Lacan's theory of anxiety, principles are deduced for a Lacanian-oriented treatment of panic disorder. This Lacanian approach is related to Freud's theory of the actual neuroses, and is comparable in some ways with the approach taken in Panic-Focused Psychodynamic Psychotherapy (PFPP). The Lacanian conceptualization of panic retains the idea that both repressed material and unsymbolized mental states lie at its basis. People suffering from panic attacks are overwhelmed by signifiers, aspects of corporeal excitation, and/or existential questions that remain too Real. Psychoanalytic therapy aims to create a name for such Real elements. The three registers that Lacan situates at the basis of his psychoanalytic approach (the Symbolic, the Imaginary, and the Real) are discussed, as well as the treatment principles for conducting this clinical work. The case study of a young woman with panic disorder is presented to illustrate how a brief, Lacanian-oriented treatment (forty-eight sessions) progressed, and where the patient managed to both name and find a symbolic place for psychic experiences that were too Real. During this treatment, the patient overcame her avoidant-defensive mode of functioning and her persistent difficulties related to separation.

Contemporary perspectives on Lacanian theories of psychosis

In contemporary Lacanian psychoanalysis, Verhaeghe's theory of actualpathology psychopathology in psychosis and the Millerian idea of "ordinary psychosis" provide diverging conceptual approaches to psychosis. In this paper, the two approaches to psychosis are examined with a particular emphasis on "mild psychosis" and compensatory mechanisms. Despite the shared focus on similar clinical phenomena, particularly body disturbances, these two theories provide different explanations of psychosis. Verhaeghe's theory of psychosis is a synthesis of Lacanian theory, Freud's idea of actual neurosis and psychoanalytic attachment concepts. Moreover, these ideas are situated in the "schizophrenia/paranoia dichotomy" an important heuristic device utilized in clinical practice with psychosis. In contrast, the Millerian field of ordinary psychosis aims to broaden the idea of psychosis by reviving the idea of "mild psychosis" and the different forms of stabilization possible in psychosis. Clinicians adapting the idea of ordinary psychosis aim to rethink pivotal Lacanian concepts-"untriggered" psychosis and stabilization-beyond the scope of the schizophrenia/paranoia dichotomy. Although the idea of ordinary psychosis requires further development, it promise greater utility than Verhaeghe's model, as it provides a broader and more nuanced approach to the complex vicissitudes of triggering and restitution in psychosis.

Interpersonal problems and cognitive characteristics of interpersonal representations in alexithymia: a study using a self-report and interview-based measure of alexithymia

In this study, associations between alexithymia, interpersonal problems, and cognitive-structural aspects of internal interpersonal representations were examined. Alexithymia was measured using the Toronto Structured Interview for Alexithymia (TSIA) and the 20-item Toronto Alexithymia Scale (TAS-20). To measure interpersonal problems, the dominance and affiliation dimension scores of the Inventory of Interpersonal Problems were used, and cognitive-structural characteristics of interpersonal representations were measured using the Social Cognition and Object Relations Scale (SCORS). As hypothesized, alexithymia was related to cold and withdrawn, but not to dominant or submissive, interpersonal functioning. In terms of the SCORS, alexithymia was negatively related to complexity of interpersonal representations, both in TAT and in interview narratives, indicating a link between alexithymia and mentalization. However, alexithymia was related only to the dimension of social causality when this dimension was scored on TAT narratives. Overall, the TSIA provides the most consistent and stable results after controlling for negative affectivity.

Hysteria and its metamorphoses

OBJECTIVE: To investigate the historical evolution of hysteria and its possible psychopathological ramifications in today’s diagnostic classifications. Method: Clinical and historical problematization contrasting classical and contemporary references on the subject. Conclusion: Higher incidence of certain conditions and decline in the use of the construct of hysteria should be seen as different moments in a continuum.

Interpersonal problems in alexithymia: A study in three primary care groups

OBJECTIVES

The present study investigated the relation between alexithymia and interpersonal problems in a sample of primary care patients with either chronic fatigue syndrome (CFS); a chronic cardiovascular or auto-immune disease; or a minor medical condition. It was hypothesized that the relation between cold interpersonal functioning would account for the differences in alexithymia scores between the patient groups.

DESIGN AND METHODS

Participants were 155 primary care patients that were recruited through 52 general practitioners: 52 CFS patients; 52 patients with a chronic cardiovascular or auto-immune disease; 51 patients with a minor medical condition. Interpersonal problems were assessed by means of the Inventory of Interpersonal Problems and alexithymia was assessed by means of the Toronto Alexithymia Scale.

RESULTS

CFS patients and patients with a chronic cardiovascular or auto-immune disease have substantially higher alexithymia scores than patients with a minor medical condition. Alexithymia is positively related to cold and distant interpersonal functioning; negatively related to self-sacrificing and overly accommodating in relation to others; and positively related to vindictiveness and self-centredness. The relation between alexithymia and these interpersonal problems accounts for the differences in alexithymia scores between the patient groups.

CONCLUSIONS

Alexithymia and interpersonal problems should be considered together, in terms of one deficient affect regulatory system, and the relation between alexithymia and specific illness conditions is secondary to this. Clinical assessment of patients with problems in naming and discussing affective states should never be isolated from an examination of their interpersonal problems, and vice versa. Mentalization-based therapy is recommended for patients with problems in naming affective states, interpersonal problems, and concomitant CFS or other alexithymia-related diseases.

Impaired self-reflection in psychiatric disorders among adults: a proposal for the existence of a network of semi independent functions

Self-reflection plays a key role in healthy human adaptation. Self-reflection might involve different capacities which may be impaired to different degrees relatively independently of one another. Variation in abilities for different forms of self-reflection are commonly seen as key aspects of many adult mental disorders. Yet little has been written about whether there are different kinds of deficits in self-reflection found in mental illness, how those deficits should be distinguished from one another and how to characterize the extent to which they are interrelated. We review clinical and experimental literature and suggest four different forms of deficits in self-reflection: (a) sense of ownership of one's own thoughts and actions, (b) emotional awareness, (c) distinction between fantasy and reality and (d) the integration of a range of different views of oneself and others. We propose how these different impairments in self-reflection are linked with one another.

Challenges for alexithymia research: a commentary on "The construct of alexithymia: associations with defense mechanisms"

The author comments on an article by Helmes and colleagues (this issue, pp. 000-000) that studied defense mechanisms related to alexithymia. What these authors observed is theoretically meaningful, and a distinct strength of this study is that the results are replicated in three independent samples. The study is also exemplary for two typical drawbacks- only student samples and self-report measures are used. The author suggests that when studying alexithymia, researchers use samples that contain a substantial number of alexithymic subjects. Furthermore, variables such as emotional processing and regulation should not be measured with self-report questionnaires alone. Emotional processing and regulation are, in part, implicit and researchers should consider this. The author argues that the standard of alexithymia research could be raised by including interdisciplinary perspectives and experimental methods, and by embedding research more explicitly in theories.