Ephi J. Betan

Relationship of depression to diabetes types 1 and 2: Epidemiology, biology, and treatment

This article reviews the rapidly accumulating literature on the relationship between mood disorders and diabetes mellitus. Recent studies have demonstrated that depression and its associated symptoms constitute a major risk factor in the development of type 2 diabetes and may accelerate the onset of diabetes complications. Since the mid-1980s, multiple longitudinal and cross-sectional studies have scrutinized the association of diabetes with depressive symptoms and major depression. Utilizing the search terms depressive disorders, psychiatry, diabetes, and pathophysiology in MEDLINE searches (1966-2003), this article reviews studies investigating pathophysiological alterations related to glucose intolerance and diabetes in depressed patients. The few randomized, controlled studies of treatment of depression in patients with diabetes are also described. Short-term treatment of depression in patients with diabetes improves their dysphoria and other signs and symptoms of depression. Future research will confirm whether response to psychotherapy and/or psychopharmacologic treatment improves glucose control, encourages compliance with diabetes treatment, and perhaps even increases longevity.

Identity disturbance in adolescence: Associations with borderline personality disorder

Although establishing a coherent identity is often viewed as a normative developmental task of adolescence, an important question is whether forms of identity disturbance seen in adult personality disorders can also be distinguished in adolescents. If so, such disturbances would constitute an essential target for research and clinical interventions. The goal of this study is to investigate the nature of identity disturbance in an adolescent clinical sample and to explore its links with personality pathology, particularly borderline personality disorder. A national random sample of 139 psychiatrists and clinical psychologists completed a battery of instruments on a randomly selected adolescent patient in their care, including measures of Axis II symptoms and the Identity Disturbance Questionnaire-Adolescent Version, an instrument designed for clinically experienced observers that assesses a wide range of manifestations of potential identity disturbance among adolescents. Factor analysis of the Identity Disturbance Questionnaire--Adolescent Version yielded four clinically and conceptually coherent factors that resembled dimensions previously identified in adults: lack of normative commitment, role absorption, painful incoherence, and lack of consistency. As in adults, identity disturbance in adolescents is a clinically meaningful, multidimensional construct exhibiting significant relationships with different forms of severe personality pathology, most notably borderline personality disorder. As such, identity disturbance can be a manifestation of psychopathology above and beyond the typical Sturm und Drang (storm and stress) of adolescence.

Clinical Expertise in Psychotherapy: How Expert Therapists Use Theory in Generating Case Conceptualizations and Interventions

Case conceptualization is a primary skill that may be the linchpin of clinical practice as it sets the framework for making sense of a patient’s difficulties and guides a path toward change. Providing meaning and structure to often ambiguous and nuanced clinical information, an apt case conceptualization facilitates the therapist’s complex integration of core therapeutic skills to produce expert performance. Rooted in the cognitive sciences literature on expertise, we introduce the concept of metabolizing theory to capture expert therapists’ capacity to use theoretical and clinical knowledge in an intuitive, flexible manner that responds and adapts to the unique and complex context of the treatment.

Countertransference and Personality Pathology: Development and Clinical Application of the Countertransference Questionnaire

Mario, an accountant in his early 30s, came to therapy angry and ready to challenge the parameters of treatment (i.e., time, fees, and interventions). He displayed barely concealed disdain toward his therapist and therapy despite a desperate plea for help. He was isolated, new to the city with few attachments to tether him to the world. He was in conflict with his supervisor and coworkers after only a few months at his new job. He was intensely suspicious – of authority figures, of peers, of family, of strangers, of everyone with whom he came in contact. He was terrified of his internal experience of ever-impending annihilation of self. Seeking help was necessary to contain his terror, yet stimulated his expectation of intrusion and damage.

Essential activities in a session of brief dynamic/interpersonal psychotherapy.

Therapeutic discourse combines inquiry and dialogue strategies, which correspond, respectively, to the construction and deconstruction of a patients maladaptive personal story line. This story line refers to a pattern of dysfunctional thinking/emotional management and a corresponding maladaptive interpersonal pattern that has been identified as the root cause of the patients presenting problems. Identifying and critically examining a patients personal story line is the superordinate technical strategy that guides our work each session. More specific technical guidance is provided by the change processes that we attempt to activate in each session: cognitive insight around emotionally loaded issues, corrective emotional/interpersonal experiences, and practice implementing the insights gained during a therapy session.

Book Review: THE MUSICAL EDGE OF THERAPEUTIC DIALOGUE. By Steven H. Knoblauch. Hillside, NJ: Analytic Press, 2000, 184 pp.

In psychoanalytic writing, a good metaphor can be a basis for elaborating clinical techniqu and shaping alternative modes of relating in the therapeutic dyad. In The Musical Edge of Therapeutic Dialogue, Steven Knoblauch offers music as a metaphor for conceptualizing the nonverbal dimensions of communication as rhythms of relational exchange that carry the resonance of unformulated emotional experiences. In speaking of the melodic dimension of therapeutic engagement, he directs our attention to the how of speech—tone, rhythm, and cadence—and how these reverberate in body and emotion within and between patient and analyst. Just as music renders affect by both inducing and framing emotions, so do the nonverbal nuances of interaction—breathing, body movement, tone and rhythm of speech. Knoblauch shows how an analyst attending to rhythm, volume, and tone can recognize important shifts in affect and thereby “hear” in the process the powerful unconscious representations of self and other, as well as the “dissociated affect states” that shape the interchange. The musical edge of therapeutic dialogue is a metaphor for the connections and disconnections of relatedness, as the exchange can be one of harmony and accompaniment, or one of being out of rhythm with each other. Empathy and emotional regulation in the analytic space emerge in concert as patient and analyst find one another’s rhythms, harmonize, and improvise. B o o k R e v i e w s