Bent Rosenbaum

Prospective investigations of the prodromal state of schizophrenia: review of studies

Objective:  The paper presents a comprehensive overview of prospective studies monitoring or intervening in the pre‐onset phase of first episode psychosis.

Prospective investigations of the prodromal state of schizophrenia: assessment instruments

Objective:  To review assessment instruments used for detection of prodromal or at‐risk mental states, and discuss their role in current research.

Supportive Psychodynamic Psychotherapy versus Treatment as Usual for First-Episode Psychosis: Two-Year Outcome

During recent decades, the field of treatment of schizophrenia has lacked empirical, systematic outcome studies that support psychodynamic psychotherapy as an evidence-based intervention for patients with schizophrenia. The Danish schizophrenia project (DNS) compared psychodynamic psychotherapy for psychosis with standard treatment in patients with a first-episode schizophrenia spectrum disorder. The study was designed as a prospective, comparative, longitudinal multi-site investigation of consecutively referred patients who were included during two years. The patients were treated with either manualized individual supportive psychodynamic psychotherapy (SPP) in addition to treatment as usual or with treatment as usual alone (TaU). Symptoms and functional outcomes were measured using the Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning scale (GAF). The study included 269 consecutively admitted patients, age 18–35, of whom 79% remained in the study after two years. The intervention group improved significantly on measures of both PANSS and GAF scores, with large effect sizes at two years follow-up after inclusion. Further, improvement on GAFfunction (p = 0.000) and GAFsymptom (p = 0.010) significantly favored SPP in combination with TaU over TaU alone. In spite of limitations, this study speaks in favor of including supportive psychodynamic psychotherapy in the treatment for patients with schizophrenic first-episode psychoses.

The influence of extreme traumatization on body, mind and social relations

Extreme traumatization affects the individuals relation to others in several social and psychological ways. The post‐traumatic experiences are characterized by helplessness, insecurity, anxiety, loss of basic trust, and fragmentation of perspectives on ones own life. Special considerations should be given to the destruction of the ability to regulate negative emotions (extreme fear, distress, anguish, anger, rage, shame) in relation to others and activate internal good and empathic object relations. Destruction of the capacity for symbolization of traumatic experience may threaten the mind with chaotic states against which the ‘I’ tries to defend itself and find a balanced psychic mise‐en‐scene. The authors emphasize three dimensions that the analyst should observe in his understanding of the traumatized mind and its conflicts. The proposed dimensions are called the body‐other dimension, the subject‐group dimension, and the subject‐discourse dimension. All three dimensions have specific structural characteristics that are expressed in the analytic relation. Extreme trauma causes disturbances in each of these dimensions. The authors present clinical material from a traumatized refugee to illustrate the analytic work.

Psychosis and the dynamics of the psychotherapy process

The role of psychotherapy in the treatment of psychoses remains controversial but there is improving acceptance that an understanding of the dynamics of the psychological processes involved in treatment and in the disorder itself may be important. Psychosis is understood as a detachment of the ‘self’ from the ‘world which results in changed abilities in inter-subjective relating to oneself and others. This understanding has led to guidelines for psychotherapists who engage in treatment of psychoses and these are summarized in this article. As a result of the disturbance in the inter-subjective process, a therapeutic relationship is disrupted and a therapeutic alliance is not assured. Therapists have to pay particular attention to the empathic aspects of the interaction as they attempt to integrate affects to restore meaning to the inner life of the patient. The psychodynamics of this process are described with additional discussion about the role of cognitive interventions and their limitations.

Extreme Traumatisation: Strategies for Mental Survival

Disruption and loss characterise the life of the person who has undergone extreme traumatisation (torture, concentration camp, etc.), especially when he/she lives in exile. This presents new challenges both in understanding trauma and massive traumatisation and in treating it. When planning and conducting treatment, it is of special importance to take into consideration the mental survival strategies that the person has developed. These are mental capacities that aim both at developing methods of avoiding the pain of re-experiencing and at achieving solutions to the dilemmas posed by the posttraumatic phase. The latter often consists of aborted attempts at mentalisation and integration of traumatic experiences. The traumatised person will often experience the therapeutic encounter as threatening because of fear of re-experiencing and re-traumatisation, and also because having experienced atrocities disturbs or damages the capacity for developing a trusting relationship. This paper discusses the complexities of the consequences of this situation and describes a model for a psychoanalytic approach to the treatment of these patients, focusing on the disturbance of symbolisation and mentalisation caused by trauma. Treatment must address this and provide a setting where experiences that have been insufficiently symbolised (expressed in somatisation, acting, non-verbal characteristics of speech, procedural aspects of transference, etc.) can be placed in context through a process of historisation.

Rorschach Inkblot Method data at baseline and after 2 years treatment of consecutively admitted patients with first-episode schizophrenia

Background: The Rorschach Inkblot Method is regarded as an important clinical instrument for detailed diagnostic description of the integrative capacities of individuals in psychotic states and as an instrument for measuring progression in the course of treatment. Aims: To describe relevant Rorschach variables at baseline in a group of consecutively admitted patients with first-episode schizophrenia. Furthermore, to describe the changes in these variables from baseline to year 2 for the group of patients given psychiatric standard treatment, and to compare these changes with changes in other outcome measures [Positive and Negative Syndrome Scale (PANSS), Global Assessment of Functioning (GAF), Strauss–Carpenter and socio-demographic variables]. Methods: In a prospective study, 34 patients consecutively admitted to treatment for a first episode of schizophrenia were tested using Exners Rorschach Comprehensive System at inclusion and after 2 years. Results: Core variables of the Rorschach, assumed to show changes (e.g. reality testing, perceptual and thought disorders) in patients with a first episode of schizophrenia, all improved but revealed no significant changes after 2 years of treatment, while other measurements (PANSS, GAF) did. Furthermore, discrepancies were found between the Perceptual-Thinking Index (PTI) and PANSSpositive symptoms of delusions and hallucinations. Conclusion: The small sample limits the conclusions, but the Rorschach variables may have problems reflecting major changes in psychotic symptoms and social functioning. With short protocols, PTI seems at risk of being unnecessarily insensitive and PTI may benefit from changes in the scoring procedures.

The DiaS trial: dialectical behavior therapy versus collaborative assessment and management of suicidality on self-harm in patients with a recent suicide attempt and borderline personality disorder traits - study protocol for a randomized controlled trial

BackgroundIn Denmark 8,000 to 10,000 people will attempt suicide each year. The Centre of Excellence in Suicide Prevention in the Capital Region of Denmark is treating patients with suicidal behavior, and a recent survey has shown that 30% of the patients are suffering from borderline personality disorder. The majority of patients (70% to 75%) with borderline personality disorder have a history of deliberate self-harm and 10% have a lifetime risk to die by suicide. The DiaS trial is comparing dialectical behavior therapy with collaborative assessment and management of suicidality-informed supportive psychotherapy, for the risk of repetition of deliberate self-harm in patients with a recent suicide attempt and personality traits within the spectrum of borderline personality disorder. Both treatments have previously shown effects in this group of patients on suicide ideation and self-harm compared with treatment as usual.Methods/DesignThe trial is designed as a single-center, two-armed, parallel-group observer-blinded randomized clinical superiority trial. We will recruit 160 participants with a recent suicide attempt and at least two traits of the borderline personality disorder from the Centre of Excellence in Suicide Prevention, Capital Region of Denmark. Randomization will be performed though a centralized and computer-generated approach that conceals the randomization sequence. The interventions that are offered are a modified version of a dialectical behavior therapy program lasting 16 weeks versus collaborative assessment and management of suicidality-informed supportive psychotherapy, where the duration treatment will vary in accordance with established methods up to 16 weeks. The primary outcome measure is the ratio of deliberate self-harming acts including suicide attempts measured at week 28. Other exploratory outcomes are included such as severity of symptoms, suicide intention and ideation, depression, hopelessness, self-esteem, impulsivity, anger, and duration of respective treatments.Trial registrationClinical Trial.gov: NCT01512602.

The Unconscious: How does it speak to us today?

More than six decades after Freuds death, psychoanalysts are certainly not more unified in their view of the concept of the unconscious—its structure and its way of working—than in ‘the good old days’. Challenges are facing psychoanalysis from many perspectives, urging psychoanalysts to continuously reconsider their theoretical grounds. This paper pursues three lines of argumentation concerning the Unconscious. The first line concerns the relation to neuroscience and this paper suggests the concept of background feelings (Damasio) as a contribution to another understanding of deficits in the psychoanalytic relationship. The second line concerns the relation to cognitive semiotics, and here, the paper stresses the concept of basic image sehemata as a possible link between the subjects pre-reflective awareness of the other and the internal world of phantasy. The third line pursues a concept of the analytic interpretation which is close to the Freudian idea that psychoanalysis is the communication between two Unconscious, and, consequently, that the psycho-analytic interpretation is not per se a conscious act.

Transdiagnostic group CBT for anxiety disorders: the unified protocol in mental health services

Abstract Comorbidity among the anxiety disorders is common and may negatively impact treatment outcome. Potentially, transdiagnostic cognitive-behavioral treatments (CBT) deal more effectively with comorbidity than standard CBT. The present study tested the effectiveness of The Unified Protocol (UP) applied to Mental Health Services. Pre-post-treatment effects were examined for psychiatric outpatients with anxiety disorders receiving UP treatment in groups. Forty-seven patients (mean-age = 34.1 (SD = 9.92), 77% females) with a principal diagnosis of anxiety were included. We found significant and clinically meaningful changes in the primary outcomes Clinical Global Impression Severity Scale (CGI-S; d = 1.36), Hamilton Anxiety Scale (HARS; d = .71), and WHO-5 Well-being Index (WHO-5; d = .54). Also, comorbid depressive symptoms and levels of positive and negative affect changed significantly after treatment. Patients with high levels of comorbidity profited as much as patients with less comorbidity; however, these patients had higher scores after treatment due to higher symptom burden at onset. Patients with comorbid depression profited more from treatment than patients without comorbid depression. The treatment effects found in the present study correspond to treatment effects of other TCBT studies, other UP group studies, and effectiveness studies on standard CBT for outpatients. The results indicate that the UP can be successfully applied to a MHS group setting, demonstrating positive effects on anxiety and depressive symptoms for even highly comorbid cases.