Psychodynamic Psychiatry and the Care of Persons with Vision Loss and Blindness.

The authors describe the clinical relevance of the psychiatric concept of bidirectionality when caring for persons with comorbid disorders, and they propose a psychodynamic framework to guide the treatment of persons with vision loss and blindness. Since persons with vision loss have an increased risk of depressive and anxiety disorders, they recommend targeted screening, integrated services, and a biopsychosocial approach to clinical care. The psychoanalytic concept of aphanisis, first described by Ernest Jones and later developed by Lacan and Kohut, is briefly discussed. Common psychotherapy themes in the treatment of persons who experience vision loss from systemic illness include reactivation of memories of past traumas resulting in avoidance, social withdrawal, depressive states, catastrophic thinking, a sense of foreshortened future, anhedonia, and fear of disintegration and invisibility. Psychotherapy also serves to correct negative introjects from ableist societal attitudes.

The Impact of Patient Suicide on Clinicians.

The experience of patient suicide on clinicians is associated with complex affective states that include grief, guilt, shame, and fear and distressing subjective experiences of incompetence and helplessness. The authors review the literature of the subject and highlight the work of Rajagopalan and colleagues in Singapore, who implemented a one-time reflective group session to help clinicians process the experience of patient suicide to reduce psychological distress and prevent burnout and moral injury.

Clinical Implications of Countertransference in the Treatment of Addictions.

The author provides a historical overview of the psychodynamics of addiction with particular emphasis on countertransference awareness and its relationship with treatment outcomes and prognosis. Countertransferences that frequently occur in the treatment of substance use disorders include shared helplessness, hopelessness, sadness, anxiety, fear, anger, rage, shame, and guilt. These emotional states in clinicians may lead to fatigue, avoidance, and acting out unless therapists are able to ground themselves and disidentify with the projected affective states. Positive emotions may lead to excessive enthusiasm in clinicians and deflect from the therapeutic process, resulting in deviation from established practice guidelines. Coexisting negative and positive affective states may lead to rescue fantasies and transgressions of boundaries. Contemporary psychodynamic clinicians appreciate the quantitative aspect of emotional reactions, where countertransferences accumulate exponentially over time, causing allostatic overload and compassion fatigue. Unanalyzed negative countertransferences are linked to either clinical avoidance or aggression, resulting in withdrawing care, failure of empathy, and dissolution or fragmentation of the therapeutic alliance. The negativism associated with the treatment of addictions may be rooted in unanalyzed countertransferences and psychosocial factors such as internalized negative societal attitudes and stigma. Degrading and dehumanizing attitudes toward people with substance use disorders could stem from internalized negative societal constructs against disenfranchised, minoritized, and stigmatized persons. This editorial introduces the work of Bernardine Han, an addiction psychiatrist who utilizes psychodynamic concepts to guide interventions with people with substance use disorders.

An Overview of the Psychodynamics of Addiction.

The author provides an overview of the psychodynamics of addiction, diverging from outdated conceptualizations such as orality and regression, and emphasizing the clinical relevance of the self-medication hypothesis. Rado and Bion paved the way for Khantzian's self-medication hypothesis by describing the drug user's need to escape unpleasure and seek self- containment. The author reviews research corroborating the relevance of the self-medication hypothesis and other relevant constructs such as self-deceptive attempts at adaptation, inability to prioritize self-care or delay gratification, excessive hedonism and novelty seeking, and impulsivity. Adverse childhood experiences, abuse and neglect are known to cause epigenetic changes altering gene expression, which may endure throughout life and be transmitted intergenerationally. Effective psychotherapeutic interventions have the potential to reverse DNA methylation and other epigenetic changes triggered by trauma and co-morbid psychopathology. Lastly, this editorial also introduces the psychodynamically informed clinical recommendations of Baurer and Gottdiener, further described in separate articles in this issue of Psychodynamic Psychiatry.

Clinical Reasoning in Forensic Psychiatry: Concepts, Processes, and Pitfalls.

Forensic psychiatrists are often sought by the court of law to provide professional opinion on specific legal matters that have a major impact on the evaluee and possibly society at large. The quality of that opinion and recommendations rely on the quality of the analysis from the assessment results conducted by the psychiatrist. However, the definition and scope of a forensic psychiatric analysis is not clear. While existing literature on forensic psychiatric analysis generally includes organizing information, identifying relevant details, and formulating a set of forensic psychiatric opinions as components, there is no explicit and unified definition of these terms and process. This lack of clarity and guidelines may hinder forensic psychiatry from achieving its goal of providing objective information to the court or other relevant parties. Forensic psychiatric analysis exhibits numerous parallels to clinical reasoning in other fields of medicine. Therefore, this review aims to elaborate forensic psychiatric analysis through the lens of clinical reasoning, which has been developed by incorporating advances in cognitive sciences. We describe forensic psychiatric analysis through three prominent clinical reasoning theories: hypothetico-deductive model, illness script theory, and dual process theory. We expand those theories to elucidate how forensic psychiatrists use clinical reasoning not only to diagnose mental disorders, but also to determine mental capacities as requested by law. Cognitive biases are also described as potential threat to the accuracy of the assessment and analysis. Additionally, situated cognition theory helps elucidate how contextual factors influence risk of errors. Understanding the processes involved in forensic psychiatric analysis and their pitfalls can assist forensic psychiatrists to be aware of and try to mitigate their bias. Debiasing strategies that have been implemented in other fields of medicine to mitigate errors in clinical reasoning can be adapted for forensic psychiatry. This may also shape the training program of general psychiatrists and forensic psychiatrists alike.

Intermittent Treatment with the Psychodynamic Psychiatrist: A Patient-Centered Approach.

This study examines the experiences of patients in treatment with psychodynamic psychiatrists on an intermittent basis following an initial brief period of intensive psychotherapy and stabilization. Patients with non-psychotic disorders who received intermittent treatment answered a web-based questionnaire describing the usefulness of various supportive, cognitive-behavioral, and psychodynamic interventions. Forty-eight out of 58 patients invited to participate completed the survey (83% response rate). The majority (75%) of respondents welcomed the intermittent treatment frame. Therapeutic factors deemed to be most helpful included supportive interventions such as ability to relate to the clinician, ability of clinician to listen empathically, and feeling supported by a non-judgemental therapist when talking about private matters. The majority of respondents also endorsed as highly beneficial various cognitive-behavioral interventions such as understanding how thinking patterns impact behavior and feelings and discussing alternative coping skills. Also highly rated were psychodynamic interventions, including understanding how the present is modeled from past experiences and expression and regulation of affect. In the open-ended qualitative feedback, therapeutic factors including collaboration, forming an alliance, and empathic attunement emerged as important. Our preliminary findings suggest that the intermittent psychodynamic treatment frame is well received by patients. Patients welcome integration of different psychotherapeutic approaches to individualize treatment. The common factors in psychotherapy are important patient-reported therapeutic factors in the intermittent treatment approach.

Systematic Review and Meta-Analysis for Sexual Dysfunction in Women With Hypertension.

INTRODUCTION: Sexual dysfunction in hypertensive women is an often-neglected subject despite a reported prevalence of 42.1%. Although few reviews exist, a definitive relationship between hypertension and sexual dysfunction in women has not been clearly established. AIM: To review the existing literature to definitively examine sexual dysfunction in women with hypertension, in both treated and untreated subjects. METHODS: We performed a systematic search for published literature of 3 electronic databases (Scopus, EBSCOhost Medline Complete, and Cochrane Library) in August 2018. The search terms with relevant truncation and Boolean were developed according to a population exposure-comparator-outcome model combining pilot searches. The quality of included studies was assessed with the McMaster Critical Review Form for Quantitative Studies. Initial search, limited to the English language, included a total of 2,198 studies. 31 studies (18,260 subjects) met our inclusion criteria and were included in the review. Sexual dysfunction in these studies was measured using different tools. We extracted information of study setting, country, number of subjects, participants' age and blood pressure, comparators, and outcome. We ran a meta-analysis on the presence of sexual dysfunction as an outcome from the following comparisons: (i) hypertensive vs normotensive (ii) treated vs untreated hypertension, and (iii) exposure vs absence of specific class of anti-hypertensive drug. MAIN OUTCOME MEASURES: Women with sexual dysfunction and hypertension were included. RESULTS: We found significant sexual dysfunction in women with hypertension compared with the normotensive group (pooled odds ratio [OR] = 2.789, 95% CI = 1.452-5.357, P = .002). However, there was no statistical difference of sexual dysfunction in women with treated or untreated hypertension (OR = 1.229, 95% CI = 0.675-2.236, P = .5). Treatment with alpha-/beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, and diuretics resulted in no statistical difference in sexual dysfunction in hypertensive women. CLINICAL IMPLICATIONS: Because sexual dysfunction is prevalent in women with hypertension, it is imperative to address the underlying medical condition to manage this important clinical problem. STRENGTH & LIMITATIONS: Many studies had to be excluded from the meta-analysis, due to unavailability and incompleteness of data. Nevertheless, results of the review are useful to derive recommendations for alerting physicians of the need to routinely assess the sexual functioning of women with hypertension. CONCLUSION: We conclude that women with hypertension are at increased risk for sexual dysfunction, and our findings imply that evaluation for sexual dysfunction needs to be part of the clinical management guidelines for women with hypertension. Choy CL, Sidi H, Koon CS, et al. Systematic Review and Meta-Analysis for Sexual Dysfunction in Women With Hypertension. J Sex Med 2019;16:1029-1048.

On the Birth of Psychodynamic Psychiatry.

Psychodynamic psychiatry emerged from psychoanalytic theory, but the influence of the latter has been only partial. Equally important are other disciplines outlined within is article. Modern psychodynamic publications and presentations should honor all of the foundational pillars of the field. In this way, the new area lends itself to bio-psycho-social integrations that remain a challenge for all researchers and clinicians who seek to understand and treat patients with mental disorders.

Innovative Educational Initiatives to Train Psychodynamic Psychiatrists in Underserved Areas of the World.

Psychodynamic psychiatry remains a challenging subject to teach in underserved areas, where enthusiasm to learn is substantial. Besides logistical and psychiatric workforce shortcomings, sensible cultural adaptations to make psychodynamic psychiatry relevant outside of high-income countries require creative effort. Innovative pedagogical methods that include carefully crafted mentoring and incorporate videoconferencing in combination with site visits can be implemented through international collaborations. Emphasis on mentoring is essential to adequately train future psychodynamic psychotherapy supervisors. Examples of World Psychiatric Association initiatives in countries such as Indonesia, Iran, Malaysia, and Thailand are presented as possible models to emulate elsewhere.

An Integrative Approach to Treatment-Resistant Obsessive-Compulsive Disorder.

Obsessive-compulsive disorder (OCD) is a debilitating psychiatric disorder that often runs a chronic unremitting course. Treatment outcomes can be unsatisfactory despite the availability of various somatic and psychological therapies. Psychodynamic psychotherapy in combination with cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) could help patients with treatment-resistant OCD achieve better outcomes. An integrative approach can help patients gain insight, strengthen the therapeutic alliance, improve treatment adherence, and provide symptomatic relief when other treatments seem insufficient or have failed. We describe the treatment process of a person with treatment-resistant OCD who received pharmacotherapy, concurrent CBT/ERP, and a brief course of psychodynamic psychotherapy. Case formulations from cognitive behavioral and psychodynamic perspectives are presented. The authors discuss the advantages of doing a psychodynamic assessment and formulation in treatment refractory cases and the wisdom of integrating psychotherapy interventions for OCD, as well as the unique clinical features of cases that warrant a multimodal treatment approach.

Learning Psychodynamic Psychotherapy in Southeast Asia.

The subjective nature of psychodynamic psychotherapy (PP) makes training and supervision more abstract compared to other forms of psychotherapy. The issues encountered in the learning and supervision process of PP of Malaysian psychiatry trainees are discussed in this article. Issues of preparation before starting PP, case selection, assessment of patients, dynamic formulations, supervision, anxieties in the therapy, countertransference, termination of therapy, the treatment alliance, transfer of care, the therapeutic setting, and bioethical considerations are explored. Everyone's experience of learning PP is unique and there is no algorithmic approach to its practice. With creative thinking, effort, and "good enough" supervision, a trainee can improve PP skills, even in underserved areas of the world.