Heinz Weiss

The INDDEP study: inpatient and day hospital treatment for depression – symptom course and predictors of change

BackgroundDepression can be treated in an outpatient, inpatient or day hospital setting. In the German health care system, episodes of inpatient or day hospital treatment are common, but there is a lack of studies evaluating effectiveness in routine care and subgroups of patients with a good or insufficient treatment response. Our study aims at identifying prognostic and prescriptive outcome predictors as well as comparative effectiveness in psychosomatic inpatient and day hospital treatment in depression.Methods/DesignIn a naturalistic study, 300 consecutive inpatient and 300 day hospital treatment episodes in seven psychosomatic hospitals in Germany will be included. Patients are assessed at four time points of measurement (admission, discharge, 3-months follow-up, 12-months follow-up) including a broad range of variables (self-report and expert ratings). First, the whole sample will be analysed to identify prognostic and prescriptive predictors of outcome (primary outcome criterion: Quick Inventory of Depressive Symptoms QIDS-total score, expert rating). Secondly, for a comparison of inpatient and day hospital treatment, samples will be matched according to known predictors of outcome.DiscussionNaturalistic studies with good external validity are needed to assess treatment outcome in depression in routine care and to identify subgroups of patients with different therapeutic needs.Trial registrationCurrent Controlled Trials ISRCTN20317064

Reporting a dream accompanying an enactment in the transference situation

Patients with pathological organisations of the personality present the analyst with considerable technical difficulties. One of these problems arises from the fact that, in such patients, dreams frequently are not being used for communication of unconscious meaning, but instead for purposes of manipulation of the transference situation. They then represent attempts to identify the analyst with a part of the patients self or with a particular internal object in order to draw him/her into collusive enactments. Following the work of Bion and Segal the paper presents a two‐dimensional model in order to clarify the structure and use of dreams in this situation. The model may serve as a background orientation for the analyst in the clinical situation, as is subsequently illustrated in a detailed clinical sequence with a borderline patient. To conclude, the author suggests that whenever tendencies towards acting in are predominant, the interpretation of the enactment should generally be given preference over the interpretation of the dream content. The possible advantages and disadvantages of both strategies of interpretation are discussed. Finally, the author highlights consequences that arise when dealing with countertransference.

The explosion of the present and the encapsulation of time: Transference phenomena in the analysis of a psychotic patient†

The paper deals with some basic problems concerning the experience of time and space in the psychoanalytic treatment of psychotic patients. Whereas borderline patients tend to distort the experience of time and space under emotional pressure, the concepts of time and space seem to dissolve in acute psychotic states of mind. Sometimes this manifests itself in an explosion of the present, where the past is ubiquitous and the future is perceived as the end of all times. The case of a 48 year‐old patient with the external diagnosis of ‘paranoid–hallucinatory schizophrenia’ is presented to illustrate that the main task is to recreate a structure to contain the experience of space and time. Such a development may occur if primitive psychotic anxieties can be taken up and metabolized. A near‐psychotic decompensation before the first break and the development of a transference psychosis in the second year of the analysis are depicted in detail. Subsequently some developments became visible which helped the patient to better tolerate catastrophic fears of loss. This included the formation of a structure which the patient called ‘hibernation’ enabling her to psychically survive without falling apart. By retreating into her ‘time capsule’ she managed to overcome breaks and to delay her fears of fragmentation until they could be taken up and worked through in the transference. The creation of a structure like the patients ‘time capsule’ is considered to be an attempt to construct the experience of time and space. It prevented a collapse of her internal space thereby enabling further steps towards thinking and symbolization. In conclusion, some theoretical and clinical aspects are discussed including the role of the countertransference.

Krankheitsverlauf bei Myasthenia gravis Ergebnisse einer Längsschnittstudie zur Bedeutung psychosozialer Prädiktoren

ZusammenfassungIn einem Längsschnittdesign wurden 42 stationäre Patienten mit gesicherter Diagnose einer erworbenen Myasthenia gravis untersucht. Die Diagnosestellung durfte zum Zeitpunkt der Ersterhebung noch nicht länger als 1 Jahr zurückliegen, weitere Datenerhebungen erfolgten nach 6 Monaten (T2) bzw. 18 Monaten (T3). Ziel der Studie war es u.a., nach potentiellen psychosozialen Prädiktoren für den Krankheitsverlauf zu suchen. Dafür dienten als Indikatoren ein Persönlichkeitsfragebogen (FPI), ein Fragebogen zur Krankheitsverarbeitung (FKV), eine Einschätzung neurotischer Symptome durch Interviewer (PSKB) sowie eine Einschätzung der Arzt-Patient-Beziehung durch die behandelnden Ärzte. Kriterien für den Krankheitsverlauf waren 2 verschiedene Schweregradparameter (Oosterhuis-Index und Myasthenie-Score). Keinen Zusammenhang mit dem Krankheitsverlauf zeigte das Vorhandensein von neurotischer Symptomatik wie Angst oder Depressivität sowie die Qualität der Arzt-Patient-Beziehung (zum Zeitpunkt T1). Auch demographische Daten interagierten nicht mit der Schweregradentwicklung. Hingegen war das Persönlichkeitsmerkmal „Extraversion” mit einem günstigen, „Aggressivität” und „Gesundheitssorgen” mit einem ungünstigen Krankheitsverlauf assoziiert. Bei der Krankheitsverarbeitung war „Religiosität und Sinnsuche” mit einem günstigen Verlauf assoziiert, was sich jedoch nur bezüglich des Oosterhuis-Index zeigte (Schweregradparameter, der mehr die Lebensqualität mitberücksichtigt). Da sich mehrere T1-Persönlichkeitsmerkmale als Prädiktoren für die T3-Schweregradparameter fanden, umgekehrt aber (mit einer Ausnahme) die T1-Schweregradparameter keine Prädiktoren für die entsprechenden T3-Persönlichkeitsmerkmale waren, kann dies als Hinweis für eine Beeinflussung des Schweregrades durch die genannten Persönlichkeitsfaktoren verstanden werden. Mögliche Erklärungsmodelle für einen derartigen Zusammenhang werden diskutiert. Um eine solche Hypothese jedoch zu erhärten, wären weitere Studien mit experimentellem Design erforderlich.SummaryForty-two patients suffering from myasthenia gravis were examined in a longitudinal study design. The aim of the study was to investigate possible psychosocial predictors for the course of the disease. At the time of the first examination (T1) the diagnosis myasthenia gravis had been established for no longer than 1 year. Two further examinations were done at 6 months (T2) and 18 months (T3) after T1. Methods consisted of a personality questionnaire (FPI), a coping questionnaire (FKV), an assessment of neurotic symptoms by interviewers (PSKB) and an assessment of the doctor-patient relationship by the attending physicians. Two different severity scores (Oosterhuis Index, Myasthenia Score) served as criteria for the course of the disease. There was no connection between the course of myasthenia gravis and neurotic symptoms like anxiety or depression and the quality of the doctor-patient relationship (both assessed at T1). Also demographic data were independent from the development of severity scores. The personality factor extraversion was associated with a positive course of the disease, aggressiveness and worrying about health with a negative one. Among the coping behaviors religiousness and looking for sense were associated with a favorable course, but that was shown only regarding the Oosterhuis Index and not the Myasthenia Score. As several T1 personality factors were predictive for the severity scores at T3, these results may suggest a causal influence of personality factors on the severity of the illness. Whether or not this relationship is actually in operation, however, remains ellusive. Further studies using an experimental design are needed to strengthen this hypothesis.

Prognostic and prescriptive predictors of improvement in a naturalistic study on inpatient and day hospital treatment of depression.

BACKGROUND The study aimed to identify prognostic (associated with general outcome) and prescriptive (associated with differential outcome in two different settings) predictors of improvement in a naturalistic multi-center study on inpatient and day hospital treatment in major depressive disorder (MDD). METHODS 250 inpatients and 250 day hospital patients of eight psychosomatic hospitals were assessed at admission, discharge and a 3-months follow-up. Primary outcome was defined as a reduction of depressive symptomatology from admission to discharge and from discharge to follow-up (QIDS-C, total score). Percent improvement scores at discharge and at follow-up were entered as dependent variables into two General Linear Models with a set of predictor variables and the respective interaction terms with treatment setting. The selection of predictor sets was guided by statistical methods of variable preselection (LASSO). RESULTS Three variables were associated with less improvement from admission to discharge: the number of additional axis-I diagnoses, axis-II co-morbidity (SCID) and lower motivation (expert assessment). Social support (F-SozU) predicted symptom course between discharge and 3-month follow-up. Patients with no absent / sick days prior to admission showed a less favorable symptom course after discharge when treated as inpatients. CONCLUSIONS Patients with co-morbidity show less improvement during the active treatment phase. Motivation can be considered a prerequisite for symptom reduction, whereas social support seems to be an important factor for the maintenance of treatment gains. The lack in prescriptive predictors found may point to the fact that inpatient and day hospital treatment have comparable effects for most subgroups of patients with MDD.

Projective identification and working through of the countertransference: A multiphase model

Referring to Melanie Kleins unpublished views on projective identification, Bions theory of container/contained and Money‐Kyrles understanding of countertransference as a process of transformation, the author develops a multiphase model of projective identification. He differentiates five subphases of (1) adhesion, (2) penetration, (3) linking of the projection with an internal object of the analyst, (4) transformation and (5) re‐projection. In the authors view the differentiation of overlapping subphases may be helpful to better localize problems of working through the countertransference. Some technical implications are illustrated by brief clinical vignettes. To conclude, the paper discusses typical impasses and options for interpretation.

Introduction: The Role of Shame in Psychoanalytic Theory and Practice

Translations of summary Introducing three papers by Leon Wurmser, Claude Janin and John Steiner the author gives an overview of the development of the concept of shame in psychoanalytic theory and practice. Different aspects of the phenomenon of shame are being discussed including its relation to guilt, object relations and identity as well as the role of gaze when emerging from a psychic retreat.

The surprising modernity of Klein’s Lectures on Technique and Clinical Seminars: Putting them in context

ABSTRACT Focusing on the vividness and modernity of Kleins 1936 lectures the author argues that Klein was very aware of the complexity of the transference-situation and the analysts involvement in it. The Clinical Seminars of 1958 show that the concept of projective identification helped to further clarify her ideas and to anticipate later developments. Nevertheless she remaines sceptical about the counter-transference simply seen as a response to the patients projections and warned against re-projecting it back into the patient.

Influence of childhood trauma on depression in the INDDEP study

Traumatic experiences during childhood have been shown to be associated with a higher risk for depressive disorders, more severe symptoms, higher rates of comorbidity, and poorer response to therapy. This study aims to further investigate these links in a clinical sample, focusing especially on therapeutic outcome. Data were collected in a large naturalistic study on inpatient and day hospital treatment of depression at the beginning, the end and after treatment, with this article being a secondary data analysis. Occurrence of childhood trauma, depressive and other symptoms and therapeutic results were compared using robust MANOVA, multiple regression, mixed ANOVA, and Spearman’s correlation. Results provide support for a relationship between childhood trauma and depressive and general symptom severity, the age of onset of depression and the occurrence of personality disorders and somatic diagnoses. There was a significant reduction of depressive symptomatology after therapy. Patients with childhood trauma did not differ significantly from controls in their response to treatment. Clinicians should take the high probability of childhood trauma in depressive patients and the consequent risk of more severe symptoms into account when taking a history and consider adjusting treatment, even if the present data showed that patients generally benefitted from therapy.

Patterns of symptom change in major depression: Classification and clustering of long term courses

To evaluate treatment effects in depression, it is important to monitor change during treatment and also to follow up for a reasonably long time. Describing the variability of symptom change trajectories is useful to better predict long-term status and to improve interventions. Outcome data (N_complete = 518, 4 time points, 1 year of observation time) from a large naturalistic multi-center study on the effects of inpatient and day hospital treatment of unipolar depression were used to identify clusters of symptom trajectories. Common outcome classifications and statistical methods of longitudinal cluster analysis were applied. However, common outcome classifications (in terms of e.g. remission, relapse or recurrence) were not exhaustive, as 49.3% of the trajectories could not be allocated to its classes. Longitudinal cluster analysis reveals 7 clusters (fast response, slow response, retarded response, temporary or persistent relapse, recurrence, and nonresponse). Nonresponse at the end of treatment was a predictor of poor outcome at long term follow up. The classification of patterns of symptom change in depression should be extended. Longitudinal cluster analysis seems a valid option to analyze outcome trajectories over time if a limited number of time points of measurement are available.