[Delusional depression : Diagnostics, phenomenology and therapy]. / Die wahnhafte Depression : Diagnostik, Phänomenologie und Therapie.

Depressive delusion is the key symptom of psychotic depression also known as major depressive disorder with psychotic features (ICD-10: F 32.3). Delusional topics are limited to guilt, impoverishment and hypochondria. Kurt Schneider described these as being the three primordial fears of human beings. Psychotic depression is distinguished by the particular severity and frequency of the episodes of illness as well as by increased suicidal tendencies. Although one in five patients with a major depression experiences psychotic symptoms, this condition is all too easily overlooked and the appropriate therapy is not initiated. Here we use case histories to illustrate some of the obstacles to diagnosis arising from the difficulty of identifying delusions hidden in a person's experience of depression, life history and personality. A targeted active exploration of these difficulties is significant taking into account the observable symptoms and not only the subjectively experienced symptoms. A phenomenological approach is chosen to explore the matter of depressive delusion and to investigate the interaction of delusion and affect and the special importance of anxiety for the genesis of delusion. In accordance with the current treatment recommendations and against this background, it is proposed that the pharmacological strategy should be supplemented by the use of benzodiazepines more often than has it has been in the past.

Effect of Treatment of Residual Disease After Immunotherapy-Based Combinations on Complete Response Rate of Patients With Metastatic Renal Cell Carcinomas.

INTRODUCTION: Immune checkpoint inhibitor (ICI)-based combinations have revolutionized the management of first-line metastatic renal cell carcinoma (mRCC) by improving patient survival. Large phase 3 randomized trials assessing ICI-based combinations have reported complete response (CR) rates of 10% to 18% in the first-line setting. However, there is a scarcity of data about the effect of treatment of residual disease regarding CR rates improvement. MATERIALS AND METHODS: We included retrospectively all consecutive mRCC patients treated in first-line setting at the Institut de Cancérologie Strasbourg Europe with an ICI-based combination involving ICI or TKI, either alone or with added local treatment of residual disease. Patients were characterized according to IMDC risk. Radiologic response was defined according to RECIST v1.1. RESULTS: We enrolled 80 mRCC patients treated with ICI-based combinations between May 2015 and May 2022. The median age was 63 years. Regarding IMDC risk, there were 12 favourable (15%), 50 intermediate (63%), and 18 poor-risk (22%) patients. Forty-seven patients (59%) received ICI + ICI, 24 (30%) received ICI + TKI, and 9 (11%) received another ICI-based therapy. In total, 8 achieved CR (10%), 36 patients (45%) achieved partial response, 23 (29%) achieved stable disease and 12 achieved progressive disease (15%) as the best response with systemic therapy alone. By adding local treatment of residual disease, 11 additional patients (14%) achieved radiological NED. Residual disease resected sites included kidney (n = 6), lymph nodes (n = 5), lung metastases (n = 2) and liver metastases (n = 1). CONCLUSIONS: The resection of residual disease after first-line ICI-based therapy is associated with improved CR rate (CR + NED) in patients with mRCC. These results need to be validated in prospective trial. PATIENT SUMMARY: In recent years, the advent of immunotherapy has radically changed the management of patients with metastatic kidney cancer. Approximately 10% to 18% of these patients using immune checkpoint inhibitor (ICI)-based combinations no longer have detectable disease on CT scans (complete response). There are currently few data on the use of treatment of residual disease to increase the number of patients in complete response. In this retrospective study, the complete response rate with ICI-based treatment was 10%. When local treatment was added, the number of patients with a complete response increased to 24%. This strategy could increase the number of patients with a prolonged complete response in the future.

[On the differential diagnostics of depersonalization experiences]. / Zur Differenzialdiagnostik der Depersonalisationserlebnisse.

Depersonalization represents an unspecific symptom which is to be found across the entire spectrum of psychiatric nosology. Delineating the historical lines of development of the depersonalization concept and reviewing existing psychopathological experiential knowledge reveals that depersonalization is underpinned by highly diverse modes of experience. In terms of differential diagnostics at the symptom level, a distinction can be made between depersonalization as a neurotic phenomenon on the one hand and a psychotic form occurring in schizophrenia and melancholia on the other. The reference points defined here extend beyond current descriptive classifications and open up the diagnostic process to allow an inclusion of etiological and therapeutic aspects.

[The psychopathology of ego disturbances: history and phenomenology]. / Zur Psychopathologie der Ich-Störungen: Geschichte und Phänomenologie.

The phenomena which Kurt Schneider grouped together to form the ego disturbances have always been of particular diagnostic relevance for schizophrenia. While little importance was historically attached to accurately describing and distinguishing psychopathological symptoms, Karl Jaspers' and Kurt Schneider's descriptive psychopathology aims to draw a sharp yet differentiated distinction between psychotic and non-psychotic disorders at the symptom level. New developments in phenomenology including aspects of symptom development are presented. The depersonalization experience is focused on as a transitional phenomenon which is distinguishes from neurotic depersonalization through a disturbed sense of mineness. The ego disturbances indicate that disturbed mineness can be seen as the common denominator of first-rank symptoms of schizophrenia.

[On the hermeneutics of depressive despair]. / Zur Hermeneutik depressiver Verzweiflung.

Despair refers to a psychopathological phenomenon which is difficult to grasp. Its formal structure (Formalanzeige) has previously been described in a publication. The formal structure serves in the following as the basis for a hermeneutic examination of depression. Depressive despair is a development which originates from an antagonism within the biographically evolved personality. This antagonism increasingly tears apart aspects of reality and aspects of desire, begins to oscillate in the form of dichotomies and, in the worst case, leads to hopelessness and suicide. In favourable cases, this process can result in a renewal of one's own individual values. The paper closes with a discussion of the corresponding therapeutic implications.

[The history and phenomenology of the concept of psychosis. A perspective of the Heidelberg school (1913-2008)]. / Zur Geschichte und Phänomenologie des Psychose-Begriffs. Eine Heidelberger Perspektive (1913-2008).

The accomplishments of Heidelberg psychopathology and their continued development are illustrated using the example of the concept of psychosis. Jaspers founded the Heidelberg school by methodologically collating the psychiatric knowledge of his time in a structured fashion and in doing so laid the foundation for modern nosology. While, however, ICD and DSM classifications tend to be modelled on symptoms of expression and behaviour, the phenomenological models which Jaspers introduced into the field of psychiatry rather focused on symptoms of subjective experience. The phenomenological developments of psychopathology which originated in this context are, in the case of the schizophrenic psychoses, presented in a kaleidoscope-like manner. It becomes evident that a legacy-oriented, phenomenological search for specific symptoms is of continued relevance. This historical wealth of knowledge and the clinical exploration of phenomena continue to represent sources of impetus and momentum for the field of psychopathology.

The narcissistic function in obsessive-compulsive neurosis.

Freud's intrapersonal concept of anal-sadistic regression is set against the interpretation of obsessive-compulsive neurosis as a structural ego deficit. The interpersonal dimension that comes to the fore as a result of this, becomes clear if we focus on obsessive-compulsive behavioral disorder: Persons suffering from obsessive-compulsive neurosis lack the self-assessment factor. It needs another person as part of their own ego who accepts and supports them in their behavior. A clinical example illustrates this narcissistic function of compulsion together with the changes in the psychodynamic approach and resulting therapy. Against DSM-classification with the concept of obsessive-compulsive disorder, which contains an unspecific symptomatology that occurs both in neurosis, schizophrenia, melancholia, and organic psychosis, this article advocates the specific and differentiated concept of obsessive-compulsive neurosis.

[A introduction to despair as a psychopathological phenomenon]. / Prolegomena zu einer Psychopathologie der Verzweiflung.

Despair as a phenomenon has not received much attention from psychopathologists, which is difficult to grasp in the clinical context. This paper is an attempt to elaborate upon despair as a key concept and thus open up a new field in psychopathology. The historical approach leads to a twofold view on despair, namely as an affect and as a cognitive structure. The paper therefore follows both the affect theories developed since the onset of the modern era and the cognitive theories on doubt at risk of progressing into despair. Using current approaches of cognitive emotional psychology, despair is defined as an oscillating, affective-cognitive process: the oscillation of doubt is reflected in the alternation of various single affects such as hope, fear, anxiety, anger, shame, guilt, and sadness and then moves towards the negative pole of increasing affect diffusion, loss of object relation, hopelessness, and suicidality. On the basis of this model it is possible to elaborate specific types of despair in individual psychiatric disorders, assessments of the stage of the process, and possible therapeutic strategies.

Obsession in the strict sense: A helpful psychopathological phenomenon in the differential diagnosis between obsessive-compulsive disorder and schizophrenia.

The paper presented follows the hypothesis that differentiation between obsessive-compulsive disorder and schizophrenia is possible only by focusing on the single phenomenon of obsession. The statement of a nosological specificity of obsession, called obsession in the strict sense, is set against the current views of ICD-10 and DSM-IV of obsession as a ubiquitous, non-specific phenomenon appearing in comorbidities. In the succession of the paper, the historical development of these two very different views and their clinically mixing is reconstructed. The phenomenological clarification of the structure of the obsessive phenomena leads to the term of obsession in the strict sense. The distinction between obsessive-compulsive disorder and schizophrenia can take place at the psychopathological interface between obsession in the strict sense and delusional idea. The examination of the literature on the connection between obsessive-compulsive disorder and schizophrenia shows that there is no definitive connection between obsession in the strict sense and schizophrenia. Finally, some case reports are presented to sharpen clinical suspicion for other possibly wrong diagnoses.

Psychopathology of obsessive-compulsive disorder: a phenomenological approach.

Until the beginning of the 20th century, the idea of obsession found in the literature was mostly a broad and unspecific one, and it has, to some extent, persisted in this form until the present day. At the same time, however, Esquirol and Westphal began to develop a concept of obsession in the strict sense, and Jaspers used the phenomenological method as a basis to give it its final form. The concept of obsession in the strict sense represents the formal and nosologically specific core symptom of obsessive-compulsive disorder. In conjunction with the distinction between primary and secondary obsessions, obsession in the strict sense is proving helpful in differential diagnosis, but it can also serve as a guideline in the further phenomenological investigation of obsessive-compulsive disorder. It is shown how the interaction between personality, affect and release situation develops the obsessive-compulsive disorder. The clarification of these aspects with the patient can at the same time be the starting point of psychotherapeutic treatment.

[Obsessive compulsive disorder and schizophrenia. An attempt at psychopathologic differentiation by focusing on the single phenomenon of obsession]. / Zwangsstörung und Schizophrenie. Versuch einer psychopathologischen Differenzierung am Einzelphänomen Zwang.

This paper follows the hypothesis that differentiation between obsessive compulsive disorder and schizophrenia is possible only by focusing on the single phenomenon of obsession. The declaration of a nosological specificity of obsession is set against the current view of ICD-10 and DSM-IV, of obsession as a ubiquitous nonspecific phenomenon appearing with comorbidities. The historic development of these two most different views of obsession and their combination is explained. The distinction between obsessive compulsive disorder and schizophrenia can be made at the psychopathologic dividing line between obsession and delusional thoughts. Examination of the literature on the transition from obsessive compulsive disorder into schizophrenia shows that there is no clear link between obsession and schizophrenia.

[2 basic problems of psychoanalytic psychotherapy and their philosophical revision]. / Zwei Grundprobleme tiefenpsychologischer Psychotherapie und deren philosophische Revision.

The presupposition of the cartesian cogito provokes a ¿potential decrease of transcendental philosophy,¿ which means, that reevaluation of the scientific reflexive reason leads into a metaphysical evacuation. Original philosophical subjects develop into subjects of a scientific psychology respectively depth psychology. Two fundamental problems, resulting from this historical context of philosophy, should be described: Firstly the consciousness, which is objectivated and hardened as psyche by the influence of reflection. Secondly the unconsciousness, which seems like a hidden psychological entity with an indifferent essence. The effort to revise those two problems should be made by the use of phenomenological and existential philosophy. The intention of this revision is first to reintegrate the isolated reflexive consciousness in a field of consciousness and secondly to replace the confrontation with the unconsciousness by the dialogue with the fellow being.

[The question of the connection between obsessive-compulsive disorder and narcissism]. / Zur Frage des Zusammenhangs zwischen Zwangsstörung und Narzissmus.

Freud's psychodynamic concept of the anal-sadistic regression in obsessive-compulsive neurosis is completed with the clinical observation of the structural ego deficit in connection with obsessive-compulsive disorder. Not being able to rely on one's own behaviour, described by Quint, for example, explains that the self-assessing function is lacking in the obsessive-compulsive patient. Such patients need the other person to acknowledge and confirm their behaviour as a self-object, i.e. as a part of his self. The aspect of the narcissistic bond of the obsessive-compulsive patient is emphasised here as a differentiation to the more superficial criteria of narcissism in the DSM-IV. The obsessive-compulsive symptomatology has the function to hold on to his self-object as no autonomy is available and loss of bond is experienced as loss of self. The relation of obsessive-compulsive disorder and narcissism is described on the basis of three case histories and supported by biographic and psychotherapeutic data. Furthermore attention is drawn to the consequences of this opinion for a modified psychodynamic therapeutical approach.

[Self-reflection, interpersonal behavior and psychoanalytic ethics]. / Selbstreflexion, Interpersonalität und psychoanalytische Ethik.

In the middle ages, ethical practice included a metaphysical theory of value. In comparison with that, self-reflection and interpersonality should be described as principles of more individual ethics and proceeding from philosophy to psychoanalysis in modern times. Drawing a borderline between human philosophy and metaphysies, Kant defined his so-called categorial imperative as a basic phenomenon of human reciprocity. Ethical relationship to another person, however, requires realization of one's own self, i.e. self-reflection. Hegel's subsequent association of intersubjectivity and selfreflection supplied the basis for Sarte's constitution of consciousness: Existence as existing for the good of the fellow-being. Self-reflection, basing on the sight of one's own self by the other person, leads to Sartre's concept of existential psychoanalysis and to his understanding of ethics. His concept illustrates the decline of significance of philosophy for the analysis of human relationship. Habermas describes self-reflection and interpersonality as fundamental principles of the psychoanalytic therapy and its ethical demands. With the historical concept of the super-ego, Freud established therapeutical one-sidedness and abstinence from ethics; however, as therapeutical interrelationship continued to intensity, ethics of depth psychology also began to develop. This ethical demand was not expressly formulated within the context of psychoanalysis, with the exception of jung and his epigones. Nevertheless, psychoanalytic interaction implies the development of self-reflection, which definitely represents a step forward in the sense of "ethical enlightenment" represented by Kant.

[Clozapine and obsessive-compulsive symptoms in schizophrenia. A case history of one patient]. / Clozapin und Zwangssymptome bei Schizophrenie. Eine Einzelfalluntersuchung.

In the examination in question, the case history of a patient who had exhibited serious obsessive-compulsive symptoms since the age of 14 is described. It is not an independent obsessive-compulsive disorder, but a case of schizophrenia masked by obsessive-compulsive symptoms. During therapy for the schizophrenic symptoms with clozapine, which set in at the age of 31, neither psychotic symptoms nor obsessive-compulsive symptoms worth mentioning can be found at the 1-year catamnesis. Whereas the literature increasingly points to obsessive-compulsive symptoms being a side-effect of clozapine medication, usually in the clinical indication area of chronic schizophrenic psychoses, as far as the author knows, this describes a rare case of improvement of obsessive-compulsive symptoms using clozapine after first suffering from a schizophrenic disorder. The meaning of differential diagnostics of obsessive-compulsive phenomena for adequate pharmacotherapy is discussed using the example of the individual case.

[Dysmorphophobia. Becoming estranged with oneself as a disorder of communication]. / Dysmorphophobie. Das Sich-selbst-fremd-werden als Störung der Kommunikation.

Dysmorphophobia shall be described as an example for a communicative disorder and be deliminated from other syndromes under which it has been subsumed so far. On the background of available literature, the "fear of deformity" is to be elaborated as feeling ashamed of the contemptuous look of another person, whose look has turned into the own view. This results in a discrepancy with the ego and the own self conveyed by others, finally leading to depersonalisation. This basic interpersonal appearance shall be further illustrated by two individual examples.

[Psychodynamics and therapy of trichotillomania]. / Psychodynamik und Therapie einer Trichotillomanie.

After a short review of the literature, some aspects of the psychodynamics and therapy of trichotillomania with an adolescent patient are presented that up to now have not been described in great detail. Against the backdrop of previous fears of being abandoned, the patient feels threatened that while coping with the developmental tasks of sexuality and aggressiveness she will be dropped once again. This psychodynamically oriented therapy makes it possible for the patient to accept and verbalize the corresponding feelings in a relationship that gives a feeling of security. Therefore, the symptoms that previously served the purpose of regulating diffuse inner tensions and fears may be abandoned.

[Psychotherapy in psychiatry--an assessment of current status. Report on the DGPPN Status Colloquium "Psychotherapy in Psychiatry" 22-24 February 1996 in Heidelberg]. / Psychotherapie in der Psychiatrie--eine Bestandsaufnahme. Bericht über das DGPPN-Statuskolloquium "Psychotherapie in der Psychiatrie" 22.-24. Februar 1996 in Heidelberg.

The German psychiatrists have agreed to new training regulations which now include psychotherapy. On this occasion the German Psychiatric Association organized a symposium "psychotherapy within psychiatry". Psychotherapy researchers of all psychiatric departments in German speaking countries were invited. As a result, a cross-sectional picture of current psychotherapy research within psychiatry showed a great variety of methods and ways of thinking about research on psychotherapeutic process, outcome, and applications. Even non behavioural approaches showed a trend towards operationalized and quantifying, but also standardized qualitative research. All participants agreed on the necessity of better and in comparison with psychopharmacological research more fair financing of psychotherapy research.