Monthly Archives: June 2009

Review: Clinical Varieties of Transference

The article reviewed here is ‘Clinical Varieties of Transference’, a transcript of a talk given by Donald Winnicott at the 19th International Psycho-Analytical Congress in Geneva 1955. Despite being fairly brief (just a few pages) the article is rich in ideas and I found it took some reading and rereading. As it’s one of his latter papers, there is a lot of referencing to his earlier work as well as that of his contemporaries. He first of all remarks that in initial years, psychoanalytic theory was developed through work with a group of patients who had passed through certain phases of development without difficulty as there had been ‘good enough infant care’. As a result

The earlier stages of the establishment of the ego could be taken for granted by the analyst

He then refers to the primary identification and describes it as a period in the infant’s development in which the individual has not been distinguished from the environment. On progressing from this primary identification, Winnicott outlines two possibilities – either there is a good-enough adaptation of the ego to the environment or there isn’t in which case

instead there develops a pseudo-self which is a collection of innumerable reactions to a succession of failures of adaptation

This pseudo-self he refers to as the false self which allows the real self to experience a ‘continuity of being’ but ‘cannot, however, experience life or feel real’. Then Winnicott suggests that in therapy session the analyst may make mistakes which are helpful in the therapeutic process but overall when the therapy is considered ‘good-enough’ then

raises a hope that the true self may at last be able to take the risks involved in its starting to experience living

There follows a period in which the ego can ‘experience id impulses’. He distinguishes the ‘objective anger’ at the analyst’s mistakes from the ‘negative transference of neurotic analysis’.

The ideas discussed here are profound and relate to the very practical aspects of the therapeutic process. While it would have been helpful to have excerpts from the therapy sessions to illustrate the points, this paper was derived from a talk where perhaps the primar aim was to disseminate practical insights to fellow therapists rather than develop the underlying theory at that point.

References

Donald Winnicott. Clinical Varieties of Transference [1955-1956]. Read before the 19th International Psycho-Analytical Congress, Geneva, 1955. Int J Psycho-Anal, Vol XXXVII, p386, 1956. Chapter XXIII (pp295-299) In D.W.Winnicott. Through Paediatrics to Psycho-Analysis. With an Introduction by M.Masud R.Khan. The International Psycho-Analytical Library. Edited by M.Masud R.Khan. The Hogarth Press and the Institute of Psycho-Analysis. 1978.

Steps to Treatment

STT3 (Advice is relevant to treatment but needs to be tested in intervention studies which then need to be incorporated into relevant policies if successful).

Steps To Treatment (STT)

STT = Steps To Treatment. An estimate of the number of steps between the results and translation into treatment. This is an opinion.

Responses

If you have any comments, you can leave them below or alternatively e-mail justinmarley17@yahoo.co.uk

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

Review: Discussion of Puzzlingly High Correlations in fMRI Studies of Emotion, Personality and Social Cognition

The featured article is a response by Lazar to Vul et al’s paper on statistics used in fMRI (and reviewed here) and Lazar’s article is freely available here. Vul’s article presents a useful focus for examining the statistical techniques used in fMRI and a systematic analysis of the responses to this paper should offer insights into the diversity of approaches considered in such analysis. Lazar is based in the Department of Statistics at the University of Georgia. He starts off the article with this neat observation

Statistical tools were originally devised for a rather specific set of circumstances – mostly small or moderately sized data sets, collected under controlled experimental conditions

I was reassured to find that Lazar refers to Vul et al’s use of the term ‘non-independence error’ as a ‘selection bias’ which I had also considered in my original review above. He discusses the issue of selection bias in other fields further and I was intrigued to read of Benjamini’s experience in discussing a possible selection bias in the field of genetics.

Lazar has many interesting sessions and reiterates an important point made elsewhere

Increased transparency in reporting the details of an analysis will also help

Lazar tells us that he is working with colleagues to develop new statistical approaches to analysing imaging data and suggests that researchers will move away from the correlation analysis as more appropriate forms of analysis take their place. He also warns us against the basic mistake of analysing the same data set twice and notes the increasing complexity of data available for analysis.

While relatively brief, I thought this was a thought-provoking article which suggests changes not just in neuroimaging but also in the field of statistics.

Responses

If you have any comments, you can leave them below or alternatively e-mail justinmarley17@yahoo.co.uk

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

News Round-Up: June 2009 4th Edition

Research in Dementia

In one post-mortem study all subjects with Lewy Bodies were retrospectively found to be functionally impaired although the calculation of an odds ratio was not possible (paper freely available here) (Byford et al, 2009)(STT4). A type of swelling in the Purkinje cell axons referred to as a Torpedo was found to be elevated in people with Alzheimer’s Disease, Parkinson’s Disease and to a greater extent in cerebellar essential tremor in this post-mortem study (Louis et al, 2009)(STT5). In an autopsy series (n=466) there was found to be no association between a measure of atherosclerosis in the circle of Willis (a marker of large vessel disease) and amyloid plaque in the frontal cortex or neurofibrillary tangles in the hippocampus (Luoto et al, 2009)(STT4).

Research in Psychosis

A naturalistic study (n=325) provided evidence that had greater efficacy for treatment of schizophrenia (using outcome measures including the PANSS) than chlorpromazine or haloperidol (Ravanic et al, 2009)(STT4).

News in Brief

In a prospective 5-year study of 906 older adults decreasing social activities (using a Likert Scale) were significantly associated with decreasing motor skills including strength and balance. A comparison of elderly people in the United States (from the Health and Retirement Study) and England (from the English longitudinal study of Aging) found that the American cohort performed significantly better on a number of cognitive measures than their counterparts in England. Members of the researcher team suggested that different treatment approaches to hypertension between the two countries may have contributed to these differences. The long and short versions of the period3 gene have been implicated in response to sleep deprivation and this study found that a different pattern of recruitment of cortical regions in a working memory task which the authors suggest as a potential intermediate step in the causal chain from gene to sleep deprivation response. A study has provided evidence that Amitriptylline binds to the tRKA and tRKB receptors causing dimerisation and results in outgrowth of neurites actions which parallel those of Nerve Growth Factor.

An MRI study (n=77 roughly) of people with dyslexia and a roughly equal number of controls without provided evidence of a difference between the groups in the right cerebellar declive and the right lentiform nucleus (the original article is freely available here). There have been previous studies which have implicated the cerebellum in language. The Canadian ‘Center for Addiction and Mental Health’ recently estimated that 1/25 of deaths globally are alcohol related (also covered here). Gaze is important in human social interactions and one study provided evidence that our interpretation of another person’s direction of gaze is influenced by our understanding of their internal state. These findings are relevant to social cognition theory. The authors of a recently published meta-analysis concluded that CBT was not effective in treatment of schizophrenia or in prevention of relapse in Bipolar Disorder and it will be interesting to see responses to this meta-analysis. A recent study provided evidence that Rhesus monkeys and humans share a similar mechanism for recognising faces by using a paradigm which involved the ‘Thatcher Effect’. This involves inverting facial features, the eyes and mouth and interferes with the task of facial recognition in both species.

In one study, students with higher levels of anxiety were found to spend more time focusing on irrelevant words (distractors) in a reading task. They were also given a maths task and it was found that the correct responses were similar in both the anxiety and control groups but the former group took longer to complete the tasks. (the article is freely available here). A recent study involved 1224 bloggers and found that the main principles which bloggers valued were ‘truth, accountability, minimising harm and attribution’. Depending on the purpose of the blog, the priority of these values differed. Three 35,000 year-old bone and ivory flutes have been found in Germany.

References

Byford M, Brayne C, McKeith I, Chatfield M, Ince PG, Matthews FE, Cfas. Neuropathology Group M.BMC Geriatr. 2009 Jun 15;9(1):22. [Epub ahead of print]. Lewy bodies and neuronal loss in subcortical areas and disability in non-demented older people: a population based neuropathological cohort study.

Louis ED, Faust PL, Vonsattel JP, Honig LS, Rajput A, Rajput A, Pahwa R, Lyons KE, Ross WG, Elble RJ, Erickson-Davis C, Moskowitz CB, Lawton A. Mov Disord. 2009 Jun 12. [Epub ahead of print]. Torpedoes in Parkinson’s disease, Alzheimer’s disease, essential tremor, and control brains.

Luoto TM, Haikonen S, Haapasalo H, Goebeler S, Huhtala H, Erkinjuntti T, Karhunen PJ. Eur Neurol. 2009 Jun 12;62(2):93-98. [Epub ahead of print]. Large Vessel Cerebral Atherosclerosis Is Not in Direct Association with Neuropathological Lesions of Alzheimer’s Disease.

Ravanic DB, Dejanovic SM, Janjic V, Jovic SD, Milovanovic DR, Jakovljevic V, Pantovic V, Ravanic B, Pantovic M, Pantovic MM.Arq Neuropsiquiatr. 2009 Jun;67(2A):195-202. Effectiveness of clozapine, haloperidol and chlorpromazine in schizophrenia during a five-year period.


Responses

If you have any comments, you can leave them below or alternatively e-mail justinmarley17@yahoo.co.uk

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

Podcast Review: Betts on Jung’s Analytical Psychology #17

The podcast reviewed here is the 17th in John Betts series on Analytical Psychology and freely available here. Betts continues with the Moreau guidelines for analysing fairy tales and focuses here on techniques for amplifying symbolism in fairy tales including the appropriate use of symbol dictionaries. Here Betts tells us that people who preferentially use the sensing function may overamplify symbols. He advises the listener to read plenty of fairy tales (just before bedtime!) and myths. The suggestion of reading fairy tales just before going to sleep is an interesting one as this is the time that children are typically read bedtime stories. Perhaps fairy stories are meant to be the stuff of dreams! He mentions a few of the more important symbols used. Betts also makes a number of others suggestions for the analysis of fairy tales including assessing how it relates to the process of individuation and examining your feelings in response to the tale. He then goes on to analyse the Nixie of the Millpond which he read in an earlier episode of the series. He moves through the characters identifying those that are the most appropriate for analysis and as a result of his skills makes the process appear effortless. Betts gives us a fascinating insight into the son in this story. He argues that the son must work through the issues that his father has not been able to succesfully work through. He provides a number of other insights into this story also. Betts practical suggestion of reading a story just before bedtime complements his suggestion in an earlier episode of writing down recalled dreams first thing in the morning and both activities perhaps shouldn’t take too much time and may be time well invested for those with an interest in this area.

Responses

If you have any comments, you can leave them below or alternatively e-mail justinmarley17@yahoo.co.uk

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

Blog Review: Buckeye Psychiatry, LLC

The featured blog is ‘Buckeye Psychiatry, LLC‘ by Dr Adam Brandemihl, a psychiatrist based in Dublin, Ohio and which began in August 2008. Brandemihl’s interests include ADHD  which is reflected in a number of the postings. The postings are broadly speaking of two types. The first type predominates and is a report on news stories. These are about developments in psychiatry. Thus there are a number of articles on drug trials or new applications of medications as well as a diverse range of other articles on psychological and social issues relevant to psychiatry. In the latter group Brandemihl covers the USA healthcare system.  I found that Brandemihl selects very interesting articles particularly those relating to cognition which is relevant not only to ADHD but a number of other psychiatric conditions. The other type of article is aimed at the lay audience and consists for instance of tips about lifestyle although these are much less frequent. Brandemihl uses many sources for his articles and keeps a finger on the pulse of developments in psychiatry and I would recommend this blog to those with an interest in this area

Responses

If you have any comments, you can leave them below or alternatively e-mail justinmarley17@yahoo.co.uk

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

Book Review: Seeing Voices

The book reviewed here is ‘Seeing Voices’ by Oliver Sacks. Excerpts from this book were included in a compilation book also – Vintage Sacks (reviewed here). In this book, Sacks explores the world of people who are deaf. He moves from the medicalisation of deafness which considers this as a deficit – a loss of function and transforms this through his words in a vivid, dynamic culturally rich experience. What I found particularly interesting was the first section of the book which was originally written as a book review. Thus Sacks takes the book review to a different level, extending it to an entire section of the book and interweaving his thoughts and diverse readings. Sacks takes questions such as ‘how does deafness affect thinking’ and ‘what difference does this make to communication’ and accumulates evidence from different directions. He describes the case of someone learning to use words for the first time but only understanding their significance after ‘hundreds of thousands of repetitions of words’. Similarly he reflects on language acquisition during the developmental period as being a ‘dialectical leap’

‘the leap from sensation to thought – involves not just talking, but the right sort of talking, a dialogue rich in communicative intent, in mutuality and in the right sort of questioning, if the child is to make this great leap successfully

He emphasises the importance of language in the developing mother-child relationship and this reminded me of an earlier paper I had reviewed by Feeley on the developmental period (reviewed here). Is it possible that the rapid proportional increase in brain volume is related to the critical period of language acquisition? Sacks goes onto consider the neurobiology of signing-

we see then in Sign, at every level – lexical, grammatical, syntactic – a linguistic use of space

Indeed when he considers signing in this way he gives the reader an entirely new perspective on the intracacies and sheer wonder of signing before going on to suggest

Perhaps, indeed, there have been two parallel evolutionary streams for spoken and signed forms of language

Already there is more than enough here to reflect on, but Sacks ever an empathic observer takes us on a  journey through the lives of individuals and communities. Thus in the third section he examines a protest at Gaulladet University where deaf students petition for a deaf president to be elected. Along the way he captures many fascinating insights into the life of deaf students on campus

I had to see the wonderful social scene in the student bar, with hands flying in all directions as a hundred separate conversations proceeded

As with other books by Sacks, he keeps the central narrative flowing while producing detailed footnotes which contain other points of interest including technical points. Sacks writing is excellent – he is a master of combining the humanities and sciences and communicating this with the reader to produce important works with a timeless quality.

References

Oliver Sacks. Seeing Voices. Picador. 1991.

Responses

If you have any comments, you can leave them below or alternatively e-mail justinmarley17@yahoo.co.uk

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

Review: Developing Service for Carers and Families of People with Mental Illness

The article reviewed here is a Department of Health document ‘Developing Service for Carers and Families of People with Mental Illness’ first published in 2002 and freely available here. The aim of the document is described as being

to help local mental health services develop support services for carers of people with mental health problems

and the reader is directed to Standard 6 of the Mental Health NSF and guidance for the Carers and Disabled Children Act 2000. In the background section the authors explain how Social Service Inspectorate reports have emphasised that carers do not always gain access to services and a number of other documents are also discussed. In section 1.3 on the evidence base and research, the authors note that helpful research has emerged from the Social Policy Research Unit (SPRU) before mentioning NICE and the National Institute for Mental Health.

Section 2 covers the principles of a carer support service and quotes estimates of care provided by carers  from The Princess Royal Trust for Carers. The identifcation of carers needs and inclusion of carers in planning service provision are emphasised before the important values for such services are discussed including being ‘positive and inclusive’, ‘flexible and individualised’, ‘accessible and responsive’ and ‘integrated and co-ordinated’.

Section 3 covers commissioning and planning of carer support services.  This includes discussion of examples of good practice and the complexity of assessing such services given the heterogenous types of care that are provided as well an emphasis on specialised and not generic carer support.

Section 4 covers the identification and assessment of carers. There are some examples of good practice which include a General Practice with a printable document for carers on the intranet which is given to carers when relevant, the supporting carers better network and the Fareham and Gosport Rethink Carer’s Group which links in with the local acute admissions unit to provide information to carers.

Section 5 covers the provision of services to carers. In this section there are a number of examples of ‘positive practice’ including information made available by MACA, Making Space, The Carer’s Advisory Group for Mental Health in London, Rethink and Sandwell Primary Care Trusts. Section 6 covers the needs of Black and Ethnic Minority Carers and Young carers with an example of good practice. Section 7 looks at carer support workers, where they should be located, their skills and how they should be recruited. In the conclusion it is noted that the content of the document will already be known to services providing relevant support to carers. The appendices contain a sample job description for carers and further reading material.

As carers play an important role, addressing their needs can be argued to influence not only their own health and wellbeing but also that of the people they are caring for. This document addresses this important area, offering a structured overview of the issues surrounding relevant service provision as well as giving useful case studies which illustrate the principles being discussed.

Responses

If you have any comments, you can leave them below or alternatively e-mail justinmarley17@yahoo.co.uk

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.