A double-blind dose-reduction trial of fluphenazine decanoate for chronic, unstable schizophrenic patients.

OBJECTIVE: This study evaluated the feasibility and impact of gradually reducing relatively high doses of fluphenazine decanoate by one-half for chronically impaired, poor inner-city patients with schizophrenia. METHOD: Forty-three patients currently receiving an average of 23 mg (0.3 mg/kg) of fluphenazine decanoate every 2 weeks were divided alternately into a group to remain at current doses (control group) and a group to undergo stepwise 50% dose reduction over 5 months under double-blind conditions. Clinical status and side effects were assessed quarterly for a year. Relapse was determined clinically and by changes in psychopathology ratings. RESULTS: Eighty-six percent (N = 37) of the patients (control group, N = 17; reduced-dose group, N = 20) completed the study. The groups did not differ at baseline in demographic or clinical variables or neuroleptic dose. In the reduced-dose group, doses were lowered to an average of 11.5 mg every 2 weeks. The two groups did not differ throughout the year in number of relapses, and hospitalization rates fell similarly in both (overall, by about 67%). Clinical measures changed little. Extrapyramidal symptoms worsened in the control group but improved slightly in the reduced-dose group. Tardive dyskinesia worsened in both groups, but less in the reduced-dose group. CONCLUSIONS: Maintenance neuroleptic doses much lower than the conventional ones can be achieved safely in schizophrenic patients by gradual reduction, without clinical worsening and perhaps with fewer extrapyramidal symptoms and less tardive dyskinesia. The two-thirds lower hospitalization rate, with substantial financial savings, apparently was due to nonspecific effects of research intervention.

Fluphenazine decanoate: a clinical problem?

The authors compared the medical records of 20 randomly selected schizophrenic patients who were receiving fluphenazine decanoate with the records of 20 other randomly selected schizophrenic patients who were receiving oral medications only. The fluphenazine decanoate group had a significantly higher mean chlorpromazine equivalent dose (2010 +/- 836) than the oral medication group (373 +/- 384). The two groups did not, however, differ on any of the other variables studied. The findings, in addition to reports in the literature, suggest that the use of fluphenazine decanoate may come at the inadvertent cost of a significantly higher dose of antipsychotic medications in a subgroup of patients.

Substance use: a powerful predictor of relapse in schizophrenia.

This study examined substance use among a group of 37 schizophrenia patients participating in a year-long fluphenazine decanoate (FD; Prolixin) dosage reduction study (Inderbitzin et al. (1994) Am. J. Psychiatry 151, 1753-1759). Ten (50%) of the 20 FD dose-reduced patients, and 6 (35%) of the 17 control group patients were identified as substance users. The dose-reduced and control groups did not differ significantly in substance use. We examine here the 37 patients regrouped by substance users (n = 16) versus non-users (n = 21) to determine the effects of substance use. In addition to identifying substance users and types of substances used, we hypothesize that substance users differ demographically from non-users, have worse symptomatology, worse compliance, higher rates of relapse, and therefore, can confound studies. Clinical and demographic data were obtained. At least half of the substance users were using alcohol or cocaine. The substance use group had a significantly higher severity of illness score on the BPRS at study onset. We found no significant differences between the two groups on other rating scales. The non-use group lived more independently, and the substance use group was younger. The substance use group had nearly twice as many hospitalizations in the 2 years prior to the study, a greater rate of missed appointments in the year before and during the study, and 4 times as many relapses during the year of the study than the non-use group. The key finding was that among 9 of the 37 patients who relapsed in the year of the study, 7 of the 9 had a history of substance use. Substance use was found to be a better predictor of relapse and hospitalization than gradual 50% dosage reduction of FD in the related study. Substance use among schizophrenia patients is a major complicating factor.

Brief psychotherapy in late adolescence: a psychodynamic and developmental approach.

Four cases were discussed in which college students presented themselves in crisis for psychiatric treatment; each was dealing with a normal developmental crisis of late adolescence centering around separation-individuation issues. A type of brief psychotherapy was described which maintained the focus on the primary dynamic conflict and promoted ego development by interpreting the unconscious intrapsychic conflict. The incestuous, aggressive, and regressive themes were explored, and defenses were actively interpreted whenever they interfered with the awareness of autonomous strivings consistent with the ego ideal. Although other authors have emphasized the necessity of establishing a contract early which specifies the number of visits, we have emphasized the importance of maintaining strict therapeutic neutrality, especially regarding the duration of treatment with late adolescents. We view this as an important cornerstone of technique in assisting the healthy late adolescent in his quest for increasing autonomy, ego-ideal integration and ego mastery.

Patient's sleep on the analytic couch.

Published reports about sleep on the couch have primarily emphasized its preoedipal (especially oral) determinants and defensive purposes. A detailed case is presented in which sleep became the central symptom of the transference neurosis. The primary determinants of the symptom were from the phallic-oedipal stage of development. Like other symptoms, the sleep symptom was a reliving of earlier experiences and was analyzed primarily through the transference. The analytic data from the case are used to illustrate resistance as an ally in the psychoanalytic process.

Negativism and countertransference.

The purpose of this work is to explore the phenomenon of negativism and the analyst's response to it during the course of analytic work with a patient in whom negativism is a central behavioral pattern. Melville's short story, "Bartleby the Scrivener," describing in telling detail the response of a sympathetic lawyer to profound and pervasive negativism in his legal scribe, is discussed as a literary analogy to the analyst-analysand dyad. Aspects of the concept of negativism within psychoanalysis are discussed. The potential usefulness of understanding certain unexpected countertransference responses to pervasive negativism is explored, as this is a relatively neglected area of psychoanalytic technique. A case is presented describing the analysis of a patient whose character, like Bartleby's, is a mixture of profound negativism along with schizoid, obsessional, and masochistic elements.

Neutrality, interpretation, and therapeutic intent.

Neutrality is a central concept within the theory of psychoanalytic technique. We spell out the major controversies in which the concept has become embroiled, and provide a definition that we believe coincides with actual psychoanalytic practice. We discuss its merits and weaknesses, noting also the negative consequences of relying on older definitions. We relate neutrality to the interpretive process, indicating ways interpretation protects neutrality and is made more effective by it. We discuss the complex and controversial relation between neutrality and the analyst's therapeutic intent.

Safety, danger, and the analyst's authority.

The concepts of safety and danger as they pertain to the psychoanalytic situation are examined, with a special interest in casting aside familiar unquestioned presumptions about the therapeutic effects of the analyst and the setting as safe and therefore facilitating of self-disclosure, insight, and change. The merit of viewing the situation as in itself neither safe nor dangerous is argued, and problems are noted in the uncritical acceptance of the illusion of safety and attempts to use it for therapeutic purposes. Such an illusion denies the psychological and biological vulnerability of all human beings, especially in relation to aggression. In the clinical setting, working from an unexamined presumption of safety interferes with full transference expression and the analysis of aggression, often in the service of sparing the analyst from fully experiencing the analysand's adult aggressive potential. Contemporary interest in the analyst's authority, particularly efforts to undo it, can profitably be viewed as helping to maintain an illusion of safety during treatment in order to avoid the real dangers that are experienced as present and that are therefore available for exploration and mastery.

On grist for the mill: external reality as defense.

The meaning of the "grist for the mill" metaphor has undergone a shift from "analyzing everything" to "everything is analyzable." This is used as a point of departure for exploring some of the multiple, complicated, and often unrecognized ways reality is used defensively by analyst and analysand. The point of view presented is in the spirit of a balancing perspective with regard to current trends in psychoanalysis which emphasize interactions, the analyst's contribution to transference, reality experiences as causation of psychopathology, and the role of the "real" relationship in the mechanism of therapeutic action.

Unconscious fantasy: a reconsideration of the concept.

Despite general agreement about the clinical importance of unconscious fantasy, the concept itself has remained unclear. After reviewing Freud's work on the subject, the conceptual dilemma is specified: where in current psychoanalytic theory do we place this important, dynamically repressed, structuralized mental content? Three conceptual paths have been followed in attempting to deal with this problem. The first emphasizes the structural, tripartite model, discarding topographic concepts. The second replaces the structural model with a schema model borrowed from academic psychology. The third combines the structural and topographic models. None of these approaches is entirely satisfactory and without problems. Because of their central role in mental life, unconscious fantasies deserve careful definition. They should be distinguished from conscious fantasies and daydreams as well as from the process of fantasizing. They are differentiated from other varieties of unconscious content by their enduring quality and their organized, storylike quality reflecting the distortions typical of the primary process. As dynamically unconscious templates from the childhood past, they shape subsequent compromise formations and are relatively impervious to new experience. The development of psychoanalytic theory from a macrostructural to a microstructural emphasis is discussed in relation to the unconscious fantasy concept.

The analytic surface and the theory of technique.

This paper examines the concept of the analytic surface as a starting point for the interpretive process in relation to the theory of psychoanalytic technique. The history of the concept of the analytic surface within psychoanalysis is reviewed. Four different conceptualizations of analytic surfaces are described (M.M. Gill, P. Gray, A. Kris, E.A. Schwaber). The advantages of a "surface" approach are explored in relation to clinical work, the teaching of psychoanalytic technique, and opportunities for research. Some criticisms of the concept are explored.

Suggestion and psychoanalytic technique.

The role of the analyst's suggestive influence on the course and outcome of psychoanalytic treatment is explored, and traditional and newer perspectives on analytic technique are contrasted. The intersubjective critique of the neutral, objective analyst in relation to suggestion is examined. The inevitable presence and need for suggestive factors in analysis, and the relationship of suggestion to transference susceptibility, are emphasized. The manner in which the analysis of suggestive factors is subsumed in transference analysis as part of traditional technique is highlighted.

Regression and psychoanalytic technique: the concretization of a concept.

An exploration of the regression concept historically and conceptually reveals that its familiarity and frequent use have resulted in decreasing conceptual clarity and precision. Rooted in an outmoded fixation-regression model of development and psychopathology, the concept has become concretized. This paper is a beginning exploration of problematic aspects of the concept of regression, with emphasis on potentially detrimental consequences for psychoanalytic technique that derive from its unexamined use. Some of the salient issues are illustrated with clinical examples.

Repetition compulsion revisited: implications for technique.

Freud's repetition compulsion concept is reviewed and examined critically. It has been used as an explanatory concept to cover a wide variety of clinical phenomena similar only in their manifest repetitive quality, and it appears frequently in psychoanalytic and psychiatric literature. Its relationship to trauma and posttraumatic stress disorder is explored. Emphasis is on the detrimental technical legacy of the concept, which has cast a pessimistic aura of unanalyzability over a wide variety of repetitive phenomena, especially analyzable resistances related to aggressive conflicts. We conclude that the repetition compulsion is an anachronistic concept with detrimental technical implications and that it should be retired.

On those wrecked by success: a clinical inquiry.

Freud's description of those wrecked by success outlines conflicted oedipal triumph as the central underlying dynamic in this character type. It does not distinguish those patients who avoid success from those driven to achieve and then wreck their success. We present a complex picture that we believe is prototypic of patients who destroy their success. A clinical case illustrates our point of view. We emphasize the developmental problems we believe typical of patients who dramatically wreck the success they achieve. We hope to extend rather than replace Freud's landmark contribution to our understanding of this type of character pathology.

EM-PSYCH: a training program scheduling database.

EM-PSYCH is a scheduling database for training programs. It stores scheduling records and generates schedules and letters informing students, supervisors, and advisors of deadlines. Since EM-PSYCH was originally designed for a psychoanalytic institute, the institute model is presented as well as the database model to illustrate how the database program can be applied. EM-PSYCH is very user friendly and makes scheduling and sending reminders efficient and easy. It can handle any number of trainees and can be modified for any number of years or schedule interval. It can be easily adapted for psychiatric residencies, medical student education, psychology internships, and other training programs.

Primary health care in the CMHC: a role for the nurse practitioner.

Although persons with chronic mental illness have a high incidence of physical health problems, they are often ill equipped to seek care within complex health care systems and tend to depend on community mental health centers as their only source of regular health care. The authors describe a role for the nurse practitioner in assessing the medical needs of chronic mentally ill outpatients at a community mental health center and in devising strategies to meet those needs. The nurse practitioner's activities include direct physical health screening and treatment, referral for specialized medical services, consultation, research, and staff and patient education.