Continuity of care in suicide prevention: current status and future directions

Introduction

Continuity of Care (CoC) is central to suicide prevention. The present study aims to review contemporary definitions, operationalization in research, and key components of CoC in the prevention of suicide.

Methods

The present study is a narrative review. A thorough search of available literature on CoC and suicidality was conducted. Studies published between 1995 and 2021 were reviewed and selected based on relevance to CoC and suicidality. Selected research was subsequently summarized to outline definitions of CoC, its operationalization in research, and key components for suicide prevention.

Results

The definition, measurement, and operationalization of CoC in suicide prevention varies tremendously, derailing clinical practice. Key elements of CoC identified across the literature include (1) CoC across multiple levels of care, (2) the role of primary care providers and case managers in CoC of suicidal patients, (3) the importance of follow up contact with suicidal patients post-treatment, and (4) the role of national and institutional guidelines for CoC of suicidal patients. Limitations: There is a dearth of randomized controlled trials and insufficient evidence on specific populations.

Conclusion

CoC refers to a wide, complex concept that must be broken down into specific categories that can provide more nuanced guidance of research and clinical implications.

The Interplay Between Childhood Sexual Abuse, Self-Concept Clarity, and Dissociation: A Resilience-Based Perspective

BACKGROUND

Despite a robust consensus regarding the potentially negative implications of childhood sexual abuse (CSA), research investigating risk and protective factors-particularly among well-functioning young adults-is scant. Dissociation is one of the major maladaptive outcomes of CSA. Nevertheless, CSA explains only about 10% of the variance of dissociation. Possibly, this modest effect size is due to protective factors moderating the relation between CSA and dissociative symptoms. One such factor may be the extent to which one has succeeded in developing a clear and coherent sense of who they are.

OBJECTIVE

We aimed to explore whether self-concept clarity (SCC) moderates the relationship between CSA and dissociation (Model 1), and an alternative hypothesis, whereby CSA may moderate the relationship between SCC and dissociation (Model 2).

PARTICIPANTS AND SETTING

This was tested among 65 well-functioning young women drawn from an earlier study that intentionally oversampled CSA survivors.

METHODS

We included data from survivors of CSA by a known perpetrator (n = 35) and women with no sexual trauma (n = 30).

RESULTS

Findings were consistent with both Model 1 and Model 2, but only when depersonalization-derealization, namely detachment, was considered. Simple effects analyses revealed that CSA was related to depersonalization-derealization only under low SCC levels (Model 1), and SCC was negatively related to depersonalization-derealization only in the CSA group (Model 2).

CONCLUSIONS

Findings suggest that SCC is a protective factor, buffering the association between CSA and detachment (depersonalization-derealization) symptoms. Clinical implications are discussed.

Anxiety in the face of the first wave of the spread of COVID-19 in Israel: Psychosocial determinants of a "Panic-to-complacency-continuum"

BACKGROUND AND METHODS

Based on an established ongoing prospective-longitudinal study examining anxiety in response to COVID-19, a representative sample of 1018 Jewish-Israeli adults were recruited online. A baseline assessment was employed two days prior to the first spread of COVID-19, followed by six weekly assessments. Three classes of general anxiety and virus-specific anxiety were identified: (1) "Panic" (a very high and stable anxiety throughout the spread), (2) "Complacency" (a very low and stable anxiety throughout the spread), and (3) "Threat-Sensitivity" (a linear increase, plateauing at the 5th wave). For general-anxiety only, a fourth, "Balanced," class was identified, exhibiting a stable, middle-level of anxiety. We tested theory-based, baseline, social-cognitive predictors of these classes: self-criticism, perceived social support, and perceptions/attitudes towards the Israeli Ministry of Health. We also controlled for trait anxiety. Multinomial regression analyses in the context of General Mixture Modeling were utilized.

RESULTS

Baseline virus-specific anxiety linearly predicted emerging virus-specific anxiety classes. Virus-specific panic has higher trait anxiety than the other two classes. The general anxiety panic class was over-represented by women and exhibited higher baseline general anxiety and self-criticism than all other classes, and higher baseline virus-specific anxiety along with lower perceived support and less positive perceptions of the ministry of health than two of the three other classes.

CONCLUSIONS

Preexisting anxiety shapes subsequent anxious responses to the spread of COVID-19. The general-anxiety panic class may be markedly demoralized, requiring targeted public-health interventions.

Self-Criticism in the General Population: Development and Psychometric Properties of the Depressive Experiences Questionnaire Self-Criticism 4 (DEQ-SC4)

Self-criticism is a stable personality trait identified as a serious risk factor for psychopathology and weight-related health problems. Therefore, it is relevant to epidemiological research, which requires a relatively brief instrument for measuring trait self-criticism in the general population. The current study introduces a brief measure of self-criticism and presents empirical results that inform on its reliability and validity. Based on the six-item version of the Depressive Experiences Questionnaire Self-Criticism (DEQ-SC6), thorough psychometric analyses on a German representative sample (N = 2,516) were conducted and resulted in the final four-item scale: the Depressive Experiences Questionnaire Self-Criticism 4 (DEQ-SC4). Its internal consistency was good and a one-dimensional factor structure showed a good model fit. In terms of construct validity, the DEQ-SC4 was moderately linked to symptoms of depression and a non-linear association between the DEQ-SC4 and body mass index was observed, with the highest levels of self-criticism reported by underweight participants. In addition, the DEQ-SC4 showed high positive correlations with another short version of the DEQ-SC and the Big Five personality dimensions assessed in samples of university students (N = 206) and patients (N = 55), meeting theoretically-based expectations. The DEQ-SC4 therefore represents a brief screening measure of self-criticism in the general population with good psychometric properties.

The Personification of Chronic Pain: an Examination Using the Ben-Gurion University Illness Personification Scale (BGU-IPS)

Objective: Relying on anthropomorphism research, Illness Personification Theory (ILL-PERF) posits that individuals living with a chronic illness ascribe human-like characteristics to their illness. Herein we examine the personification of chronic pain using a new measure: the Ben-Gurion University Illness Personification Scale (BGU-IPS). Method: Three samples of chronic pain patients (Sample 1 and 2 are distinct samples sharing similar characteristics, collected in the context of a cross-sectional design, Ns = 259, 263; Sample 3: a 2-waves longitudinal, N =163) completed the 12-item BGU-IPS, and measures of pain and related factors. Results: An orthogonal, two-factor structure was revealed for the BGU-IPS pertaining to negative vs. positive personifications. Negative personification was associated with pain intensity and illness-related distress (e.g., depression and low adjustment to pain). Positive personification was correlated with hope, pain-related sense of control, and low depression. However, positive personification also augmented the associations between negative personification and several risk factors. Conclusions: Pain personification, particularly as assessed via the BGU-IPS, plays a major role in (mal)adaptation to chronic pain.

Centrality of Self-Criticism in Depression and Anxiety Experienced by Breast Cancer Patients Undergoing Short-Term Psychodynamic Psychotherapy

INTRODUCTION

Depression and anxiety are prevalent in women suffering from breast cancer. However, the determinants of depression and anxiety in this population are not well known, particularly in the context of psychotherapy. Drawing from Blatt's theory, we examined the role of Depressive Personality Vulnerability (DPV) in depression and anxiety experienced in female sufferers of breast cancer treated for depression as part of a Randomized Clinical Trial.

METHODS

Seventy-eight patients were treated by Short-Term Psychodynamic Psychotherapy and 79 patients by Treatment as Usual. Assessments were conducted pre-treatment, at termination, and at six-month follow-up. Main outcomes were the depression and anxiety subscales of the Hospital Depression and Anxiety Scale. Predictors were pre-treatment dependency, self-criticism, and self-efficacy, assessed via the Depressive Experiences Questionnaire. Analyses targeted associations of these dimensions with baseline levels, main effects on pretreatment-termination and pretreatment-follow-up changes in depression and anxiety, and DPV by treatment interactions.

RESULTS

Consistent with our hypotheses, self-criticism - implicated in previous research as a serious dimension of vulnerability to psychopathology - predicted elevated levels, as well as pretreatment-follow-up changes, in both depression and anxiety. However, self-criticism also augmented the effect of STPP (compared with TAU) on depression in the pretreatment-termination period.

CONCLUSIONS

These findings highlight the centrality of self-criticism for both risk and resilience processes in breast cancer.

Changes in General and Virus-Specific Anxiety During the Spread of COVID-19 in Israel: A 7-Wave Longitudinal Study

We compared three hypothetical trajectories of change in both general and COVID-19-specific anxiety during the 1^st wave of the spread in the state of Israel: panic (very high anxiety, either from the outset or rapidly increasing), complacency (stable and low anxiety), and threat-sensitive (a moderate, linear increase compatible with the increase in threat). A representative sample of 1018 Jewish-Israeli adults was recruited online. A baseline assessment commenced two days prior to the identification of the first case, followed by six weekly assessments. Latent Mixture Modeling analyses revealed the presence of the three trajectories: (1) "threat-sensitivity" (29% and 66%, for general and virus-specific anxiety, respectively), (2) Panic (12% and 25%), and (3) Complacency (29% and 9%). Only for general anxiety, a fourth class representing a stable mid-level anxiety was identified ("balanced": 30%). For general anxiety, females and the initially anxious - both generally and specifically from the spread of the virus - were more likely to belong to the panic class. Men and older participants were more likely to belong to the complacency class. Findings indicate a marked heterogeneity in anxiety responses to the first wave of the spread of COVID-19, including a large group evincing a "balanced" response.

Integrative Psychotherapy With Physicians In the Trenches: Convergence of Cognitive, Existential, and Psychodynamic Processes

In this article, I present insights gleaned from over a decade of working in therapy with physicians in the trenches who practice at general hospitals located in an area afflicted by the community and political violence, and recently, by the COVID-19 pandemic. Psychotherapy with these physicians requires an integrative psychotherapeutic approach that heeds their changing needs. Espousing cognitive-existential psychodynamics (CEP), a theory-based psychotherapeutic perspective developed for complex cases, I show how cognitive, existential, and psychodynamic processes strongly converge during the treatment of physicians in the trenches. Such convergence is manifested in issues of mental representations (of death, medicine, and the hospital) and choice/meaning.

Reformulated Object Relations Theory: A Bridge Between Clinical Psychoanalysis, Psychotherapy Integration, and the Understanding and Treatment of Suicidal Depression

In contrast to the fruitful relationship between psychoanalysis/psychoanalysts and the humanities, institutionalized psychoanalysis has been largely resistant to the integration of psychoanalysis with other empirical branches of knowledge (infant observation, psychotherapy research, psychological and neurobiological sciences), as well as clinical ones [primarily cognitive-behavioral therapy (CBT)]. Drawing from two decades of theoretical and empirical work on psychopathology, psychotherapy, and psychoanalysis, the author aims to show how a reformulation of object relations theory (RORT) using (neuro-)psychological science may enhance a clinical-psychoanalytic understanding and treatment of suicidal depression, which constitutes one of the most formidable health challenges of our time. Specifically, he rewrote the notion of Melanie Klein positions-primarily the depressive position-using extant knowledge of structure of emotions, the centrality of mental representations of the future ("prospection") and the toxic nature of criticism-based emotions. This reformulation enables a dialog between clinical psychoanalysis and other therapeutic schools of thought and sheds light on the understanding and treatment of suicidal depression.

Perceived social support, loneliness, and hope during the COVID-19 Pandemic: Testing a mediating model in the UK, USA, and Israel

Objectives

The COVID‐19 epidemic is affecting the entire world and hence provides an opportunity examine how people from different countries engage in hopeful thinking. The aim of this study was to examine the potentially facilitating role of perceived social support vis‐à‐vis hope as well as the mediating role of loneliness between perceived social support and hope. This mediating model was tested concurrently in the UK, the USA, and Israel.

Methods

In April 2020, as the first wave of the virus struck the three aforementioned countries, we assessed perceived social support, loneliness, and hope in 400 adults per country (N = 1,200). Assessments in the UK/USA were conducted via the Prolific platform, whereas in Israel they were conducted via Facebook/WhatsApp.

Results

In all three countries, perceived social support predicted elevated hope, although the effect was smallest in the UK. Loneliness mediated this effect in all three countries, although full mediation was attained only in the UK.

Conclusions

Perceived social support may facilitate hope in dire times, possibly through the reduction of loneliness.

Practitioner Points

Findings are consistent with respect to the potentially protective role of perceived social support vis‐à‐vis hope.

Perceived social support may increase hope through decreasing loneliness.

In the UK, the above‐noted mediating effect of loneliness appears to be stronger than in Israel and the USA.

Elevated levels of perceived social support should serve as a desired outcome in individual and group psychotherapy, as well as in community based interventions.

Prenatal maternal sleep and trajectories of postpartum depression and anxiety symptoms

Postpartum emotional distress is very common, with 10%-20% of postpartum women reporting depressive or anxiety disorders. Sleep is a modifiable risk factor for emotional distress that has a pivotal role in postpartum adjustment. The present study aimed to examine whether sleep duration and quality during pregnancy predict trajectories of emotional distress in the postpartum period. Participants were 215 women that were assessed from the third trimester of pregnancy to 18-months postpartum. At all five time points (third trimester, 3-, 6-, 12-, and 18-months postpartum), measures of sleep duration and quality (measured by wake time after sleep onset; WASO) were derived from both actiography and diary-based measures. Repeated measures of depression and anxiety symptoms were collected using self-report measures. Results indicated four bivariate postpartum depression and anxiety growth trajectories, including (a) high comorbidity (5.4%); (b) moderate comorbidity (19.4%); (c) low anxiety and decreasing depression symptomology (18.6%); and (d) low symptomology (56.6%). Multinomial logistic regression analyses showed that mothers with shorter sleep durations during pregnancy were more likely to belong to the high comorbidity or moderate symptoms classes compared to the low symptomology class. In addition, mothers with higher WASO (i.e. lower sleep quality) at 3-months postpartum were more likely to belong to the moderate class compared to the low symptomology class. Given the potential negative implications of disrupted sleep in the perinatal period, the present study may inform future intervention studies that target sleep problems during pregnancy.

Using termination as an intervention (UTAI): A view from an integrative, cognitive-existential psychodynamics perspective

Treatment termination is, arguably, one of the most important events in the course of psychotherapy. In the present article, we present an approach to termination that views the latter as a key intervention. Developed from an integrated, cognitive-existential psychodynamics (CEP) perspective (Shahar & Govrin, 2017), Using Termination as an Intervention (UTAI) is a prescheduled, albeit tentative, treatment termination that may be used as an intervention for patients' remoralization (Howard, Kopta, Krause, & Orlinsky, 1986). Specifically, for some psychotherapy patients, prescheduling a treatment termination is useful in instilling a sense of responsibility and agency and in deepening a therapeutic examination of patients' interpersonal schemas and scripts (i.e., "object relations"). The integrative nature of Using Termination as an Intervention is delineated, and caveats are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Peer Victimization, Coping Strategies, Depression, and Suicidal Ideation Among Young Adolescents

Abstract. Background: Victimization by bullying among adolescents is a widespread phenomenon associated with depression and suicidal ideation. Coping with bullying may include aggressive responding and self-blame. Aims: The purpose of this study was to examine the role adolescent self-blame and aggression – representing coping with peer bullying – in depression and suicide ideation. Method: We recruited 97 "pure" victims (41 girls; mean age = 12.69, SD = .80) identified from a sample of 505 adolescents (242 girls; mean age = 12.73, SD = .81) from two Israeli high schools. Self-report questionnaires were used to assess victimization, aggressive responses, self-blame, depression, and suicide ideation. Results: Self-blame in the face of peer bullying was uniquely associated with both depression and suicide ideation. The effect was robust even after controlling for level of victimization. No direct effect of aggressive coping or moderating effects of self-blame or aggression on the association between victimization and depression/suicide ideation were found. Limitations: This study used a cross-sectional design and made exclusive use of self-report measures. Conclusion: Adolescents who blame themselves for being bullied might be at a heightened risk for depression and suicidality compared to adolescents who did not use self-blame.

Dysfunctional pain perception and modulation among torture survivors: The role of pain personification

OBJECTIVE

Individuals exposed to trauma, especially those who develop posttraumatic stress disorder (PTSD), are at a higher risk of suffering from chronic pain as well as altered pain perception and modulation. However, the underlying mechanisms of these processes are yet to be established. Recent findings have indicated that trauma survivors tend to personify chronic pain that is developed after the exposure, in a way that resonates with the traumatic experience. The aim of this study was to test whether pain personification plays a significant role in explaining the long-term links between trauma, PTSD and pain.

METHODS

This study is part of a large-scale longitudinal study on ex-prisoners of war (ex-POWs) from the 1973 Yom-Kippur war, who were followed over 35 years after the war. Fifty-nine ex-POWs who were exposed to torture and 44 matched combatants were assessed for PTSD at 18, 30, and 35 post-war. Quantitative somatosensory testing of heat-pain threshold, pain tolerance, conditioned pain modulation (CPM), and temporal summation of pain (TSP), as well as torturing personification, were assessed at 35 years after the war.

RESULTS

Sequential mediation analyses revealed that the associations between torture and heat pain threshold, as well as pain tolerance were mediated by PTSD at several time-points (-1.43<indirect effect < 1.47). Torturing personification significantly mediated the associations between torture, PTSD, CPM and TSP (-0.16 < indirect effect).

CONCLUSIONS

These findings point to the effect of trauma on the subjective orientation towards bodily signals as a key factor in dysfunctional pain modulation.

Parents' malevolent personification of mass vaccination solidifies vaccine hesitancy

Parental hesitancy to vaccinate their children derails the success of mass vaccination campaigns. We examined the effect of parents' personification of the vaccinating agency on vaccine hesitancy (i.e. negative or positive mind change) in 555 parents in a mass wild poliovirus vaccination campaign. Parents were assessed before and after the campaign on attitudes toward vaccination and the vaccinating agency ("The Israeli MoH is caring" vs "hysteric"). Positive mind change was predicted by a gender and malevolent personification. A negative mind change was predicted by parental anxiety. We conclude that parental hesitancy is influenced by parents' attachment to the vaccinating agency.

The subjective-agentic personality sector (SAPS): Introduction to the special issue on self, identity, and psychopathology

This special issue is predicated upon the premise that there exists a subjective-agentic personality sector (SAPS) that is crucially relevant to the understanding and treatment of psychopathology. SAPS is often overlooked by "trait" models in personality psychology. It is comprised of "hot" cognitions about one's self and identity as they unfold throughout the life span and are brought to bear on interpersonal relationships. There are four ways in which SAPS may be involved in psychopathology: (a) inherently, as a component of psychiatric disorders, (b) as a passive vulnerability dimension, namely by interacting with life stress, (c) as an active vulnerability dimension, that is, by propelling external situations that culminate in psychopathology, and (d) by constituting a central consequent of psychopathology (i.e., the scarring pattern, see below). In this Journal of Personality special issue, experts in personality and psychopathology demonstrate the centrality of SAPS in unipolar depression, anxiety disorders, bipolar spectrum disorder, eating disorders, posttraumatic stress disorder, complex trauma and borderline personality disorder, social anxiety disorder, suicidality in the context of mood disorders, and recovery from schizophrenia. A commentary by Dan McAdams, a leader in the study of self and identity, concludes this special issue.

[인지-인본주의적 정신 역동들 : Sidney Blatt의 이론적-철학적 업적 (Congnitive-Humanistic Psychodynamics : Sidney Blatt's Theoretical-Philosophical Legacy)]

( 초록 ) 수많은 이론적-철학적 명제들이 Blatt의 광범위하고 탁월한 학문적 업적으로부터 나왔다. 그의 주요 연구 주제들은 (1) 인지, 특히 현실에 대한 마음의 지형도 혹은 표상; (2) 인본주의적인 요소들의 영향 (예컨데, 에이전시, 성장에 대한 열망, 게슈탈트, 균형 욕구 그리고 회복 탄력성); (3) 프로이트가 말한 역동적 무의식에 대한 끝없는 통찰, 이렇게 요약할 수 있을 것이다. 철학적 입장에서, Blatt은 '인지-인본주의적 정신역동'이라고 부를만한, 통합적 역량과 추종을 불허하는 업적들을 남겼다.

Attenuated psychosis and basic self-disturbance as risk factors for depression and suicidal ideation/behaviour in community-dwelling adolescents

BACKGROUND AND AIMS

Adolescents at clinical high risk (CHR) for psychosis, as defined by the presence of attenuated psychosis symptoms (APS), exhibit increased levels of suicidal ideation and behaviour. However, no research thus far has examined the link between basic self-disturbances (SDs), an established marker for CHR, and suicidality/self-harm in this population. The goal of this pilot study was to assess the association between SD, depression and suicidal ideation and behaviour among non-help-seeking adolescents from the community.

METHOD

A total of 100 community-dwelling adolescents (age range: 13-16) were assessed using the Examination of Anomalous Self-experience, Prodromal Questionnaire, Structured Interview for Prodromal Syndromes, Mood and Anxiety Symptom Questionnaire and the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS). The K-SADS was used to derive a binary diagnosis of unipolar depression, as well as to measure suicidal ideation and behaviour and self-harm.

RESULTS

In a multiple regression analysis, SD accounted for variance in depressive symptoms and suicidality/self-harm over and above that accounted for by APS. Moreover, SD accounted for variance in suicidality/self-harm over and above that accounted for by depression symptoms.

CONCLUSIONS

These pilot results suggest that SD might be a unique dimension of vulnerability to depression and suicidality/self-harm in adolescence. Also, they encourage assessment of SD as part of a suicide risk assessment, particularly in the context of risk for subsequent psychosis.

Role of perceived social support in depressive and somatic symptoms experienced by Bedouin Arab and Jewish Israeli undergraduates

Elevated levels of depressive and somatic symptoms have been documented among college students. Over the past two decades, there has been an increase in the number of Bedouin Arab students studying at institutions of higher education in southern Israel. To date, research on coping and mental health problems among students who are members of this ethnic minority has been limited. This study examined the role of three aspects of perceived social support - availability, satisfaction, and the ability to get emotional support - in predicting depressive and somatic symptoms among Jewish Israeli and Bedouin Arab college students. A total of 89 Bedouin and 101 Jewish first-year students participated in this study, which involved two assessment waves 12 to 14 months apart. Participants completed questionnaires assessing depressive symptoms, somatic complaints, three aspects of perceived social support, and demographics. At Time 1, Bedouin students exhibited higher levels of depressive and somatic symptoms and lower levels of all three aspects of social support. Regression analyses showed that level of emotional support was a prospective predictor of somatization at Time 2. Moreover, when levels of emotional support were low, ethnic group predicted depression at Time 2; emotional support predicted depression only among Bedouin Arabs. The present study highlights the importance of the use of emotional support in predicting somatic complaints and depressive symptoms specifically among Bedouin Arab students. Clinical implications on intervention programs for ethnic minority students will be discussed.

The Four-Cluster Spectrum of Mind-Body Interrelationships: An Integrative Model

Despite the shift toward a biopsychosocial paradigm of medicine, many physicians and mental health professionals (MHPs) find it difficult to treat patients with psycho-somatic disorders. This situation is particularly troublesome due to the high prevalence of these conditions. Although progress has been made over the last few decades in understanding mechanisms underlying the mind-body relationship, disparities remain between research and its clinical implementation. One possible reason for this is the lack of a comprehensive, agreed-upon model that incorporates a biopsychosocial framework and is rooted in an understanding of the various psychobiological pathways. Such a model would enable better communication between physicians and MHPs, allowing them to provide coordinated, stratified treatment. In this paper, four archetypal case studies, together with standard care options are presented to illustrate the current state of affairs. A four-tiered conceptual model of mind-body interrelationships based on pathophysiological and psychopathological mechanisms is suggested to help optimize the treatment of somatic complaints. This Four-Cluster model consists of: (1) Organic Conditions: Structural, or degenerative processes that can affect mood and psychological responses but are not clearly exacerbated by stress. (2) Stress Exacerbated Diseases: Biological disorders with a distinct pathophysiology, such as inflammatory or autoimmune diseases, whose progression is clearly exacerbated by stress. (3) Functional Somatic Syndromes: Conditions wherein heightened sensitivity to stimuli together with hyper-reactivity of the autonomic system form a "vicious cycle" of mutually enhancing learning processes. These processes involve biological mechanisms, such as central sensitization and psychological mechanisms such as catastrophization and selective attention. (4) Conversion Disorder: Physical manifestations of psychological distress, expressed somatically. Symptoms are solely an expression of problems in patients' psychic functioning and are not caused by biological pathology. Finally, suggested management of the aforementioned case studies is presented through the lens of the Four-Cluster model and a proposed integration of our model with existing theories is discussed. As it is rooted in an understanding of psychobiological pathways of illness, the proposed model enables a new way to discern which form of mind-body interaction is manifesting in different diseases and proposes a way to coordinate treatment plans accordingly, to enhance the accuracy and efficacy of care.

Self-criticism, interpersonal conditions, and biosystemic inflammation in suicidal thoughts and behaviors within mood disorders: A bio-cognitive-interpersonal hypothesis

We review the theoretical and empirical literature on the role of self-concept in suicidal behavior in the context of mood disorders (i.e., unipolar depression and bipolar spectrum disorders). The main themes emanating from this review are then juxtaposed against (a) the Interpersonal-Psychological Theory of Suicide and (b) biological research on the role of inflammatory processes in suicidality. Such a juxtaposition paves the way for a bio-cognitive-interpersonal hypothesis. Pathologies of the self-concept-primarily self-criticism-propel mood disorder sufferers to generate interpersonal stress that culminates in two proximal causes of suicidality: thwarted belongingness and perceived burdensomeness. In turn, these two interpersonal conditions set in motion systemic biosystemic inflammation, serving as a proximal cause for suicidality in mood disorders. We conclude by describing a research project aimed at testing this hypothesis, and by outlining pertinent implications for assessment, treatment, and prevention.

The Nature of the Beast: Commentary on “Can There Be a Recovery-Oriented Diagnostic Practice?”

Pavlo, Flanagam, Leither, and Davidson attempt to reconcile the recovery movement in mental health service with a formal diagnostic practice is as courageous as it is timely. Acknowledging this, I note several points of convergence and divergence with the authors’ views. Points of convergence include (1) the inevitability of a diagnostic system when working with (severe) mental illness, (2) the importance of going beyond signs and symptoms in capturing the unique characteristics of the person, (3) the focus on humanistic values, particularly the emphasis on a collaborative assessment and on human strengths, in the diagnostic process, and (4) the role of future-oriented thinking in diagnosis. Divergence with the authors concerns (1) my own reliance on descriptive psychiatry, with its focus on signs and symptoms, as a part and parcel of an effective diagnosis, (2) the potential benefits of psychological tests, for example, self-report questionnaires and projective procedures over and above the clinical interview, and (3) my emphasis on mental representations of self-with-others, termed here and elsewhere as “agents in relations,” as the building blocks of personality and psychopathology.

The (Suicidal-) Depressive Position: A Scientifically Informed Reformulation

Despite considerable progress in depression research and treatment, the disorder continues to pose daunting challenges to scientists and practitioners alike. This article presents a novel conceptualization of the psychological dynamics of depression which draws from Melanie Klein's notion of the positions, reformulated using social-cognitive terms. Specifically, Klein's notion of position, consisting of anxieties (persecutory vs. "depressive"), defense mechanisms ("primitive"/split based vs. neurotic/repression based), and object relations (part vs. whole) is reformulated to include (1) affect, broadly defined, (2) affect regulatory strategies (defense mechanisms, coping strategies, and motivation regulation), and (3) mental representations of self-with-others, all pertaining to the past, present, and future. I reformulate the depressive position to include-beyond sadness, anxiety, and anhedonia-also anger/agitation, shame, disgust, and contempt, all of which are down-regulated via diverse mechanisms. In the depressive position, the self is experienced as wronged and others as punitive, albeit seductive. Attempts to appease internal others (objects) are projected into the future, only to be thwarted by awkward and inept interpersonal behavior. This might propel the use of counter-phobic, counter-dependent, and "manic" affect regulatory mechanisms, potentially leading to suicidal depression.

Perceived Stress and Intent to Die in Young Soldiers Who Attempt Suicide

Abstract. Background: Intent to die is an important component of suicide risk assessment. The authors compared the predictive effect of two forms of stress – military and perceived – in intent to die by suicide among young adult Israeli soldiers with a history of suicide attempts. Depression, suicide ideation, and habituation/acquired capacity for suicidality served as covariates. Methods: Participants were 60 young adult soldiers in the Israeli Defense Force (ISF; aged 18–21 years), who made a suicide attempt during their military service. Study variables were assessed using self-report measures. Results: Intent to die by suicide correlated with suicide ideation, habituation/acquired capacity, depressive symptoms, and perceived stress. In a multiple regression analysis, perceived stress predicted intent to die (b = .44, p = .002) over and above the prediction by suicide ideation (b = .42, p = .013) and acquired capacity/habituation (b = .28, p = .023). Limitations: The cross-sectional design restricts causal inference. In addition, an exclusive reliance on self-report measures might have inflated shared method variance. Conclusions: Perceived stress captures a unique dimension of intent to die by suicide among young suicide attempters.

Depressive personality vulnerability in chronic physical pain: Centrality of sociotropy

OBJECTIVE

Chronic physical pain is one of modern medicine's principal challenges. Recently, there has been a keen research interest in the role of depressive personality vulnerability (DPV) in the course of chronic pain. This is the first attempt to examine the role of three leading DPV dimensions-sociotropy, autonomy, and self-criticism-in chronic pain.

METHOD

Chronic pain patients (N = 428) were assessed four times as to their pain, disability, anxious depression, and pain-based catastrophizing. At Time 1, sociotropy, autonomy, and self-criticism were also assessed. The effects of sociotropy, autonomy, and self-criticism on pain, disability, anxious depression, and pain-based catastrophizing were examined using structural equation modeling analyses.

RESULTS

All DPV dimensions uniquely predicted Time 1, but not Time 2, anxious depression. Sociotropy predicted Time 1 pain and catastrophizing over and above anxious depression, as well as an increase in catastrophizing over time. Autonomy predicted a decrease in catastrophizing and disability, and Time 1 anxious depression predicted an increase in self-criticism.

CONCLUSIONS

Sociotropy appears to be a unique dimension of DPV in chronic pain.

Chronic pain under missile attacks: Role of pain catastrophizing, media, and stress-related exposure

OBJECTIVE

We examined the effects of exposure to missile attacks on patients' pain and depressive symptoms, moderated by pain-related catastrophizing.

METHOD

One-hundred Israeli chronic pain patients were assessed both prior and subsequent to military operation "Protective Edge," during which thousands of missiles landed on populated areas across the country. Baseline assessment included pain, depression, and catastrophizing, and postwar assessment tapped exposure to missiles, pain, and depression.

RESULTS

Media exposure predicted an increase in sensory pain under high levels of catastrophizing (1 SD above the mean; unstandardized simple slope = 0.57, p = .01), and depression in the entire sample (b = 0.61, p = .01). Perceived stress related to the missiles exhibited an expected effect, predicting an increase in depressive symptoms (b = 1.45, p = .03). Unexpectedly, perceived stress predicted a decrease in sensory pain under high levels of catastrophizing (unstandardized simple slope = -0.49, p = .02).

CONCLUSIONS

Media exposure to acute stress may render chronic pain patients more vulnerable to experiencing pain and depressive symptoms, depending on their use of pain-based catastrophizing. High catastrophizers may attend more to outside threats, amplifying the sensory and affective aspects of pain they experience. Perceived stress also plays a significant role in eliciting depressive symptoms in this population. (PsycINFO Database Record

Psychodynamizing and existentializing cognitive-behavioral interventions: The case of behavioral activation (BA)

From the point of view of Cognitive-Existential Psychodynamics (Shahar, 2015a, 2016; Shahar & Schiller, 2016; Ziv-Beiman & Shahar, 2016), active techniques-primarily cognitive-behavioral therapy ones-might not only reduce distress but also bolster the therapeutic relationships and serve as powerful vehicles for self-discovery and growth. This, however, is contingent upon therapists' ability to view, and present to patients, the psychodynamic and existential nature of active techniques. Our focus herein is on behavioral activation, an intervention that consists of encouraging patients to participate in enjoyable and meaningful activities, in the face of depressive anhedonia. We posit that psychodynamizing and existentializing behavioral activation has the potential to increase awareness of inner multiplicity, strengthen eco-functions, assist in creating a "holding environment," bolster responsibility through agency, and offer a sense of transcendence. These benefits of behavioral activation are illustrated via a clinical case. (PsycINFO Database Record

Torturing personification of chronic pain among torture survivors

BACKGROUND

Consistent with the human tendency to anthropomorphize objects, events, and situations, individuals might ascribe human characteristics to physical symptoms and illnesses. This manuscript presents an examination of chronic pain personification in torture survivors. Specifically, it was hypothesized that torture survivors personify chronic pain as a torturing sensation. It was further hypothesized that PTSD mediates the effect of past torture on torturing pain personification.

METHODS

Fifty-nine Israeli ex-prisoners of war (ex-POWs), who experienced severe torture in captivity, and 44 matched controls completed self-administered questionnaires at 18, 30, and 35years post captivity.

RESULTS

Whereas ex-POWs exhibit higher torturing personification than controls, no differences were found in concrete description of chronic pain. PTSD trajectories were implicated in different levels of torturing personification. Finally, sequential mediation analysis revealed that PTSD at T2 and T3 mediated the association between torture and torturing personification.

CONCLUSIONS

The findings suggest that trauma shapes the way individuals relate to and experience their bodily sensations.

Benevolent personification of the MoH increases compliance with an emergency polio vaccination

OBJECTIVE

Parental compliance is crucial to the success of mass vaccination campaigns targeting children. Relying on psychological/neuroscientific research concerning the role of personification (i.e., viewing the inanimate as human) in behavior, the authors examined the effect of parents' personification of the Israeli Ministry of Health (MoH) on compliance with a publicly controversial mass vaccination campaign, which was aimed at stopping the spread of a wild poliovirus.

METHODS

Participants were 555 parents of children aged 9 or younger, residing in the center/north of Israel, an area covered by Phase 2 of the campaign. T1 assessment, employed two days prior to Phase 2, tapped into demographics, attitudes towards vaccination, intent to comply, and a benevolent personification of the MoH (i.e., "The MoH is caring") vs. a malevolent personification of the MoH ("The MoH is hysteric"). T2 assessment, transpiring four months after the end of the campaign, addressed presence and reasons for (non-)compliance.

RESULTS

The study's overall compliance rate was 61.8%. The principal reason for compliance was "adherence to the recommendations of the MoH" (68.49%). In a multivariate logistic regression analysis, prospective predictors of compliance were: an early intent to comply (O.R.=2.56, p=0.000), being male (O. R.=1.51, p=0.023), and a benevolent personification of the MoH (O.R.=1.21, p=0.019).

CONCLUSION

Parents who experienced the Israeli MoH as a benevolent protagonist were more likely to comply with the mass vaccination campaign. Findings highlight the role of leadership in public health campaigns during emergencies.

Cognitive-Humanistic Psychodynamics: Sidney Blatt's Theoretical-Philosophical Legacy

A number of broad-based, theoretical-philosophical tenets are to be gleaned from Sidney Blatt's voluminous, extensive, and unique scholarly work. Dominant themes in Blatt's life and work include (1) his fascination with cognition, particularly mental maps, or representations, of reality; (2) the influence of humanistic values (e.g., agency, need for growth, gestalts, need for balance, and an optimistic focus on resilience); and (3) a steadfast adherence to Freud's revolutionary discovery of the dynamic unconscious. Philosophically speaking, Blatt has left a unique, integrative, and vibrant legacy for the field, one that might be called cognitive-humanistic psychodynamics.

Depression and Somatic Symptoms Among Two Ethnic Groups in Israel: Testing Three Theoretical Models

INTRODUCTION

This study examined three theoretical models of the relationship between depressive symptoms and somatic complaints among Bedouin Arab and Jewish college/university students in Israel. The functional model suggests that somatic complaints may precede depressive symptoms; the affect-dysregulation model suggests that depressive symptoms may precede somatic complaints; and the sociocultural model suggests that depressive symptoms are strongly linked to somatic complaints mainly in Western cultural contexts.

METHOD

One hundred and ninety individuals participated in the study, including 89 Bedouin Arab students and 101 Jewish students. Two assessment waves, one year apart, were employed. Participants completed measures regarding depression, somatic complaints and demographics.

RESULTS

Bedouin Arabs reported higher levels of both depression (Time 1 and Time 2) and somatization (only Time 1) as compared to Jewish students. A multiple-group, cross-lagged SEM analysis provided support for the functional model among the Bedouin Arab and Jewish student: Somatic complaints prospectively predicted depression in both groups. However, support for the affect-dysregulation model was found only among the Bedouin Arab students, among whom depression prospectively predicted somatic complaints.

CONCLUSIONS

This study highlights cultural/ethnic similarities concerning the functional model and the cross-sectional associations between depression and somatization. However, these findings also underscore ethnic differences concerning the affect-dysregulation model.

Role of Pain-Based Catastrophizing in Pain, Disability, Distress, and Suicidal Ideation

BACKGROUND

In chronic pain, patients' coping affects their adaptation. In two studies, we examined the role of pain catastrophizing, a maladaptive coping strategy, in pain, distress, and disability. In Study 2 we compared catastrophizing to pain acceptance and to other coping strategies.

METHODS

Study 1. Chronic pain patients (N = 428) were assessed four times as to their pain, disability, catastrophizing, and distress (depression and anxiety). Study 2. Patients (N = 165) were assessed as to coping and pain acceptance, pain, related distress, depression, hope, suicidal ideations, perceived burdensomeness, and thwarted belongingness.

RESULTS

Study 1. A Structural Equation Modeling (SEM) analysis revealed that Time 1 Pain-based catastrophizing prospectively predicted pain (β =.36, p < .001). Distress prospectively predicted pain related disability (β = .34, p <.001). Study 2. Pain-based catastrophizing predicted sensory pain (β = .22, p = .018), depression (β = .43, p < .001), and suicidal ideation (O.R. = 1.88), which were also predicted by depression and perceived burdensomeness. Distraction predicted sensory pain (β = .21, p = .017, respectively). Activity engagement predicted low levels of depression (β = -.29, p < .001, respectively), and willingness to accept pain predicted low pain-related distress (β = -.16, p = .05).

CONCLUSIONS

Pain catastro-phizing and pain acceptance constitute risk and resilience factors. Both should be assessed and targeted in pain management.

Therapeutic self-disclosure in integrative psychotherapy: When is this a clinical error?

Ascending to prominence in virtually all forms of psychotherapy, therapist self-disclosure (TSD) has recently been identified as a primarily integrative intervention (Ziv-Beiman, 2013). In the present article, we discuss various instances in which using TSD in integrative psychotherapy might constitute a clinical error. First, we briefly review extant theory and empirical research on TSD, followed by our preferred version of integrative psychotherapy (i.e., a version of Wachtel's Cyclical Psychodynamics [Wachtel, 1977, 1997, 2014]), which we title cognitive existential psychodynamics. Next, we provide and discuss three examples in which implementing TSD constitutes a clinical error. In essence, we submit that using TSD constitutes an error when patients, constrained by their representational structures (object relations), experience the subjectivity of the other as impinging, and thus propels them to "react" instead of "emerge." (PsycINFO Database Record

In Eating-Disordered Inpatient Adolescents, Self-Criticism Predicts Nonsuicidal Self-Injury

We examined the role of depressive traits-self-criticism and dependency-in nonsuicidal self-injury (NSSI) and suicidal ideation among inpatient adolescents with eating disorders. In two studies (N = 103 and 55), inpatients were assessed for depressive traits, suicidal ideations, and NSSI. In Study 2, motivation for carrying out NSSI was also assessed. In both studies, depression predicted suicidal ideation and self-criticism predicted NSSI. In Study 2, depression and suicidal ideation also predicted NSSI. The automatic positive motivation for NSSI was predicted by dependency and depressive symptoms, and by a two-way interaction between self-criticism and dependency. Consistent with the "self-punishment model," self-criticism appears to constitute a dimension of vulnerability for NSSI.

Psychometric Properties of the Spanish Version of the Therapeutic Collaboration Scale (TCS)

The development of appropriately normed Spanish-language assessments is a necessity as a result of (1) a growing Latino population in need of behavioral health services and (2) a limited number of linguistically and culturally sensitive instruments that are currently available. As part of a broader assessment on the needs and satisfaction with services received, 103 Latina women completed the Therapeutic Collaboration Scale (TCS). This measure attained a substantial internal consistency (Cronbach’s alpha =.94) and good convergent validity with another instrument that also assessed the therapeutic relationship named the Therapeutic Alliance with Clinician (r = .71, p < .05). A principal component analysis evidenced one component underlying the TCS, which further confirmed the unidimensionality of this instrument. This measure achieved a good correlation with an instrument assessing the participants’ satisfaction with services (SWS, r = .44, p < .05). Conclusions and implications of this study are presented in this article.

Psychotherapy of Self-Criticism in a Case of Mixed Anaclitic-Introjective Depression

In this case study, the year-long psychotherapy of a depressed and self-critical 34-year-old women is described. Her depression was conceptualized as a “mixed” anaclitic and introjective type according to the model of Sidney Blatt. Anaclitic depression involves a preoccupation with the integrity of interpersonal relatedness (e.g., issues of dependency and abandonment), whereas introjective depression involves a preoccupation with autonomy and self-esteem (e.g., self-criticism and feelings of worthlessness). Given the potentially destructive nature of self-criticism, the therapist systematically confronted the patient’s use of this trait in a supportive manner. Changes in the patient’s functioning were assessed at the beginning and at the end of treatment using the Shedler-Westen Assessment Procedure and the Diagnostic and Statistical Manual of Mental Disorders (4th edition) Global Assessment of Functioning Scale. After 1 year of psychotherapy combining both cognitive and psychodynamic interventions, the patient evidenced significant changes in both anaclitic and introjective personality dimensions and showed significant improvements in adaptive functioning.

The effect of childhood emotional maltreatment on romantic relationships in young adulthood: A double mediation model involving self-criticism and attachment

OBJECTIVE

Despite growing recognition of the importance of childhood emotional maltreatment (CEM) on the development of psychopathology, very few studies have addressed its impact on adult romantic relationship functioning, particularly among otherwise relatively well-functioning individuals. In an attempt to further elucidate the mechanism underlying the negative impact of CEM on romantic relationships, we tested an integrative mediational model linking CEM to romantic relationships through the impact of CEM on the development of self-criticism and adult attachment. Recent work in this context suggests that while self-criticism concerns broad cognitive-affective schemas related to achievement and failure, attachment avoidance assesses the expression of these broad schemas in close relationships (Luyten & Blatt, 2011; Sibley & Overall, 2008, 2010).

METHOD

This hypothesized mediational model was examined in a sample of young adult undergraduates (N = 99, 85 female), using structural equation modeling.

RESULTS

The mediational model was in large part supported. Attachment avoidance, but not attachment anxiety, fully accounted for the mediating role of self-criticism in the relationship between CEM and romantic relationship satisfaction, even when controlling for the potential role of concurrent levels of posttraumatic stress disorder severity.

CONCLUSIONS

Understanding the long-term psychological dynamics related to CEM and identifying mediating vulnerability factors-self-criticism and attachment avoidance-might have implications for both the assessment and treatment of individuals with a history of CEM, particularly as effective interventions to address self-criticism and attachment issues are available. (PsycINFO Database Record