Use of the Depression, Anxiety and Stress Scale (DASS-21) Questionnaire to Assess Levels of Depression, Anxiety, and Stress in Healthcare and Administrative Staff in 5 Oncology Institutions in Bosnia and Herzegovina During the 2020 COVID-19 Pandemic.

BACKGROUND Providing oncology services during a pandemic can contribute to mental health challenges among healthcare workers. The present study aimed to evaluate the levels of depression, anxiety, and stress in healthcare and administrative staff in 5 oncology institutions in Bosnia and Herzegovina (BiH) in 2020 during the coronavirus disease 2019 (COVID-19) pandemic using the Depression, Anxiety and Stress Scale (DASS-21) questionnaire. MATERIAL AND METHODS A cross-sectional observational study enrolled 175 healthcare and administrative workers from 5 oncology institutions in BiH during December 2020. Data were collected using a questionnaire that captured general information about the participants and a DASS-21 questionnaire. RESULTS Statistical analysis revealed a statistically significant difference in the levels of depression, anxiety, and stress (P=0.003, P=0.011, and P=0.022, respectively) among participants with comorbidities connected with increased risk of severe illness caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) compared with participants without comorbidities. There was also a statistically significant difference in the levels of stress among participants from different cities (P=0.031). Supplement intake and educational level were significantly related (P=0.012). High levels of stress and anxiety were accompanied by high levels of depression among participants (P<0.01). CONCLUSIONS The findings from the present study showed that the COVID-19 pandemic has had an effect on depression, anxiety, and stress levels in oncology staff in BiH. Monitoring these levels and providing interventions and support to oncology staff are increasingly important for their wellbeing and retention at a time of global crisis in healthcare.

Associations between green/blue spaces and mental health across 18 countries.

Living near, recreating in, and feeling psychologically connected to, the natural world are all associated with better mental health, but many exposure-related questions remain. Using data from an 18-country survey (n = 16,307) we explored associations between multiple measures of mental health (positive well-being, mental distress, depression/anxiety medication use) and: (a) exposures (residential/recreational visits) to different natural settings (green/inland-blue/coastal-blue spaces); and (b) nature connectedness, across season and country. People who lived in greener/coastal neighbourhoods reported higher positive well-being, but this association largely disappeared when recreational visits were controlled for. Frequency of recreational visits to green, inland-blue, and coastal-blue spaces in the last 4 weeks were all positively associated with positive well-being and negatively associated with mental distress. Associations with green space visits were relatively consistent across seasons and countries but associations with blue space visits showed greater heterogeneity. Nature connectedness was also positively associated with positive well-being and negatively associated with mental distress and was, along with green space visits, associated with a lower likelihood of using medication for depression. By contrast inland-blue space visits were associated with a greater likelihood of using anxiety medication. Results highlight the benefits of multi-exposure, multi-response, multi-country studies in exploring complexity in nature-health associations.

'Brain fag': a syndrome associated with 'overstudy' and mental exhaustion in 19th century Britain.

The relationship between mental exhaustion and somatic sensations has been described across cultures for millennia, including the contextual relationship with studying and learning. In 19th century Britain, concern regarding the impact of 'excessive' study ('overstudy') and the mental impact on 'brainworkers' led to the coining of the term 'Brain Fag' in 1850. Anxiety became heightened following the promulgation of the Education Acts from 1870 with compulsory child education. This was felt to be a public health crisis with social class distinctions. Brain fag anxiety subsequently transmitted across the British colonies while declining in Britain. Over a century later, this linguistic and colonial residue was observed in British West Africa where it was described as a culture bound syndrome.

[Carl Wernicke (1848-1905) and the "Wernicke-Kleist-Leonhard school". Connections to "Erlangen School" of psychiatry]. / Carl Wernicke (1848­1905) und die "Wernicke-Kleist-Leonhard Schule". Beziehungen zur "Erlanger Schule" der Psychiatrie.

BACKGROUND: To celebrate Carl Wernicke's 170th anniversary, the paper aims at analysing possible connections of Wernicke and his "Wernicke-Kleist-Leonhard (WKL) school" to the "Erlangen school" of psychiatry. METHODS: Relevant primary and secondary literature as well as archival material were examined to test the hypothesis. RESULTS: Wernicke's efforts to realise his nosological system in clinical practice were continued by his pupil Karl Kleist (1879-1960). After Wernicke's tragic early death Kleist worked under Gustav Specht's "Erlangen school of psychiatry". Karl Leonhard (1904-1988), who worked under Specht as well as under Kleist, continued Wernicke's and Kleist's research and ended up with a very differentiated classification of endogenous psychoses. DISCUSSION: Specht's "Erlangen school" of psychiatry can be regarded as a link in the development of the "Wernicke-Kleist-Leonhard school". Wernicke's description of "anxiety psychosis" motivated Specht to study the emotion of anxiety in "manic-depressive disorder". Specht's study again stimulated Leonhard's concept of "anxiety-happiness psychosis". Generally, Specht's intensive focus on bipolarity has influenced Leonhard's concept of cycloid psychoses. Specht's description of "pathologic affect" had an impact on Leonhard's concept of "affect-laden paraphrenia". CONCLUSION: Modern methods of neuro-imaging open a new perspective to Wernicke's localisation theory. The natural-scientific-philosophical "double orientation" of the WKL school motivates an increased integration of philosophical elements (ethics, religiosity, spirituality) in the field of psychiatry, psychosomatic medicine and psychotherapy.

Different Places, Different Ideas: Reimagining Practice in American Psychiatric Nursing After World War II.

In 1952, Hildegard Peplau published her textbook Interpersonal Relations in Nursing: A Conceptual Frame of Reference for Psychodynamic Nursing. This was the same year the American Psychiatric Association (APA) published the first edition of the Diagnostic and Statistical Manual of Mental Disorders (1st ed.; DSM-I; APA). These events occurred in the context of a rapidly changing policy and practice environment in the United States after World War II, where the passing of the National Mental Health Act in 1946 released vast amounts of funding for the establishment of the National Institute of Mental Health and the development of advanced educational programs for the mental health professions including nursing. This article explores the work of two nurse leaders, Hildegard Peplau and Dorothy Mereness, as they developed their respective graduate psychiatric nursing programs and sought to create new knowledge for psychiatric nursing that would facilitate the development of advanced nursing practice. Both nurses had strong ideas about what they felt this practice should look like and developed distinct and particular approaches to their respective programs. This reflected a common belief that it was only through nurse-led education that psychiatric nursing could shape its own practice and control its own future. At the same time, there are similarities in the thinking of Peplau and Mereness that demonstrate the link between the specific social context of mental health immediately after World War II and the development of modern psychiatric nursing. Psychiatric nurses were able to gain significant control of their own education and practice after the war, but this was not without a struggle and some limitations, which continue to impact on the profession today.

The history of generalized anxiety disorder as a diagnostic category.

From the 19th century into the 20th century, the terms used to diagnose generalized anxiety included "pantophobia" and "anxiety neurosis." Such terms designated paroxysmal manifestations (panic attacks) as well as interparoxysmal phenomenology (the apprehensive mental state). Also, generalized anxiety was considered one of numerous symptoms of neurasthenia, a vaguely defined illness. Generalized anxiety disorder (GAD) appeared as a diagnostic category in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980, when anxiety neurosis was split into GAD and panic disorder. The distinct responses these two disorders had to imipramine therapy was one reason to distinguish between the two. Since the revised DSM-III (DSM-III-R), worry about a number of life circumstances has been gradually emphasized as the distinctive symptom of GAD. Thus, a cognitive aspect of anxiety has become the core criterion of GAD. The validity of GAD as an independent category has been questioned from DSM-III up to preparation of DSM-5. Areas of concern have included the difficulty to establish clear boundaries between GAD and (i) personality dimensions, (ii) other anxiety-spectrum disorders, and (iii) nonbipolar depression. The National Institute of Mental Health has recently proposed the Research Domain Criteria (RDoC), a framework destined to facilitate biological research into the etiology of mental symptoms. Within the RDoC framework, generalized anxiety might be studied as a dimension denominated "anxious apprehension" that would typically fit into the research domain called "negative valence systems" and the more specific construct termed "potential threat."

Desde el sigh XIX y hasta el siglo XX, los términos empleados para diagnosticar la ansiedad generalizada incluyeron la "pantofobia" y la "neurosis de ansiedad". Tales términos designaron manifestaciones paroxísticas (ataques de pánico) como también fenomenología interparoxística (el estado mental de aprensión). También la ansiedad generalizada fue considerada uno de Ios numerosos síntomas de la neurastenia, una enfermedad definida vagamente. El trastorno de ansiedad generalizada (TAG) apareció como una categoría diagnóstica en la tercera edición del Manual Diagnóstico y Estadístico de Ios Trastornos Mentales (DSM-III) en 1980, cuando la neurosis de ansiedad fue dividida entre el TAG y el trastorno de pánico. Una de las razones para distínguir estos dos trastornos fue la respuesta diferente que tuvieron a la terapia con imipramina. A partir de la edición revisada del DSM-III (DSM-III-R), la preocupación People Like Us - situaciones de vida se ha enfatizado gradualmente como el síntoma distintivo del TAG. En consecuencia, un aspecto cognitivo de la ansiedad ha llegado a ser el criterio central del TAG. La validez del TAG como una categoría independiente ha sido cuestionada desde el DSM-III hasta la preparación del DSM-5. Algunos aspectos tornados en cuenta han incluido la dificultad para establecer límites claros entre el TAG y 1) dimensiones de la personalidad, 2) otros trastornos del espectro ansioso y 3) la depresión no bipolar. Recientemente, el Instituto National de Salud Mental de EE.UU. propuso Ios Research Domain Criteria (RDoC), un sistema destinado a facilitar la investigación biológica acerca de la etiología de Ios síntomas mentales. Dentro del sistema RDoC, la ansiedad generalizada podría ser estudiada como una dimensión denominada "aprensión ansiosa", la cual podría ajustar típicamente con el dominio de investigación llamado "sistemas de valencía negativa" y más específicamente con el constructo llamado "amenaza potencial".

Entre le XIXe et le XXe siècle, plusieurs termes ont été utilisés pour dénommer l'anxiété généralisée, notamment la «pantophobie¼ et la «névrose d'angoisse¼. Ces termes désignaient à la fois des manifestations paroxystiques (les attaques de panique) ainsi que les symptômes intercritiques (l'état mental d'appréhension). D'autre part, l'anxiété généralisée était aussi considérée comme l'un des nombreux symptômes de neurasthénie, une maladie de définition imprécise. Le trouble anxieux généralisé (TAG) est apparu pour la première fois en tant que diagnostic dans la 3e édition du manuel statistique et diagnostique des troubles mentaux (DSM-III) en 1980 quand la névrose d'angoisse a été divisée en TAG et trouble panique. Ces deux troubles ont été distingués sur la base d'une réponse différente au traitement par imipramine. À partir de la révision du DSM-III (DSM-III-R), l'inquiétude face à un certain nombre de situations de la vie courante a été conceptualisée petit à petit comme le symptôme cardinal du TAG. Ainsi, un aspect cognitif de l'anxiété est devenu le critère primordial du TAG. La validité du TAG en tant que catégorie diagnostique indépendante a été mise en doute depuis le DSM-III jusqu'à la préparation du DSM-5. Les questionnements reposaient sur la difficulté à établir des frontières claires entre le TAG et (1) les dimensions de personnalité, (2) les autres troubles du spectre de l'anxiété et (3) la dépression non-bipolaire. L'institut national de la santé mentale aux États-Unis a récemment mis en place le Research Domain Criteria [RDoC], un cadre destiné à faciliter les recherches biologiques dans le domaine de l'étiologie des troubles mentaux. Dans le cadre du RDoC, l'anxiété généralisée pourrait être étudiée comme une dimension appelée «appréhension anxieuse¼, qui appartiendrait typiquement au domaine de recherche dénommé «systèmes de valences négatives¼ et plus spécifiquement au concept dit de «menace potentielle¼.

Platzschwindel, agoraphobia and their influence on theories of anxiety at the end of the nineteenth century: theories of the role of biology and 'representations' (Vorstellungen).

During the 1860s, Berlin's exterior physiognomy transformed radically. The city eroded the surrounding rural areas, and the frontiers of the old city centre were abolished. These transformations led to the disappearance of the visible frontiers that once demarcated the limits of the old residential Prussian city. In this context, the description of the clinical picture of agoraphobia by the Berlin psychiatrist Carl Westphal in 1872 marked a turning point, not only in psychiatric theories on anxiety but also in the conceptualization of our experience of space. In this paper, the authors trace the emergence of a new psychology-neurology episteme during the last third of the nineteenth century; and they argue that such an episteme became possible once the relations between anxiety and modern city-scape had been clearly articulated.

From Georgia to Jerusalem: some Medical Aspects of "The Knight in the Panther's Skin" by Shota Rustaveli.

The Georgian poet Rustaveli wrote his epic poem The Knight in the Panther's Skin around 1200. He knew the works of Hippocrates and Galen, and believed in the unity of body and soul.Thereare many references to health and medicine in the poem, and we shall highlight some of them. In 1185 Rustaveli left Georgia and settled in Jerusalem. There he lived and died at the Monastery of the Cross, where he was buried.

A history of anxiety: from Hippocrates to DSM.

This article describes the history of the nosology of anxiety disorders. Greek and Latin physicians and philosophers distinguished anxiety from other types of negative affect, and identified it as a medical disorder. Ancient Epicurean and Stoic philosophers suggested techniques to reach an anxiety-free state of mind that are reminiscent of modern cognitive psychology. Between classical antiquity and the late 19(th) century there was a long interval during which anxiety was not classified as a separate illness. However, typical cases of anxiety disorders kept being reported, even if under different names. In the 17(th) century, Robert Burton described anxiety in The Anatomy of Melancholy. Panic attacks and generalized anxiety disorder may be recognized in the "panophobias" in the nosology published by Boissier de Sauvages in the 18(th) century. Also, anxiety symptoms were an important component of new disease constructs, culminating in neurasthenia in the 19(th) century. Emil Kraepelin devoted much attention to the possible presence of severe anxiety in manic-depressive illness, thereby anticipating the "anxious distress" specifier of bipolar disorders in DSM-5. A pitfall to consider is that the meaning of common medical terms, such as melancholia, evolves according to places and epochs.

Este artículo describe la historia de la nosología de los trastornos de ansiedad. Los médicos y los filósofos griegos y latinos diferenciaban la ansiedad de otros tipos de afectos negativos y la identificaban como un trastorno médico. Los antiguos filósofos epicúreos y estoicos sugirieron técnicas para alcanzar un estado mental sin ansiedad que recuerdan a la psicología cognitiva moderna. Entre la Antigüedad Clásica y finales del siglo XIX hubo un largo intervalo durante el cual la ansiedad no se clasificó como una enfermedad independiente. Sin embargo, se reportaron casos típicos de trastornos de ansiedad aunque con diferentes nombres. En el siglo XVII, Robert Burton describió la ansiedad en el texte The Anatomy of Melancholy. Los ataques de pánico y el trastorno de ansiedad generalizada pueden ser reconocidos en las "panofobias" de la nosología publicada por Boissier de Sauvages en el siglo XVIII. Los síntomas ansiosos también fueron un componente importante de los nuevos constructos de enfermedad, culminando en la neurastenia en el siglo XIX. Emil Kraepelin puso mucha atención en la posible presencia de la ansiedad grave en la enfermedad maníaco depresiva, anticipando así el especificador "distrés ansioso" de los trastornos bipolares en el DSM-5. Una dificultad a tener en cuenta es que el significado de términos médicos comunes, como melancolia, evoluciona de acuerdo a lugares y épocas.

Cet article relate l'histoire de la nosologie des troubles anxieux. Les philosophes et les médecins de l'antiquité gréco-romaine avaient déjà distingué l'anxiété des autres affects négatifs et l'avaient déjà identifiée comme un trouble médical. Les philosophes des écoles épicurienne et stoïcienne avaient proposé des techniques visant à atteindre un état d'esprit libre d'anxiété qui rappellent les enseignements actuels des thérapies cognitives. Il y a eu, entre l'antiquité classique et la fin du XIXe siècle un long intervalle durant lequel l'anxiété n'a plus été répertoriée comme une affection distincte. Cependant, des cas typiques de troubles anxieux ont continué à être décrits, même si cela se faisait sous des noms différents. Au XVIIe siècle, Robert Burton a décrit l'anxiété dans " L'anatomie de la mélancolie ". Des attaques de paniques et l'anxiété généralisée peuvent être identifiées dans les " panophobies " de la nosologie publiée par Boissier de Sauvages au XVIIIe siècle. De plus, les symptômes anxieux étaient une composante importante des nouvelles entités morbides conceptualisées au XIXe siècle, avec notamment la neurasthénie. Emil Kraepelin s'est beaucoup intéressé à la présence possible d'une anxiété sévère dans la maladie maniaco-dépressive, anticipant ainsi la spécification " détresse anxieuse " apparue pour les troubles bipolaires dans le DSM-5. Il faut se garder des anachronismes dans l'interprétation des textes historiques en psychiatrie et garder par exemple à l'esprit que des termes médicaux courants, comme la mélancolie, ont connu des sens divers selon les lieux et les époques.

Disease-mongering through clinical trials.

Our goal in this paper is to articulate a precise concept of at least a certain kind of disease-mongering, showing how pharmaceutical marketing can commercially exploit certain diseases when their best definition is given through the success of a treatment in a clinical trial. We distinguish two types of disease-mongering according to the way they exploit the definition of the trial population for marketing purposes. We argue that behind these two forms of disease-mongering there are two well-known problems in the statistical methodology of clinical trials (the reference class problem and the distinction between statistical and clinical significance). Overcoming them is far from simple.

No man is an island. A personal tribute to Bob Blanchard and ethoexperimental approaches to the study of behaviour.

I first met Bob Blanchard at an international conference in Paris some 40 years ago. We collaborated intensively during the late 1980s/early 1990s on the ethopharmacology of antipredator defence in wild and laboratory rats, and remained good friends until his untimely passing in November 2013. Bob will undoubtedly be remembered as one of the most influential behavioural neuroscientists of the 20th century and, with Caroline, the most eloquent advocate of ethoexperimental approaches to the study of behaviour. In this brief trip down memory lane, I describe when and where Bob and I first met and how, over a lengthy period, he directly and indirectly helped shape my own research career. His profound influence in this regard is illustrated by reference to not only our collaborative research on antipredator behaviour but also my other work on the ethopharmacology of agonistic behaviour, social conflict analgesia, anxiety, and appetite. The element common to all of this work has been ethoexperimental analysis and, for teaching me the true value of this approach, I shall always remain indebted to the big man. Literally and figuratively, Bob was most certainly larger than life.

'Febrile anxiety', by Robert James (1745): with an introduction by.

The current class of psychiatric conditions called 'Anxiety Disorders' was constructed during the 20th century. Before 1900, its clinical components were conceptualized differently: some were not considered as diseases at all and others were looked after by physicians (not alienists). Whether it can be claimed that the complaints included under the 'Anxiety Disorders' have always existed, that is, constitute a form of 'natural kind', is a moot point that needs further historical investigation. This is because psychiatric complaints (mental symptoms) are no more than culturally configured segments of biological or symbolic information. Therefore, symptom-invariance or -perdurance can be explained by either biological or cultural factors. This can only be resolved by studying symptoms individually. Classic Text No. 97 shows how 'Anxiety' was conceptualized during the 18th century.

The psychological study of anxiety in the era of the Second World War.

The mid-twentieth century in Britain ushered in a new age of anxiety with the development of total war and the aerial bombing of civilians. Rather than trying to chart and quantify levels of anxiety and fear on the British home front during the Blitz, this article's goal is to examine how these emotions were conceptualized by psychological experts immediately prior to and during the war. The essay follows the rising problematization of anxiety and fear as new concepts calling for professional knowledge and management. It emphasizes the contribution of psychoanalysts to this development while pointing to gradual change between the two world wars.

Goethe's anxieties, depressive episodes and (self-)therapeutic strategies: a contribution to method integration in psychotherapy.

BACKGROUND: In psychiatry and psychotherapy, abstract scientific principles need to be exemplified by narrative case reports to gain practical precision. Goethe was one of the most creative writers, productive scientists, and effective statesmen that ever lived. His descriptions of feelings, emotions, and mental states related to anxieties, depressive episodes, dysthymia, and creativity are unique in their phenomenological precision and richness. His life and work can thus serve as an excellent example enhancing our understanding of the relationship between anxiety, depression and creativity. Furthermore, he described (self-)therapeutic strategies that reinforce and refine modern views. METHODS: Goethe's self-assessments in his works and letters, and the descriptions by others are analyzed under the perspective of current psychiatric classification. His therapeutic techniques and recommendations are compared with cognitive-behavioral, psychodynamic, and existential psychotherapy to amplify modern concepts of psychotherapy. RESULTS: From a scientific perspective, several distinctive depressive episodes can be diagnosed in Goethe's life. They were characterized by extended depressive moods, lack of drive, and loss of interest and self-esteem combined with social retreat. Goethe displayed diffuse and phobic anxieties as well as dysthymia. His (self-)therapeutic strategies were: (a) the systematic use of helping alliances, (b) behavioral techniques, (c) cognitive reflection on meanings and beliefs, (d) psychodynamic and psychoanalytic remembering, repeating, and working through, and (e) existential striving for self-actualization, social commitment, meaning, and creativity. CONCLUSIONS: In Goethe's life, creative incubation, illumination, and elaboration appear to have been associated with psychic instability and dysthymia, sometimes with depressive episodes in a clinical sense. On the one hand, his creative work was triggered by anxieties, dysthymia, and depressive moods. On the other hand, his creativity helped him to cope with psychic disorders and suicidal tendencies. Furthermore, Goethe described psychotherapeutic strategies that resemble modern techniques. He integrated relational, behavioral, cognitive, psychodynamic, and existential techniques and attitudes. These modern psychotherapeutic approaches can be exemplified and enhanced by reflecting upon the (self-)therapeutic efforts of one of the most creative persons that have ever lived. Hermeneutics as the art of communication and understanding derived from Goethe's (self-)therapy and creative works can serve as a meta-theoretical framework for the integration of different psychotherapeutic approaches.

Surviving death-anxieties in liquid modern times: examining Zygmunt Bauman's cultural theory of death and dying.

Despite his prominence as a leading contemporary social theorist, Zygmunt Bauman's long-term writing on the cultural theory of death and dying has largely been overlooked in the sociological literature of death and dying, particularly in the United States. Bauman uniquely theorizes how we survive death-anxieties today: Contemporary, liquid modern culture has engaged us in ceaseless pursuit of the unattainable consumer sensation of bodily fitness as a way to suppress and thus survive our death-anxieties. Bauman also argues that the prevalence of this cultural formula to survive death-anxieties has simultaneously increased, more than ever before in social history, the volume of individual responsibility for restlessly coping with existential anxieties in the societies of consumers. While unique and insightful, his theoretical argument has a limitation; largely succeeding Freud's classic view of mortality, Bauman's contemporary theory may lead us to neglect potentially important social, cultural, and historical variations in how mortality has been understood.

[For a critical history of the concept of anxiety]. / Pour une histoire critique du concept d'angoisse.

Anxiety, tension, anguish... These are words, but first of all, states of the self. Accepted since the dawn of time by human distress and by the effort to understand them, they were taken back in hand by Psychopathology, established as a little dark concepts, and as such have become today so sovereign in the most ordinary way that their "reality" seems to be obvious. This recent acknowledgement is however the result of a history. To attempt to restore the original bases enables to find in it the old and well-thought-out acknowledgement in a common nature, the unknown factors of which were considered for a long time with familiarity and distance by common people as well as by doctors. This unconventional look, that we suggest to have here over a long period of time, allows us to restore, in the outermost bounds of Psychosomatics, all the ambiguities of a present notion which was at first physiological before appearing in psychiatric Nosology. It also means to take a certain distance from the medicalization of affects which, whatever we think, naturally come from our mortal condition.

Sigmund Freud and Otto Rank: debates and confrontations about anxiety and birth.

The publication of Otto Rank's The Trauma of Birth (1924) gave rise to an intense debate within the secret Committee and confronted Freud with one of his most beloved disciples. After analyzing the letters that the Professor exchanged with his closest collaborators and reviewing the works he published during this period, it is clear that anxiety was a crucial element among the topics in dispute. His reflections linked to the signal anxiety concept allowed Freud to refute Rank's thesis that defined birth trauma as the paradigmatic key to understanding neurosis, and, in turn, was a way of confirming the validity of the concepts of Oedipus complex, repression and castration in the conceptualization of anxiety. The reasons for the modifications of anxiety theory in the mid-1920s cannot be reduced, as Freud would affirm officially in his work of 1926, to the detection of internal contradictions in his theory or to the desire to establish a metapsychological version of the problem, for they gain their essential impulse from the debate with Rank.