Psychodynamic Psychiatry

Abstract In this 10-year longitudinal study 150 mother-daughter pairs were recruited to participate in a study examining gender-based abuse across three generations. Forms of gender-based abuse included: child sexual abuse, witnessing intimate partner violence against their mothers, and intimate partner violence or dating violence in adolescence or adulthood. Daughters were interviewed when they were on average 9, 14, and 16 years old. Regression analyses revealed that if the grandmother (G1) was abused by her husband, her daughter (G2) was more likely to be sexually molested in childhood and was also more likely to be in an abusive relationship as an adult. If the mother (G2) was sexually abused as a child her daughter (G3) was at increased risk for child sexual abuse. In turn, child sexual abuse for the daughters related to their reports of dating violence in adolescence. Daughters (G3) who were sexually abused expressed more anxiety about romantic relationships, reflecting early attachment conflicts. Both child sexual abuse and anxious romantic attachment style independently predicted adolescent sexual risk-taking as in having multiple sexual partners or dating older men. These findings demonstrate how informative it is to include multiple forms of gender-based abuse in research and practice to better illuminate complex family dynamics. In addition, the findings support previous empirical work showing the importance of attachment behavior in women who are in abusive relationships, which has unique clinical implications.

Abstract Transference-focused psychotherapy (TFP) is a manualized, psychodynamic treatment for severe personality disorders. Training in TFP during residency can provide a readily applicable model for understanding and treating personality pathology in a variety of settings, even for residents who do not obtain additional training in psychodynamic treatments or go on to practice psychotherapy. Although TFP was developed as a long-term outpatient treatment, the authors have found the diagnostic and theoretical framework and the clinical techniques described in the TFP treatment manual to be useful in acute settings, even when the clinician does not have a clearly established relationship with the patient. In the authors' experience, residents find this model of understanding and working with patients with personality disorders enjoyable to learn and easy to apply.

Abstract While there is consensus that bipolar disorder exists in children and adolescents, its diagnostic criteria are debated. Excessive sexual behavior has been reported in youth who may have juvenile bipolar disorder (JBD), and has been termed "hypersexuality." Although there is no universal definition of this term, this observation has led to a hypothesis that increased sexual behavior characterizes the bipolar syndrome in children and adolescents, and differentiates it from attention deficit hyperactivity disorder. Although this hypothesis is plausible, evidence for it is incomplete, because testing it definitively would require both establishing a standard definition of hypersexuality in children and adolescents, and also reaching consensus about the other nonsexual criteria for pediatric bipolar disorder. In addition, studies to test it would need to control factors other than JBD that are known to increase sexual behavior in children and adolescents. These include sexual abuse and related posttraumatic stress disorder, excessive exposure to sexual stimuli, psychiatric illness in general, and social variables such as family chaos and social stress. Some of these factors might increase sexual behavior in youth with bipolar disorder through psychodynamic mechanisms rather than as a result of the illness itself. Therefore, further research is needed to determine whether increased sexual behavior can serve as a diagnostically valuable criterion for bipolar disorder in children and adolescents, and whether it differentiates the disorder from other conditions known to be associated with increased sexual behavior in youth.

Models of adult attachment have proven to be useful for understanding illness behavior, stress responses, susceptibility to disease processes, and psychotherapeutic approaches to difficult patients. Two methods of assessing patterns of attachment, using self-report instruments and using techniques such as the Adult Attachment Interview (AAI), are only weakly related and each has drawbacks for clinical use. We have previously assessed commonalities and differences in the descriptions of attachment patterns that emerge from these schools and synthesized them in empirically based attachment prototypes. In this companion article, we describe a prototype-based model of attachment. This model defines dimensions of attachment anxiety and attachment avoidance as composites of particular aspects of internal working models of self and other, behavior in current close relationships, patterns of expression of affect, and narrative coherence. The model emphasizes the clinical importance of the severity of attachment insecurity, defined as a dimension which incorporates problems in the previously listed domains of attachment as well as deficits in mentalizing, self-agency, and resolution of trauma. The model locates the central tendencies of prototypic ("textbook") descriptions of four patterns of attachment (secure, dismissing, preoccupied, and fearful/disorganized) while avoiding definitions of the boundaries between categories of attachment. We compare the prototype-based model to the two most prominent current models of attachment, the 4-category, 2-dimension model derived from self-report methods of assessment and categories of "attachment states of mind" derived from the Adult Attachment Interview. Finally, we discuss limitations of the prototype-based model and areas requiring further research.

Abstract It has become increasingly apparent that older adults may not only benefit from psychoanalysis and psychodynamic psychotherapy but may be particularly well suited to such treatment. Clinical evidence to support this is presented, including discussion of the successful psychoanalysis of a woman in her seventies. An overview of the psychoanalytic literature indicates that psychoanalytic beliefs about the feasibility of treating older patients have always been favorable, but have had difficulty gaining traction. The modern psychoanalytic literature is compatible with extra-analytic studies of aging that provide further rationale for the potential usefulness of psychoanalytically oriented interventions in the elderly population.

Abstract From menarche to menopause, women are highly vulnerable to major depression. While biological and psychosocial differences between men and women have been established, the reason for the preponderance of depression in women has yet to be fully elucidated. Women may be predisposed to depressive illness because of biological factors related to brain structure, function, and the impact of reproductive life stages. They may also be at increased risk because they are differentially disadvantaged with respect to environmental stressors including interpersonal violence, socioeconomic instability, and caregiving burden, among others. However, not all women develop depression, nor do all individuals who suffer from adverse life events. This narrative review focuses on emerging research related to the interaction between sex, genetics, and environmental factors that may help offer clues about why some individuals suffer from depression, and why others may be resilient to this outcome. While many questions remain unanswered, the psychodynamic psychotherapist can use this information to help patients suffering from depression understand some of the complexities of the determinants of risk and resilience, with the goal of moving forward toward recovery.

Objectives: The aim of the study was to analyze the association between secure attachment style, loneliness, and social network as risk factors for late-life depression. Methods: This cross-sectional study examined 969 subjects of the KORA-Age study. We applied the Relationship-Specific Attachment Scales for Adults (Beziehungsspezifische Bindungsskalen für Erwachsene, BBE), the UCLA Loneliness Scale, and the Social Network Index (SNI). Depression was operationalized through the Geriatric Depression Scale (GDS-15) and/or use of antidepressants. Logistic-regression models were calculated, sex-stratified, and controlled for age and living status. Results: For men, lower depression scores were associated with higher attachment security scores (OR = 0.26, 95% CI = 0.15-0.44) and not reporting feelings of loneliness (OR = 0.27, 95% CI = 0.14-0.53). For women, independent determinants of not having late life depression consist of not feeling lonely (OR = 0.22, 95% CI = 0.13-0.38). Discussion: Loneliness is a risk factor for late life depression in women and men, attachment style is a risk factor more for men, while social network size is not a risk factor.

My memoirs start with a description of the different spiritual climates in the early psychoanalytic centers of Vienna and Berlin. Whereas Berlin was enthusiastic and ready for new explorations, Vienna was bound tightly to Freud's vision. In the United States, tensions between orthodoxy and new ventures soon led to many organizational splits and finally to the creation of the American Academy of Psychoanalysis, a forum for new ideas, free of ideological restrictions. © 2014 The American Academy of Psychoanalysis and Dynamic Psychiatry.

Many patients lack the capacity to manage intense affects between therapy sessions, and as a result are caught in impasses as treatment becomes organized around fending off the next crisis or recovering from the last. Risk of suicide is often part of this presentation. Among the range of interventions that may help such patients emerge from impasse and treatment resistance is residential treatment, particularly psychodynamic residential treatment. We describe the role of residential treatment for such patients and offer an illustrative case example.

Abstract Somatic or emotional experience that has not been symbolically represented, referred to as unmentalized experience, has been given an increasingly prominent role in understanding psychopathology. Panic and anxiety disorders provide a useful model for exploring these factors, as the affective and bodily symptoms can be understood in part as unmentalized experience. The authors explore models of Freud's actual neurosis, Marty and DeM'uzan's pensee operatoire, Klein's unconscious fantasy, Bion's alpha function, Bucci's multiple code system, and relational models to describe how somatic and affective experiences can be translated into symbolic representations, and what factors can interfere with these processes. Approaches to unmentalized aspects of panic and anxiety include symbolizing somatic symptoms, identifying emotional states, and identifying contextual and traumatic links to symptoms.

Abstract The discipline of psychiatry appears poised at the edge of a paradigm shift. Enthusiasm about psychopharmacological treatments and neuroscientific understandings is giving way to a sobering recognition of the limitations of current biologically oriented approaches. Psychiatry training programs have both an opportunity and a responsibility to address the challenges presented by the evidence. Although the average psychiatrist would profess a biopsychosocial ideal, an examination of our practice, journals, and training curricula suggests that we still have a long way to go before we employ a truly integrated model. There is a compelling, though oft-neglected evidence base demonstrating that pharmacologic treatment outcomes are as dependent on psychological and interpersonal factors as on medical ones. In order to maximize our usefulness to patients, psychiatry must embrace more complex and integrated understandings, transcending reductionistic models that promote mind-body splits. This article explores some of the costs of a model that places disproportionate emphasis on a biological framework. Relevant evidence bases are reviewed that demonstrate the utility of emphasizing the psychology of psychopharmacology. Implications for psychiatric training are considered, and suggestions are made for better integrating meaning factors into psychopharmacology education.

Abstract Intimate partner violence (IPV) is a serious, pervasive problem; however, professional literature focused on psychotherapy for women experiencing IPV is limited. This article delineates reasons why there is a dearth of literature on this topic. It then provides guidelines for assessment and practice, focusing on issues and approaches unique to women experiencing IPV. For assessment, the therapist should gather information on the type of IPV the client experiences, the relationship dynamics involved, and the availability of the client's social support network. Discussion of the client's developmental history, including any history of child maltreatment and violence in early dating relationships is also relevant. Assessment of the client's current mental health functioning is essential and will include a consideration of common psychological sequelae that can result from IPV. Treatment should include safety planning as well as reducing minimization of the abuse. In addition, treatment should address potential IPV-related emotion dysregulation and splitting.

Abstract A contemporary psychodynamic framework can add much to our understanding of eating disorders. Eating disorders are associated with complex comorbidities, high levels of mortality, and therapist countertransferences that can complicate psychological treatments. Mainstream models currently focus on cognitive, biological, or cultural factors to the near exclusion of attachment functioning, and the individual's dynamics. As such, standard models appear to exclude person-centred and developmental considerations when providing treatments. In this article, we describe a contemporary psychodynamic model that understands eating disorder symptoms as a consequence of vulnerability to social pressures to be thin and biological predispositions to body weight. Individual vulnerabilities are rooted in unmet attachment needs causing negative affect, and subsequent maladaptive defenses and eating disorder symptoms as a means of coping. We describe how this model can inform transdiagnostic eating disorder treatment that focuses on symptoms as well as specific attachment functions including: interpersonal style, affect regulation, reflective functioning, and coherence of mind. Two clinical examples are presented to illustrate case formulations and psychological treatments informed by these conceptualizations.

Abstract Tasca and Balfour have done admirable work highlighting the importance of attachment security in the psychopathology of eating disorders (EDs), and their contributions are extremely valuable. For their points to be fully appreciated by the research and treatment-research communities, additional data are needed in key areas. Research is needed to help clarify the relative roles and cause-and-effect relationships between attachment insecurity, reflective functioning, and emotion regulation in the development and maintenance of EDs. Tasca and Balfour furthermore call their model "psychodynamic," and call for psychodynamically informed treatment for patients with attachment insecurity. For this call to be heeded, additional research is needed to examine whether the unique elements of psychodynamic psychotherapy have particular benefit for patients with insecure attachment styles. The unique psychodynamic elements considered in this comment include a therapeutic focus on reflective functioning, the patient's developmental history, the "unconscious," and the transference and countertransference. The utility of a non-directive (or patient-directed) therapeutic process is also considered. Investigation of these treatment issues could be extremely useful to practitioners and patients alike.

Abstract Attachment theory specifically addresses the ability to use an attachment figure as a haven of safety and base of exploration. While many other relational issues are important during development, a foundation of trust based on having positive expectations that others will be available when needed is clearly relevant in the practice of psychotherapy. Yet many patients come in with histories of insecure or even disorganized attachment and have suffered different forms of maltreatment. Understanding affect-regulating strategies, defensive processes, and transference and countertransference patterns associated with insecure or disorganized patterns is enormously useful during the clinical exchange. In addition to paying attention to affect regulation strategies, it is important to note that two other motivational systems may become coopted for defensive purposes in order to cope with disorganized attachment: the caregiving system and the ranking system (the latter being the legacy of dominance hierarchies we observe in primates). The other theme in this article is the importance of paying attention to a cooperative and social engagement motivational system (sometimes referred sometimes to as a social or affiliative motive) in building a therapeutic alliance. This prosocial motive is not about safety (attachment) but about sharing and developing positive social relations with others (Cortina & Liotti, 2010). The article explores the significance of building on this cooperative and social engagement system when there is not a foundation of trust based on a secure attachment history.

Background: Healthy interpersonal functioning, and a reduction of the distress associated with maladaptive interpersonal behavior, is a focus of treatment for personality disorder (PD). Patients with PD are also known to make a preferential use of immature defenses. We examined change in interpersonal problems as a critical outcome, and defense style as a predictor of this outcome. Methods: Consecutively admitted patients to a group-oriented day treatment (DT) program were recruited (N = 32). Predictor variables were represented by subscale scores from the 40-item Defense Style Questionnaire (DSQ-40); outcomes were represented by the global distress and interpersonal octant scores from the 64-item Inventory of Interpersonal Problems-Circumplex (IIP-C). Results: Significant inverse correlations were observed between Neurotic defenses and change in both interpersonal distress and problems associated with the Vindictive, Cold, Socially Inhibited, and Non-Assertive octants. Partial correlations, adjusting for baseline IIP-C scores, remained significant. Additional inverse relations between Neurotic defenses and improvement in the Domineering, Exploitable, and Overly Nurturant octants also emerged in the partial correlation analysis. Discussion: Neurotic defenses are oriented to "splitting off" the affective element of experience; in the case of patients with PD, this affective element may often involve hostility. An orientation to use of Neurotic defenses also appears to be more trait-like and thus resistant to change. The findings highlight developing skill in affective communication, and addressing maladaptive interpersonal behaviors in the here-and-now, as mechanisms of therapeutic change in DT of patients with PD. Limitations: The sample was small and assessment of defense style and interpersonal problems relied on patient self-report.

We reviewed the techniques and evidence base of four psychotherapeutic adjuncts to the pharmacological treatment of schizophrenia: Personal therapy, cognitive behavioral therapy, cognitive enhancement therapy, and psychodynamic psychotherapy. While there is a significant evidence base for the first three of these modalities, there is a paucity of research on psychodynamic treatments for schizophrenia. We review the history of psychodynamic treatment for schizophrenia and the ways in which it informs current treatment. In light of the limited efficacy of antipsychotic medications in the treatment of schizophrenic persons, there is increasing interest in the role of social and psychological approaches.

Abstract This article describes the development of Psychodynamic-Interpersonal Therapy or the Conversational Model of therapy, as it is also known. It includes a brief description of the approach to therapy, a review of the evidence base, and a brief description of qualitative and psychotherapy process research that has been conducted on the model.

Abstract Patients with Borderline Personality Disorder (BPD) are at high risk of suicide and are frequently hospitalized in the acute setting of emotional crisis, non-suicidal self-injury, and suicidal behaviors. Historically, patients with BPD have borne tremendous stigma and have tended to overwhelm providers and care systems. The reconceptualization of the pathophysiology and development of BPD in the context of a rapidly changing health care environment warrants examination of relevant psychotherapeutic and treatment principles. Through a case discussion, this article highlights several factors relevant to acute inpatient hospitalization of patients with BPD in an academic training environment in an effort to identify both the challenges and helpful treatment philosophies and practices to advance patient care and promote recovery.

Abstract Borderline Personality Disorder (BPD) has been often described recently as a condition characterized by emotional dysregulation. Several other conditions share this attribute; namely, Bipolar Disorder (BD), Attention-Deficit/Hyperactivity Disorder (ADHD), Intermittent Explosive Disorder (IED), and Major Depressive Disorder (MDD). The dysregulation is not always in the same direction: BPD, BD, ADHD, and IED, for example, show over-reactivity or "hyperactivity" of emotional responses, whereas patients with MDD show emotional sluggishness and underactivity. At the clinical/descriptive level the "over-reactive" conditions appear separate and distinct. BPD constitutes a large domain within the psychopathological arena, appearing to contain within it a variety of etiologically diverse subtypes. Among the latter is a type of BPD linked closely with Bipolar Disorder; family studies of either condition show an overrepresentation of both: BPD patients with bipolar relatives; Bipolar patients with BPD relatives. A significant percentage of children with ADHD go on to develop either BPD or BD as they approach adulthood. If one shifts the spotlight to neurophysiology, as captured by MRI studies, however, it emerges that an important subtype of BPD, and also BD, ADHD, and IED-share common features of abnormalities and peculiarities in the limbic system and in the cortex, especially the prefrontal cortex. Deeper subcortical regions such as the periaqueductal gray may also be implicated in strong emotional reactions. The diversity of clinical "over-reactive" conditions appear to harken back to a kind of unity at the brain-change level. There are therapeutic implications here, such as the advisability of mood stabilizers in many cases of BPD, not just for Bipolar Disorder.

We examined disposition, course, and outcome for 100 outpatients offered short-term individual dynamic therapy as a primary treatment for recurrent major depression. Evaluations using the Hamilton Rating Scale for Depression (HAM-D) were conducted regularly during the year after referral. Patients failing to show a response (50% decrease in pre-treatment HAM-D scores) were referred for consultation regarding "augmentation" of therapy with antidepressant medication. Nineteen referrals failed to meet inclusion-exclusion criteria, reflecting therapist overestimation of the severity of patients' depressive symptoms; referring therapists also missed other salient clinical issues. Fourteen patients completed assessments but did not start therapy; "decliners" were more likely to report previous admissions and thus may have opted for hospitalization. Sixty-seven patients started therapy; 18 dropped out (26.9%). Of the 49 therapy completers, 23 (46.9%) did not receive augmented treatment; 20 (40.8%) demonstrated evidence of recovery during the year while 3 (6.1%) did not. Of the 26 patients (53.1%) prescribed antidepressants, 16 (32.7%) demonstrated evidence of recovery and 10 (20.4%) did not. Patient clusters also showed distinct trajectories of change on the HAM-D over the year after referral. Patients who received augmented treatment but showed no evidence of recovery scored significantly higher on indices of alexithymia. Clinical implications of the findings are considered.

Abstract Transfers of care occur routinely in medical training, but the transfer of psychotherapy patients has received relatively little attention. This article discusses important issues concerning these transfers, using case examples and findings from a survey of the experience of psychiatry residents transitioning psychotherapy patients. Residents have difficulty telling patients they are leaving and often delay doing so. Because feelings of closeness and attachment can develop in long-term therapeutic relationships, residents describe feeling guilty, uncertain, anxious, sad, and occasionally relieved as they prepare their patients for transfer. Outgoing residents can feel anxious when recognizing and addressing their patients' and their own positive feelings. Incoming residents experience discomfort at being compared to the previous therapist and often encounter the patient's negative feelings at the transfer and the loss of the previous therapy. Teaching about the two poles of transfer of care is recommended to better understand and respond to this transition for both patient and therapist. This should include addressing the stresses involved and recommendations for management.

Abstract A growing body of evidence suggests that psychiatric medication outcomes are shaped significantly by psychological and social factors surrounding the prescribing process. Little, however, is known about the extent to which psychiatry programs integrate this evidence base into residency training or the methods by which this is accomplished. Psychiatry residency program directors and chief residents participated in an exploratory online survey to establish how psychosocial factors known to impact medication outcomes are integrated into psychopharmacology education. While participants highly valued the importance of psychosocial factors in the prescribing process, there was limited emphasis of these factors in psychopharmacology training. Additionally, some teaching methods that could advance understanding of complex interactions in the psychopharmacology relationship were found to be underutilized. Given that medication outcomes are significantly influenced by psychosocial factors, psychiatric educators have a responsibility to teach residents about the evidence base available. Residents exposed to this evidence base will be better equipped to manage the complexities of the psychopharmacology role. The results of this study offer clues as to how psychosocial factors may be more fully integrated into residency psychopharmacology training.

Abstract This article addresses the complex issue of how to clarify conflicts involving value judgments. The author reviews his experiences as therapist, supervisor, and consultant in offering second opinions on in-progress therapies. He summarizes six major obstacles to effective value clarifications and interpretations. Therapists can help patients to explicitly verbalize otherwise only implicit values. Distress from guilt and shame can be reduced by helping a patient reprioritize values and gain self-reflective awareness skills for resolving moral dilemmas.

Clinicians who provide psychotherapy to spouses or partners of persons with dementia were solicited through LISTSERVs of psychodynamically oriented organizations. Interviews were conducted with the 14 clinicians who responded. In the aggregate these clinicians provide psychotherapeutic service to scores of caregivers. The interviews highlight the challenges commonly encountered by psychotherapeutic work with this cohort of patients. © 2014 The American Academy of Psychoanalysis and Dynamic Psychiatry.

Background: Split-treatment, the provision of psychotherapy and psychotropic medication by two different professionals, has become prevalent in U.S. mental health care delivery, as more Americans receive prescriptions and American psychiatrists provide less psychotherapy. Historically, communication between professionals treating the same patient has been an accepted principle of optimal care, but there has been only one formal assessment (Avena & Kalman, 2010a,b) of whether or not such communication actually takes place in the private sector. This article supplements the aforementioned survey of psychotherapists with a survey of psychiatrists. Subjects and methods: An eight-item survey was mailed to 150 full-time private practice psychiatrists in Manhattan and New Jersey. Questionnaires were completed anonymously and returned by mail. Data was gathered about years of practice experience, how many patients were seen in the prior month, and how many patients were also in psychotherapy with another professional. Frequency of communication with psychotherapists on behalf of these patients and for patients in treatment for six months or longer was also assessed. Lastly, information was compiled on which professional more frequently initiated the communication when it did occur. Results: Sixty-one psychiatrists, averaging 26.7 years in practice, returned surveys. For all respondents, the total number of medication-only patients seen in the last full month was 1903, of which 785 (41.25%) were in psychotherapy with another mental health professional. Respondents reported a total of 875 split-care patients in treatment for six months or longer, with no communication with the psychotherapist being reported on behalf of 24% of these individuals. Respondents indicated that they had initiated 68.4% of the most recent contacts with the other professional, and just 10 of 55 (18.2%) responding psychiatrists reported quarterly communication with their split-care patients' psychotherapists for all shared patients. Conclusions: We found that split-care treatment is common but that adequate communication between professionals engaged in such treatment frequently does not take place. Corroborating the findings of the earlier survey, many questions remain about the need for guidelines regarding the conduct of split-treatment and about how best to determine the importance of communication between professionals engaged in this therapeutic arrangement.

The initial and last manifest dream reports (MDRs) of 30 patients who had either successfully terminated, or continued to make satisfactory progress at an advanced stage of psychodynamic psychotherapy and combined psychotherapy/pharmacotherapy, were rated according to the following variables: Affect and Affect Valence; Affect Valence of Associations and Direction of Association Themes; Dream Narrative; Psychodynamic Formulation; Transference; and Dream Theme. Similar to previous studies, the initial MDRs contained more negative than positive affect. Conversely, the last MDRs contained more positive than negative affect. Associations to initial MDRs contained more negative affect; on the other hand, associations to last MDRs contained more positive affect. Direction of association themes were more negative in initial MDRs and more positive in last MDRs. Dream narratives were more negative in initial MDRs and more positive in last MDRs. Psychodynamic formulations were more negative in initial MDRs and more positive in last MDRs. Transference was more negative in initial MDRs and more positive in last MDRs. Relational and injury dream themes occurred more frequently than others in both initial and last MDRs. Initial MDRs contained more injury dream themes than last MDRs. The findings of this study demonstrate that there is a correlation between MDR variables and clinical improvement during treatment. The patients in this study were selected by MG, the treating therapist, on the basis of satisfactory progress. The MDRs of patients who failed to progress or did poorly were not discussed in this report. The findings, therefore, must be taken as preliminary and indicate the need for further research on manifest dreams during psychotherapy and combined psychotherapy/pharmacotherapy.

Competence as a psychodynamic psychiatrist requires more than the acquisition of a body of theoretical knowledge and a set of technical skills. It calls for the acquisition of a set of virtues-attitudes of mind and heart-that are embedded in the character and person of the developing resident. The authors enumerate and explore these psychodynamic virtues. They discuss how residency training can best serve to develop these virtues in residents. © 2013 The American Academy of Psychoanalysis and Dynamic Psychiatry.

Abstract This article reviews the articles in this special issue on the effects of intimate partner violence on women and children, integrating the findings into critical questions about intergenerational transmission of violence. The author's own psychodynamically informed framework is used to interpret the results of the studies. Finally, clinically relevant implications and research directions are briefly proposed.

Abstract This article discusses the current state of psychoanalysis and the challenges to the fundamental premises of Freud's psychoanalysis by those who have shifted to relationship or so-called two-person psychologies in our field. The author begins by briefly describing a parallel to the recent history of psychoanalysis in the sudden rise and fall of scholastic philosophy in the 14th century. He then focuses on contemporary attacks on Freud's psychoanalysis as a science, based on the contention by two-person psychologists that free association by the patient and evenly hovering attention by the analyst are actually impossible. He reviews Freud's idea of psychoanalysis, discusses psychodynamic psychotherapy, both conceived as scientific treatment procedures, and describes the current assault on their metapsychological and epistemological foundations. Returning to the parallel between what happened to medieval scholasticism and what has happened to psychoanalysis, he examines why this happened, and the resulting fragmentation of psychoanalytic practice. The article concludes with suggestions for the integration of various schools of psychoanalysis, reminding us of Benjamin Franklin's warning: "We must, indeed, all hang together or, most assuredly, we shall all hang separately."

Psychiatry must remain a profession defined by an organizing model of the mind, rather than by specific treatment techniques. Psychodynamic psychiatry offers such a model, and it is applicable to all psychiatric patients.

Abstract Conversion disorder, the development of symptoms of neurological disease with no organic basis, is a challenge for mental health professionals to diagnose and treat effectively. There are well-established predisposing factors, such as female sex, childhood trauma, and alexithymia, but less clear is how to approach the subjective suffering that is symbolized with the symptom rather than consciously recognized. While there are overlapping comorbidities such as depression and anxiety that may be treated with medication, psychotherapy is the primary effective treatment for patients with adequate capacity to engage in the process. This article addresses means of identifying patients who might benefit from psychotherapy (along with medication in some instances) as well as some guidelines for conducting psychotherapy, with case examples.

In this paper, we study the almost sure stability of discretetime jump linear systems with a finite-state Markov-form process. A general condition for almost sure stability, which is a necessary and sufficient condition for (scalar) one-dimensional systems, is derived. Many simpler testable sufficient conditions for almost sure stability are derived from this sufficient condition.

Abstract Intimate partner violence (IPV) is often a chronic form of trauma with deleterious mental health problems. Furthermore, IPV survivors have also often experienced trauma in childhood. Consequently, by examining a sample of IPV survivors, this study sought to assess typical trauma sequelae-Posttraumatic Stress Disorder (PTSD), Major Depressive Disorder (MDD), or dissociative symptoms-and trauma-related characteristics consistent with Herman's Trauma theory (1992; i.e., chronicity of trauma, age of first trauma exposure, and social support), in relation to hypothalamic-pituitary-adrenal axis function. The study compared basal and diurnal cortisol in women (n = 88) based on diagnostic status and symptom severity (PTSD [n = 14], PTSD and comorbid MDD [n = 43], subthreshold symptoms of PTSD and MDD [n = 19]), dissociative symptoms, and the aforementioned trauma-related characteristics to a matched control group (n = 12) without any lifetime history of mental health diagnoses or exposure to interpersonal trauma. Regardless of their diagnostic status and trauma-related characteristics, trauma-exposed women had higher levels of dissociative symptoms relative to women in the control group, and these dissociative symptoms were inversely related to awakening cortisol levels. Findings suggest that low cortisol levels may not be a diagnostic marker, but instead may be associated with a dissociative coping style developed in the context of trauma exposure, consistent with mechanisms posited by Trauma theory.

Abstract This article describes a course, Psychodynamic Cultural Psychiatry, taught to PGY-3 residents at the New York Presbyterian Hospital-Weill Cornell Medical Center that uses psychodynamic theory to help deepen cultural understanding. We (Sandra Park, the instructor for the course, and Elizabeth Auchincloss, the Residency Training Director) developed the class in 2006 in an effort to raise cultural awareness in the residency curriculum. We believe that despite an inherent Western bias, psychodynamic theory can be an effective way to teach cultural psychiatry. Additionally, cultural understanding can enhance understanding of psychodynamic principles. In this article, we argue that our course in Psychodynamic Cultural Psychiatry helps residents to integrate these two points of view.