There is no place for the psychoanalytic case report in the British Journal of Psychiatry

In our own words: key terms and trends in psychoanalytic history

Inspired by the work of Fonagy (2008) and Dent and Christian (2019), this study applies a form of quantitative textual analysis to 300 terms of psychoanalytic interest in the PEP archives by tracking their historical prevalence in five-year increments using the aggregate number of articles featuring each term in the field's journals. Our results confirm some of the more well-known inflection points in the history and application of psychoanalytic theory, while also revealing some intriguing surprises. Psychoanalysis remains fundamentally a depth psychology, yet it has increasingly acknowledged the external causes of distress and trauma. Changes in the prevalence of terminology around psychopathology, defense mechanisms, development, gender and sexuality, and psychoanalytic technique are discussed.

The Use of Dynamic Cognitive Behavioural Therapy (DCBT) in Social Anxiety Disorder (SAD): A Theoretical Integration Initiative

Psychotherapy theorists can often become fervent advocates of the schools they follow and place the doctrines of the theories they adopt above all else. This situation can sometimes turn into a war of theories between researchers as well. However, therapists should not aim to shape therapy sessions according to their methods but to use them in line with clients' needs. Although it is emphasised that the integration of both psychoanalytic and cognitive behavioural therapy techniques, which is going to be named dynamic cognitive behavioural therapy (DCBT) in this case report, will provide more effective and permanent treatment, a discernible gap exists regarding the integration of these theories and their use in psychotherapy. Taking into account this gap, it is considered important to use this approach with a client who has a social anxiety disorder (SAD). Therefore, this study aims to describe the almost forgotten DCBT approach step by step through a case report and reveal the effectiveness of this approach. As a result, DCBT seems to be effective in the treatment of SAD.

Transference-focused psychotherapy as an aid to learning psychodynamic psychotherapy: qualitative analysis of UK psychiatry trainees' views

AIMS & METHOD

Learning psychotherapy can be difficult and stressful. We explore core trainees' (n = 5) views on undertaking a psychodynamic psychotherapy training case using transference-focused psychotherapy (TFP), in an East London NHS Foundation Trust supervision group. We used framework analysis of focus group interviews to examine trainees' concerns, their views about this experience and its impact on general psychiatric practice.

RESULTS

Trainees described various concerns on starting: providing an effective intervention, insufficient experience and training-related pressures. However, they found that TFP addressed some of them and was helpful for learning psychodynamic psychotherapy. Difficulties around the countertransference remained at end-point. Trainees suggested that introductory teaching and learning through observation might be worthwhile.

CLINICAL IMPLICATIONS

Trainees' experience suggests that an evidence-based operationalised approach such as TFP can be integrated into the core psychiatry curriculum as a psychodynamic psychotherapy learning method. Trainees report benefits extending to other areas of their practice.

Quality of case reports of adverse drug reactions with psychotropic drugs: a 25-year review

Case reports of adverse reactions with psychotropic drugs can be useful in raising hypotheses, to be tested with more rigorous study designs. However such reports have significant methodological drawbacks, making it hard to determine causality. We undertook a systematic assessment of the quality of case reports and small case series published within Human Psychopharmacology over 25 years. For reports of adverse drug reactions, modified Bradford Hill criteria for causality (for consistency, strength, specificity, temporal relationship and plausibility) were used to ascertain the quality of the account. Reports which had been cited at least 10 times by December 2010 were examined in detail, to assess their overall contribution in extending understanding and influencing clinical practice. Of 40 reports of adverse drug reactions, only seven were sufficiently robust for confidence in probable or possible causality. Nine reports had been cited more than 10 times: the five most frequently cited reports of adverse drug reactions described movement disorders, suicidal thoughts and discontinuation symptoms with SSRIs: clinical relevance was high, but their quality was not markedly greater than less frequently cited reports. Nearly all reports of adverse drug reactions, published in a single journal over 25 years, were insufficiently robust to demonstrate probable causality. Reports that are cited frequently become influential because of their potential clinical relevance, rather than due to their methodological quality.

Treatment notes: objective measures of language style point to clinical insights

Application of a computerized text analysis procedure is proposed that has the potential for use by psychoanalytic and psychodynamic clinicians: the systematic examination of linguistic style as reflected by clinicians in their ongoing process and case notes, which are ubiquitous in the mental health field. The studies reported here are, as far as is known, the first attempts to study treatment notes systematically using such procedures. Linguistic measures are used to track the trajectory of the clinical process throughout the treatment in two contrasting cases, one rated successful, the other not. The computerized linguistic analysis used here focuses on two analytically relevant linguistic variables: Mean High Referential Activity (MHW), a measure of the degree to which language is connected to emotional processing, and Reflection (REF), the use of words referring to logical functions. Changes in the relative position of these measures indicate nodal points in the treatment that might be analytically or therapeutically problematic, and that might be overlooked in a solely clinical reading. The analyst's activity as reported in notes during such nodal periods is clinically examined to see how it may have affected the course of the analysis. This method has the potential for use in ongoing treatments, and may help clinicians refine their interventions.

Are microglia minding us? Digging up the unconscious mind-brain relationship from a neuropsychoanalytic approach

The unconscious mind-brain relationship remains unresolved. From the perspective of neuroscience, neuronal networks including synapses have been dominantly believed to play crucial roles in human mental activities, while glial contribution to mental activities has long been ignored. Recently, it has been suggested that microglia, glial cells with immunological/inflammatory functions, play important roles in psychiatric disorders. Newly revealed microglial roles, such as constant direct contact with synapses even in the normal brain, have defied the common traditional belief that microglia do not contribute to neuronal networks. Recent human neuroeconomic investigations with healthy volunteers using minocycline, an antibiotic with inhibitory effects on microglial activation, suggest that microglia may unconsciously modulate human social behaviors as “noise.” We herein propose a novel unconscious mind structural system in the brain centering on microglia from a neuropsychoanalytic approach. At least to some extent, microglial activation in the brain may activate unconscious drives as “psychological immune memory/reaction” in the mind, and result in various emotions, traumatic reactions, psychiatric symptoms including suicidal behaviors, and (psychoanalytic) transference during interpersonal relationships. Microglia have the potential to bridge the huge gap between neuroscience, biological psychiatry, psychology and psychoanalysis as a key player to connect the conscious and the unconscious world.

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.

Tavistock Adult Depression Study (TADS): a randomised controlled trial of psychoanalytic psychotherapy for treatment-resistant/treatment-refractory forms of depression

BACKGROUND

Long-term forms of depression represent a significant mental health problem for which there is a lack of effective evidence-based treatment. This study aims to produce findings about the effectiveness of psychoanalytic psychotherapy in patients with treatment-resistant/treatment-refractory depression and to deepen the understanding of this complex form of depression.

METHODS/DESIGN INDEX GROUP

Patients with treatment resistant/treatment refractory depression.

DEFINITION & INCLUSION CRITERIA

Current major depressive disorder, 2 years history of depression, a minimum of two failed treatment attempts, ≥14 on the HRSD or ≥21 on the BDI-II, plus complex personality and/or psycho-social difficulties.

EXCLUSION CRITERIA

Moderate or severe learning disability, psychotic illness, bipolar disorder, substance dependency or receipt of test intervention in the previous two years.

DESIGN

Pragmatic, randomised controlled trial with qualitative and clinical components.

TEST INTERVENTION

18 months of weekly psychoanalytic psychotherapy, manualised and fidelity-assessed using the Psychotherapy Process Q-Sort.

CONTROL CONDITION

Treatment as usual, managed by the referring practitioner.

RECRUITMENT

GP referrals from primary care.

RCT MAIN OUTCOME

HRSD (with ≤14 as remission).

SECONDARY OUTCOMES

depression severity (BDI-II), degree of co-morbid disorders Axis-I and Axis-II (SCID-I and SCID-II-PQ), quality of life and functioning (GAF, CORE, Q-les-Q), object relations (PROQ2a), Cost-effectiveness analysis (CSRI and GP medical records).

FOLLOW-UP

2 years. Plus: a). Qualitative study of participants' and therapists' problem formulation, experience of treatment and of participation in trial. (b) Narrative data from semi-structured pre/post psychodynamic interviews to produce prototypes of responders and non-responders. (c) Clinical case-studies of sub-types of TRD and of change.

DISCUSSION

TRD needs complex, long-term intervention and extended research follow-up for the proper evaluation of treatment outcome. This pushes at the limits of the design of randomised therapeutic trials. We discuss some of the consequent problems and suggest how they may be mitigated.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN40586372.