Turbulência e ausência na relação analítica / Turbulence and absence in the analytical relationship / Turbulencia y ausencia en la relación analítica / Turbulence et absence dans la relation analytique

O trabalho discute, com base em articulações teórico-clínicas, a importância da utilização da contratransferência do analista para a compreensão das comunicações do paciente acerca de seu mundo interno e do seu uso para o fortalecimento da relação analítica. Apresenta a evolução de dois casos de análise em que a turbulência e a ausência predominavam no campo analítico, com seus movimentos de aproximação e de afastamento, sendo a construção da relação analítica o enfoque principal.

The paper discusses, from theoretical-clinical articulations, the importance of using the countertransference of the analyst to understand the patient's communications about his/her internal world and their use for strengthening the analytical relationship. It presents the evolution of two cases of analysis in which turbulence and absence predominated in the analytical field, with its movements of approximation and distancing, and the construction of the analytical relationship being the main focus.

El trabajo discute, desde las articulaciones teórico-clínicas, la importancia de utilizar la contratransferencia del analista para comprender las comunicaciones del paciente sobre su mundo interno y su uso para el fortalecimiento de la relación analítica. Presenta la evolución de dos casos de análisis en los que predominaron las turbulencias y la ausencia en el campo analítico, siendo el foco principal sus movimientos de aproximación y distanciamiento, y la construcción de la relación analítica.

L'article traite, à partir d'articulations théoriques-cliniques, de l'importance d'utiliser le contre-transfert de l'analyste pour comprendre les communications du patient sur son monde interne et leur utilisation pour renforcer la relation analytique. Le présent l'évolution de deux cas d'analyse dans lesquels la turbulence et l'absence prédominaient dans le domaine analytique, avec ses mouvements d'approximation et de distanciation, et la construction de la relation analytique étant l'objectif principal.

Trauma and countertransference: development and validity of the Assessment of Countertransference Scale (ACS).

OBJECTIVES: The aim of the present study was to investigate the construct validity of the Assessment of Countertransference Scale (ACS) in the context of the trauma care, through the identification of the underlying latent constructs of the measured items and their homogeneity. METHODS: ACS assesses 23 feelings of CT in three factors: closeness, rejection and indifference. ACS was applied to 50 residents in psychiatry after the first appointment with 131 victims of trauma consecutively selected during 4 years. ACS was analyzed by exploratory (EFA) and confirmatory (CFA) factor analysis, internal consistence and convergent-discriminant validity. RESULTS In spite of the fact that closeness items obtained the highest scores, the EFA showed that the factor rejection (24% of variance, α = 0.88) presented a more consistent intercorrelation of the items, followed by closeness (15% of variance, α = 0.82) and, a distinct factor, sadness (9% of variance, α = 0.72). Thus, a modified version was proposed. In the comparison between the original and the proposed version, CFA detected better goodness-of-fit indexes for the proposed version (GFI = 0.797, TLI = 0.867, CFI = 0.885 vs. GFI = 0.824, TLI = 0.904, CFI = 0.918). CONCLUSIONS: ACS is a promising instrument for assessing CT feelings, making it valid to access during the care of trauma victims.

Countertransference in the initial visit of women victims of sexual violence / Contratransferência no atendimento inicial de mulheres vítimas de violência sexual

OBJECTIVE: To identify demographic and clinical correlates associated with therapists' countertransference feelings on the first visit of women victims of sexual violence. METHOD: Forty patients were seen by 26 therapists, during 2 consecutive years, at the Center for the Study and Treatment of Psychological Trauma, Hospital de Clínicas de Porto Alegre , Brazil. After the first visit with the patient, the therapist completed the Assessment of Countertransference Scale and the patient was evaluated with the Davidson Trauma Scale, the Standardized Assessment of Personality - Abbreviated Scale, the Beck Depression Inventory, and the Defense Style Questionnaire. RESULTS:The therapists showed a predominance of feelings of closeness (Mean = 5.42, SD = 1.25) in relation to the feelings of indifference (Mean = 1.82, SD = 1.22) and distance (Mean = 1.57, SD = 1.08) [p < 0.001]. Multivariate analyses did not present significant associations between countertransference feelings and clinical characteristics of patients. The gender of the therapists did not influence the pattern of countertransference feelings. In the subgroup of female therapists, we detected an inverse correlation between a higher probability of patients' personality disorders and feelings of closeness in the therapists. CONCLUSION: We did not detect a differential pattern of countertransference feelings associated with specific clinical characteristics. Therapists of both genders presented a similar pattern of feelings of empathy towards women victims of sexual violence, although the gender of the therapist may moderate the feelings evoked by patients with increased likelihood of personality disorders.

OBJETIVO: Identificar os correlatos demográficos e clínicos associados com sentimentos contratransferenciais de terapeutas na primeira consulta de mulheres vítimas de violência sexual. MÉTODO: Quarenta pacientes foram atendidas por 26 terapeutas, ao longo de dois anos consecutivos, no Núcleo de Estudos e Tratamento do Trauma Psíquico do Hospital de Clínicas de Porto Alegre, Brasil. Após a primeira consulta com a paciente, o terapeuta preenchia a Escala para Avaliação da Contratransferência. Os pacientes foram avaliados com a Escala Davidson de Trauma, a Standardized Assessment of Personality - Abbreviated Scale, o Inventário de Depressão de Beck, e a versão em português do Defense Style Questionaire. RESULTADOS: Os terapeutas apresentaram predominantemente sentimentos de proximidade (Mean = 5,42, SD = 1,25) em comparação aos sentimentos de indiferença (Mean = 1,82, SD = 1,22) e de distanciamento (Mean = 1,57, SD = 1,08) [p < 0,001]. As análises multivariadas revelaram a ausência de associações entre os sentimentos contratransferenciais e características clínicas dos pacientes. O gênero dos terapeutas não influenciou o padrão de sentimentos contratransferenciais. No subgrupo de terapeutas mulheres, detectamos uma correlação inversa entre alta probabilidade de transtornos de personalidade nos pacientes e sentimentos de aproximação dos terapeutas. CONCLUSÃO: Não detectamos um padrão diferencial de sentimentos contratransferenciais associados com características clínicas específicas. Terapeutas de ambos os gêneros apresentaram um padrão similar de sentimentos de empatia em relação a mulheres vítimas de violência sexual, embora o gênero do terapeuta possa moderar os sentimentos evocados por pacientes com alta probabilidade de transtornos de personalidade.

Countertransference in the initial visit of women victims of sexual violence.

OBJECTIVE: To identify demographic and clinical correlates associated with therapists' countertransference feelings on the first visit of women victims of sexual violence. METHOD: Forty patients were seen by 26 therapists, during 2 consecutive years, at the Center for the Study and Treatment of Psychological Trauma, Hospital de Clínicas de Porto Alegre , Brazil. After the first visit with the patient, the therapist completed the Assessment of Countertransference Scale and the patient was evaluated with the Davidson Trauma Scale, the Standardized Assessment of Personality - Abbreviated Scale, the Beck Depression Inventory, and the Defense Style Questionnaire. RESULTS: The therapists showed a predominance of feelings of closeness (Mean = 5.42, SD = 1.25) in relation to the feelings of indifference (Mean = 1.82, SD = 1.22) and distance (Mean = 1.57, SD = 1.08) [p < 0.001]. Multivariate analyses did not present significant associations between countertransference feelings and clinical characteristics of patients. The gender of the therapists did not influence the pattern of countertransference feelings. In the subgroup of female therapists, we detected an inverse correlation between a higher probability of patients' personality disorders and feelings of closeness in the therapists. CONCLUSION: We did not detect a differential pattern of countertransference feelings associated with specific clinical characteristics. Therapists of both genders presented a similar pattern of feelings of empathy towards women victims of sexual violence, although the gender of the therapist may moderate the feelings evoked by patients with increased likelihood of personality disorders.

Mentalization-based treatment for patients with borderline personality disorder: an overview.

OBJECTIVE: To describe the concept of mentalization, and its application in understanding the development of psychopathology in patients with borderline personality disorder; to give an account of the main features of mentalization-based treatment; to summarise the evidence supporting its effectiveness. DISCUSSION: Mentalization is a predominantly preconscious mental activity that enables the individual to understand him/herself and others in terms of subjective states and mental processes. Psychological trauma in childhood is associated with deficits in mentalization and with the development of borderline personality disorder. Mentalization-based treatment is a psychodynamically-oriented manualized psychotherapy for borderline personality disorder that aims to develop a therapeutic process in which the patient's capacity for mentalization becomes the focus of treatment. Randomized controlled trials have demonstrated the effectiveness of this treatment for patients with borderline personality disorder. CONCLUSIONS: The development of a psychodynamically-oriented therapeutic intervention that specifically targets the deficits involved in the psychopathology of borderline personality disorder is a crucial step in increasing the effectiveness of treatment. Mental health professionals should be adequately prepared to deliver effective interventions to their patients, such as mentalization-based treatment.

Mentalization-based treatment for patients with borderline personality disorder: an overview / Terapia de mentalização para pacientes com transtorno de personalidade borderline: uma atualização

OBJECTIVE: To describe the concept of mentalization, and its application in understanding the development of psychopathology in patients with borderline personality disorder; to give an account of the main features of mentalization-based treatment; to summarise the evidence supporting its effectiveness. DISCUSSION: Mentalization is a predominantly preconscious mental activity that enables the individual to understand him/herself and others in terms of subjective states and mental processes. Psychological trauma in childhood is associated with deficits in mentalization and with the development of borderline personality disorder. Mentalization-based treatment is a psychodynamically-oriented manualized psychotherapy for borderline personality disorder that aims to develop a therapeutic process in which the patient's capacity for mentalization becomes the focus of treatment. Randomized controlled trials have demonstrated the effectiveness of this treatment for patients with borderline personality disorder. CONCLUSIONS: The development of a psychodynamically-oriented therapeutic intervention that specifically targets the deficits involved in the psychopathology of borderline personality disorder is a crucial step in increasing the effectiveness of treatment. Mental health professionals should be adequately prepared to deliver effective interventions to their patients, such as mentalization-based treatment.

OBJETIVO: Descrever o conceito de mentalização e sua aplicação no entendimento do desenvolvimento da psicopatologia em pacientes com transtorno de personalidade borderline; descrever as principais características da terapia de mentalização; sumarizar as evidências que demonstram sua efetividade. DISCUSSÃO: Mentalização é uma atividade mental predominantemente pré-consciente que capacita o indivíduo a compreender a si mesmo e aos outros em termos de estados subjetivos e processos mentais. Trauma psicológico na infância está associado com déficits na capacidade de mentalização e com o desenvolvimento de transtorno de personalidade borderline. A terapia de mentalização é uma psicoterapia psicodinâmica manualizada para o tratamento de pacientes com transtorno de personalidade borderline. Seu objetivo é desenvolver um processo terapêutico no qual a capacidade de mentalização do paciente seja o foco do tratamento. Ensaios clínicos randomizados têm demonstrado sua eficácia no tratamento deste grupo de pacientes. CONCLUSÕES: O desenvolvimento de uma psicoterapia de orientação psicodinâmica que foque especificamente nos déficits envolvidos na psicopatologia do transtorno de personalidade borderline é um passo crucial para o aumento da efetividade do tratamento. Profissionais da área da saúde mental devem estar adequadamente preparados para oferecer intervenções efetivas aos seus pacientes, como a terapia de mentalização.

Contratransferência no atendimento inicial de vítimas de violência sexual e urbana: uma pesquisa qualitativa/quantitativa / Countertransference in the initial care of victims of sexual and urban violence: a qualitative-quantitative research

OBJETIVO: Avaliar a contratransferência dos terapeutas durante o atendimento inicial de pacientes mulheres vítimas de violência sexual e urbana, investigando a influência do gênero do terapeuta e da natureza e momento do trauma. MÉTODO: A amostra foi composta por 36 relatos redigidos por médicos residentes de psiquiatria do Hospital de Clínicas de Porto Alegre, oriundos do atendimento de 36 pacientes. Este estudo utilizou métodos qualitativos e quantitativos para a análise dos seus dados. Os relatos foram classificados em seis grupos, conforme o gênero do terapeuta e a natureza do trauma. Foi realizada a análise de conteúdo dos relatos. Associou-se uma análise estatística dos dados. RESULTADOS: Houve predomínio de sentimentos de aproximação nos terapeutas de ambos os sexos no atendimento de vítimas de violência sexual. Entre terapeutas mulheres, a natureza do trauma (sexual ou urbano) não influenciou os padrões contratransferenciais (p = 0,7). Entre os terapeutas homens, ao contrário, a natureza do trauma influenciou de forma significativa (p = 0,044) o padrão contratransferencial, havendo um número elevado de sentimentos de distanciamento nos relatos de atendimentos de vítimas de violência urbana. CONCLUSÕES: Houve um predomínio de sentimentos de aproximação dos terapeutas de ambos os sexos no atendimento inicial de pacientes vítimas de violência sexual. Foi observado um predomínio de sentimentos de distanciamento nos terapeutas homens que atenderam vítimas de violência urbana. Mais estudos são necessários para uma melhor compreensão das relações terapêuticas nos atendimentos de vítimas de trauma psíquico.

OBJECTIVE: To assess therapists' countertransference during initial care of female victims of sexual and urban violence with the aim of investigating influence of therapist's gender, type and moment of trauma. METHODS: The sample comprised 36 reports written by psychiatry residents at Hospital de Clínicas de Porto Alegre based on the care provided to 36 patients. This study used qualitative and quantitative methods of data analysis. Reports were classified into six groups according to therapist's gender and type of trauma. A content analysis and a statistical analysis of the data were performed. RESULTS: Therapists of both genders presented a prevalence of feelings of closeness when providing care to victims of sexual violence. Among female therapists, type of trauma (sexual or urban) did not have an influence on countertransference patterns (p = 0,7). On the other hand, among male therapists, type of trauma had a significant influence (p = 0,044) on countertransference, with a high rate of feelings of distance in reports of care provided to victims of urban violence. CONCLUSIONS: Therapists of both genders presented a prevalence of feelings of closeness when providing initial care to patients victims of sexual violence. Male therapists who provided care to victims of urban violence presented a prevalence of feelings of distance. Further studies are needed for a better understanding of therapeutic relationships in the care of victims of psychic trauma.

Contratransferência e trauma psíquico / Countertransference and psychic trauma

O objetivo deste artigo é revisar aspectos importantes da relação entre a contratransferência e o atendimento de pacientes vítimas de trauma psíquico. O tratamento de pessoas traumatizadas é potencialmente uma fonte de sofrimento psíquico também para os terapeutas, devido à grande carga emocional envolvida, bem como pelas chances de evocar fortes reações contratransferenciais. Um maior entendimento acerca deste processo poderá contribuir decisivamente para os resultados dos tratamentos, além de possibilitar a proteção e a prevenção da saúde mental dos terapeutas. Inicialmente, aborda-se o trauma a partir de seu conceito e definições, incluindo considerações sobre o transtorno de estresse pós-traumático, estendendo-se para a conceitualização de contratransferência e seu significado no contexto das situações traumáticas. O impacto de tratar pacientes vítimas de trauma será também exposto através da relevância do fenômeno de traumatização vicária, cuja compreensão vem sendo destacada como indispensável para um melhor atendimento de vítimas de traumas psicológicos.

This article aims at reviewing important aspects of the relationship between countertransference and care of patients who were victims of psychic trauma. The treatment of traumatized patients is a potential source of psychic suffering to their therapists as well, due to the emotional burden involved and to the chances of evoking strong countertransferential reactions. A better understanding of this process could be a valuable contribution to treatment outcome, besides promoting mental health protection and prevention for therapists. Firstly, psychic trauma will be approached from its concept and definitions, including considerations on posttraumatic stress disorder and extending to countertransference reactions and their meaning in the context of traumatic situations. The impact of treating trauma victims will also be discussed through the relevance of vicarious traumatization, a phenomenon whose comprehension has been pointed out as crucial to provide better care to psychological trauma victims.

Ausência paterna e sua repercussão no desenvolvimento da criança e do adolescente: um relato de caso / Father absence and its influence on child and adolescent development: a case report

A ausência paterna durante o desenvolvimento da criança e do adolescente é um tema complexo, com grandes possibilidades para estudo. É feita uma revisão da literatura a respeito do tema. Discute-se a influência da ausência paterna no desenvolvimento emocional, cognitivo e comportamental da criança e do adolescente. A participação da mãe nessas situações, do ambiente familiar como um todo e dos fatores sociais e econômicos como mediadores das conseqüências da ausência do pai na vida da criança são levados em consideração. Os autores apresentam o resumo de um caso clínico em que a ausência do pai é um ponto importante da vida do paciente. Ao longo do atendimento psicoterápico, foram surgindo as percepções e emoções do paciente associadas à ausência do pai.

Weekend holidays during methylphenidate use in ADHD children: a randomized clinical trial.

OBJECTIVE: The aim of this study was to assess whether weekend drug holidays during methylphenidate (MPH) administration would change the efficacy and tolerability to the medication in male children with Attention-Deficit Hyperactivity Disorder (ADHD). METHODS: In a 28-day, double-blind study, children with diagnoses of ADHD were randomized to receive BID MPH for 7 days a week (n = 21) or to receive BID MPH on weekdays and a placebo on weekends (n = 19). Parents completed the Conners' Abbreviated Rating Scale (ABRS) to assess ADHD symptoms and the Barkley's Side Effect Rating Scale (SERS) to assess side effects on weekends. Teachers completed the ABRS on each Monday after weekends. RESULTS: Both groups showed a significant reduction on the ABRS over time as the dose was increased. However, the group difference in the ABRS scores was not statistically significant, either on weekend parent ratings (at the endpoint, p = 0.41; effect size = 0.26) or on teachers' ratings (at the endpoint, p = 0.99; effect size = 0.002). The omission of MPH on weekends was associated with significantly less severity of insomnia (F = 3.96, d.f. = 1, p = 0.05) and a trend for less interference on appetite (F = 3.18, d. f. = 1, p = 0.08). CONCLUSION: Our findings suggest that weekend holidays during MPH administration reduce the side effects of insomnia and appetite suppression without a significant increase in symptoms, either on weekends or in the first school day after them. Possible explanations for these findings (rate-dependent response or impact of demands of the environment) are discussed in this paper.

Interrater agreement for the schedule for affective disorders and schizophrenia epidemiological version for school-age children (K-SADS-E).

OBJECTIVE: The main objective of this study was to assess the interrater agreement for the Schedule for Affective Disorders and Schizophrenia Epidemiological version for School-Age Children (K-SADS-E). METHODS: Four interviewers being trained with the K-SADS-E scored independently 29 videotaped interviews performed with psychiatric outpatients in the ADHD Outpatient Clinic at Hospital de Clínicas de Porto Alegre. Interrater agreement analysis was performed using the kappa coefficient (k). RESULTS: Kappa coefficients were.93 (p<.001) for affective disorders,.9 (p<.001) for anxiety disorders,.94 (p<.001) for attention-deficit/hyperactivity disorders and disruptive behavior disorders. CONCLUSION: These findings suggest an excellent interrater agreement for the diagnosis of several mental disorders in childhood and adolescence by the Brazilian Portuguese version of the K-SADS-E.

Is the alpha-2A adrenergic receptor gene (ADRA2A) associated with attention-deficit/hyperactivity disorder?

Attention-Deficit/Hyperactivity Disorder (ADHD) is a complex childhood-onset psychiatric disorder characterized by marked symptoms of inattention, hyperactivity, and impulsivity. The role of genetic factors in its etiology is strongly supported by family, adoption, and twin studies. Although most of the molecular studies have investigated the dopamine D4 receptor gene (DRD4) and the dopamine transporter gene (DAT1) genes in its etiology, pharmacological and brain imaging evidences seem to indicate that genes of the adrenergic system could also be attractive for association studies. We investigated a sample of 96 Brazilian ADHD children and adolescents and their parents for the ADRA2A MspI polymorphism. Although no association with either MspI allele was observed through the haplotype relative risk (HRR) analysis, effects of the ADRA2A gene on inattention and combined (inattention + hyperactivity/impulsivity) symptom scores were detected (U = 222.5, z = 2.19, P = 0.03; and U = 208.5, z = 2.32, P = 0.02, respectively). Our results suggest that the ADRA2A gene might have a small effect on ADHD susceptibility or that this gene might modulate the severity of the disorder. They are also consistent with the noradrenergic theories of ADHD, suggesting a role for the alpha2A adrenergic receptors in the disorder.

Interrater agreement for the schedule for affective disorders and schizophrenia epidemiological version for school-age children (K-SADS-E)

OBJETIVE: The main objective of this study was to assess the interrater agreement for the Schedule for Affective Disorders and Schizophrenia Epidemiological version for School-Age Children (K-SADS-E). METHODS: Four interviewers being trained with the K-SADS-E scored independently 29 videotaped interviews performed with psychiatric outpatients in the ADHD Outpatient Clinic at Hospital de Clínicas de Porto Alegre. Interrater agreement analysis was performed using the kappa coefficient (k). RESULTS: Kappa coefficients were .93 (p<.001) for affective disorders, .9 (p<.001) for anxiety disorders, .94 (p<.001) for attention-deficit/hyperactivity disorders and disruptive behavior disorders. CONCLUSION: These findings suggest an excellent interrater agreement for the diagnosis of several mental disorders in childhood and adolescence by the Brazilian Portuguese version of the K-SADS-E

Estimated mental retardation and school dropout in a sample of students from state public schools in Porto Alegre, Brazil

OBJECTIVES: To assess the association between estimated Mental Retardation (MR) and school dropout in a sample of students of the third and fourth grades at state schools in Porto Alegre, the capital of the southernmost state of Brazil. METHOD: In this case - control study, students that dropped out from schools (n=44) and a control group who continued attending schools (n=44) had their intelligence quotient (IQ) determined by the vocabulary and cubes subtests of the Wescheler Intelligence Scale ¾ third edition (WISC¾III). Students with IQ lower than 70 were considered as potential cases of MR. Other prevalent mental disorders in this age range were assessed in both groups using the Schedule for Affective Disorders and Schizophrenia for School¾ Age Children, Epidemiological Version (K-SADS-E). RESULTS: The prevalence of potential MR was significantly higher in the dropped out group than in the control group (p<0.001). Odds ratio for school dropout was significantly higher in the presence of MR even after controlling for potentially confounding factors (age, conduct disorder, grade repetition, family structure and income) (p<0.01). CONCLUSION: Children with IQ lower than 70 (potential MR) were at higher risk for school dropout. These children need to be identified at school and specific educational strategies should be implemented to assure their inclusion in the learning process

Further evidence for the association between attention-deficit/hyperactivity disorder and the dopamine-beta-hydroxylase gene.

Attention-deficit/hyperactivity disorder (ADHD) is a very common and heterogeneous psychiatric disorder of childhood with marked inattentive, hyperactive, and impulsive symptoms. The DBH gene, the locus that encodes the enzyme dopamine-beta-hydroxylase (DbetaH), seems to be an important candidate gene for association studies, since DbetaH catalyzes the conversion of dopamine to norepinephrine. The aim of this study was to test for association between the DBH gene and ADHD in a sample of 88 Brazilian nuclear families. Haplotype relative risk (HRR) analysis of the DBH TaqI restriction site polymorphism showed a preferential transmission of the TaqI A2 allele in our whole ADHD sample (chi(2)=3.61, one-tailed P=0.03). The significant effect of the A2 allele was stronger when only families with no ADHD parental diagnosis were considered (chi(2)=5.42, one-tailed P=0.01). Our results suggest a contribution of this gene to ADHD susceptibility, partially replicating previous findings that have demonstrated an association between the DBH TaqI A2 allele and ADHD.

O médico, o estudante de Medicina e a morte / The doctor, the medical student and death

O presente trabalho tem como objetivo discutir algumas idéias a respeito da morte e do morrer e refletir sobre a presença da morte em nossa vida e na prática médica. Os autores revisam várias contribuições psicanalíticas sobre o significado da morte individualmente e das suas expressões na cultura ocidental. Destacam que as dificuldades que o indivíduo encontra ao elaborar sua própria morte se refletem no modo como a sociedade contemporânea, na qual se incluem os médicos de um modo geral, reage frente ao morrer...

Pesquisa em psiquiatria da infância e da adolescência / Research on child and adolescennt psychiatry

A presente revisão busca avaliar criticamente: a) a situação da pesquisa em psiquiatria da infância e da adolescência nos EUA e no Brasil; b) as razões do desinteresse do psiquiatra de crianças e adolescentes em pesquisas e, mais ainda, nos resultados de pesquisa; c) as áreas de pesquisa em Psiquiatria da Infância e da adolescência e suas dificuldades; d) questões éticas de pesquisa nesse campo.