ACADEMY FORUM - The American Academy of Psychoanalysis and Dynamic ...

2011 in Rome was particularly auspicious. This was the weekend
that Prime Minister Berlusconi resigned and we learned
that Mario Monti would likely replace him. There was much
celebration in appreciation of this event. As my taxi driver happily
announced, “We are free!”
As a result of the Joint Meetings with OPIFER, more than
14 Italian psychiatrists have joined the Academy. These Italian
members have included such prominent psychiatrists as Dr.
Adolfo Pazzagli, the past Chair of the Psychiatry Department at
the University of Florence, and Dr. Giovanni Corsini, the preeminent
psychopharmacologist in Italy. Additionally, because of
their participation in the Joint Meetings, at least five American
psychiatrists became Academy members, including Drs. David
Lopez, Sandra Park, Craig Katz, and Charles Nemeroff. Dr.
Modasser Shah who enthusiastically attended the Rome meeting,
has recently become an Academy member. Welcome Dr. Shah!
19 th Annual CPRinc Research Conference
by Gerald P. Perman, M.D., CPRinc Trustee
10
The Consortium for Psychoanalytic
Research (CPRinc) held its
19 th Annual Research Conference
at the George Washington University
Hospital in Washington, D.C.
on Sunday, February 5, 2012. J.
Christopher Fowler, Ph.D., Associate
Director of Clinical Research
at the Menninger Department of
Psychiatry at the Baylor College
of Medicine in Houston, TX presented
“Blind Men, Elephants and Psychotherapy Effectiveness:
Skewed Views of Treatment Realities & How to Fix Them.” The
CPRinc is made up of 12 Baltimore-Washington area mental
health organizations and its purpose is to build a bridge between
clinicians and clinically relevant research. The Academy
provides the CME credits for physicians attending this de facto
winter Academy meeting.
Introduction
Bonnie Gallagher, M.S.W., L.I.C.S.W., President of the CPR,
welcomed and introduced Dr. Fowler. Prior to the formal opening,
participants had completed the study instruments, assisted
by Dr. Fowler and CPRinc Trustees.
Grasping the Complexity of Co-Morbidity
The morning session began with Dr. Fowler orienting the
audience to the complexity of the concept of co-morbidity and
the search for underlying mechanisms to guide interventions to
the study instruments. Dr. Fowler began his formal presentation
with a discussion of the metaphor of blind men and elephants.
He offered several caveats. Medication trials are often performed
on patients with a single disorder and without comorbid disorders.
This is often not the clinician’s experience with patients
in the real world. When treatment brings insufficient relief, it is
the medical profession’s responsibility to identify the barriers to
effective treatment, to assess for early detection of prodromal
TR markers, and to develop treatment augmentation strategies.
Fowler cited three vanguard CBT controlled TR studies: (1) TR
to medication among patients with schizophrenia; (2) TR with
patients with recurrent depression; and (3) TR in patients with
borderline personality disorder (BPD). All showed only modest
success. This is similar to other medical conditions.
TR disorders are currently categorized in a unitary, “yes – no”
manner in the DSM-IV, without taking into account severity
of illness and functional impairment. There is no classification
system or assessment method to identify individuals at risk for
TR across diagnostic categories. Fowler wanted to provide evidence
for a spectrum of TR psychiatric illness that cut across
diagnostic categories as well as adding a new category. Cross
cutting markers included: (1) multiple co-morbid diagnoses;
(2) a history of failed partial responses to treatment; (3) interpersonal
impairment; (4) role performance impairment; and
(5) self-defeating and self-destructive behaviors. Having any
or several of these markers makes for a poorer prognosis and
moves beyond Freud’s idea of whether the patient has sufficient
“motivation for change.”
State of the Art of Treatment
Under optimal conditions, random controlled trials and efficacy
studies show inadequate treatment responses, 15% to 50%
of the time for single disorders and more frequently for complex
disorders. One study showed that 72% of psychiatric patients
have co-morbidity. Problems abound in defining TR for any
single disorder and this problem is not unique to psychiatry, e.g.
TR epilepsy. In the STAR-D Study, no treatment outperformed
any other among various medications and psychotherapies. One
definition of TR: suboptimal improvement in target symptoms of
less than 50% and failure to return to baseline despite adequate
dose and duration of known effective treatment.
Treating single disorders minimizes complexity but can miss
the existence of co-morbidity. Categorical diagnoses obscure
severity and functional impairment. The DSM-V workgroup
for personality disorders has proposed a dimension of severity.
It has shown that co-morbid, multiple, and borderline personality
disorders (BPD) increases the risk of poor outcome.
Pre-treatment characteristics of patients with BPD that predict
worse outcomes include: more severe psychopathology, greater
functional impairment, interpersonal relationship instability and
a history of childhood trauma.
Fowler cited numerous studies indicating possible pathogenic
factors of TR that included: genetics (e.g. side effects of SSRIs
and mood instability), temperament (ability to delay gratification),
impaired relationship function, poor therapeutic alliance,
and lack of expectation of cure (trust and positive expectancy).
Placebos accounted for 75% of improvement of active drugs
with only a two point improvement on a semi-structured interview
in a second meta-analysis of many studies. This has drawn
expectable fire from pharmaceutical companies. Also, the sicker
the patient, the more the active medication is effective. Placebo
is a misnomer since both placeboes and opioid drugs activate
the rostral anterior cingulate cortex (ACC) and pons. The ACC
has also been shown to be the “seat of transference.”
Part of negative outcomes may be due to the nocebo response,
i.e. 19% of patients receiving placeboes reported side effects in