The ‘strange situation’ has been utilized to depict different attachment styles exhibited by infants, with contributions from Bowlby’s observations of primate and human attachment behavior, Bateman’s work on psychotherapeutic models in personality disorder, Freud’s structural theory of the unconscious, and Jung’s exploration of archetypes and the collective unconscious.

Erikson’s psychosocial theory of development includes eight stages of crises, while Freud’s psychosexual theory of development consists of five stages. However, there is some overlap between the two theories. For example, Freud’s phallic stage, which focuses on the development of sexual identity, broadly coincides with Erikson’s ‘initiative versus guilt’ stage, which focuses on the development of a sense of purpose and direction.

Erikson’s stages are as follows: trust vs. mistrust (0-18 months), autonomy vs. doubt (18-36 months), initiative vs. guilt (3-6 years), competence vs. inferiority (6-12 years), identity vs. confusion (12 years to adulthood), intimacy vs. isolation (adulthood), generativity vs. stagnation (middle-age), and integrity vs. despair (maturity).

Freud’s stages are: oral (0-18 months), anal (18-36 months), phallic (3-6 years), latency (6-12 years), and genital (12 years to adulthood).

While there are similarities between the two theories, it is important to note that they approach development from different perspectives and emphasize different aspects of human growth and development.

Transitional objects were conceptualized by Winnicott as items that infants between 4-18 months of age select to aid in their separation and individuation process. These objects, such as a soft toy of blanket, serve as a source of comfort and help reduce anxiety. Object relations theory was also supported by Balint and Fairbairn. Meanwhile, Kleinian theory placed significant emphasis on the interpretation of play.

Malan’s research centered on the development of the client’s challenges using two ‘triangles’ – the triangle of person and the triangle of defence. Bowlby is recognized for his work on attachment theory, while Anna Freud is known for her work on defence mechanisms and object relations. Sigmund Freud is linked to time-limited psychotherapies, and Ryle created cognitive analytic therapy.

Engrossment refers to the emotional connection that a father develops with his child. This term was coined by Greenberg and Morris in their 1974 study, which explored the impact of newborns on fathers. In contrast, Bowlby used the term ‘attachment’ to describe the bond that develops between a child and their mother. Bonding, on the other hand, refers to the process by which a mother develops a strong emotional connection with her child. Imprinting is a phenomenon observed in some animal species, where newborns acquire certain behavioral characteristics from their parents shortly after birth. Finally, sociability is a crucial aspect of attachment, as it involves the pursuit of social contact and connection with others.

Brain Regions and Functions

The brain is a complex organ with various regions that perform different functions. One of the key regions involved in the reward system is the nucleus accumbens (NA). This region receives input from the ventral tegmental area, which uses dopamine as a neurotransmitter. The NA is responsible for processing reward-related information and is often referred to as the pleasure center of the brain.

The limbic cortex, on the other hand, is not part of the reward circuit. It is involved in emotion, memory, and motivation.

Another important gland in the brain is the pituitary gland. This endocrine gland secretes nine hormones that are involved in maintaining homeostasis in the body.

The substantia nigra is part of the basal ganglia and is involved in movement, learning, and addiction. Although it has a role in reward-seeking, it is not considered to be part of the classic reward pathway.

Finally, the tegmentum is a region of the brainstem that contains several cranial nerve nuclei. It is involved in various functions such as movement, sensation, and autonomic control.

Principles of Therapeutic Communities

Therapeutic communities are based on four main principles that guide their operations. The first principle is communalism, which emphasizes that staff and service users should not be separated by uniforms of behaviours. This means that everyone in the community is treated equally and with respect. The second principle is democratisation, which involves shared decision-making and unit management. This means that everyone in the community has a say in how things are run and decisions are made collectively. The third principle is permissiveness, which involves accepting and tolerating occasional unpredictable behaviour. This means that members of the community are encouraged to be themselves and express their emotions freely. The fourth principle is reality confrontation, which involves group members challenging self-deception among others. This means that members of the community are encouraged to be honest with themselves and others.

Group cohesion is another important aspect of therapeutic communities. It refers to the sense of belonging and acceptance that members of the community feel. This sense of belonging is fostered by the shared goal that the community is working towards. Members of the community understand that they are all in this together and that they need to support each other to achieve their goals. The sense of belonging and acceptance that comes with group cohesion is essential for the success of therapeutic communities.

The Millon Clinical Multiaxial Inventory-III (MCMI-III) is a self-report questionnaire that can be utilized to evaluate personality disorders. It is designed to provide information on a patient’s personality traits, clinical syndromes, and overall psychological functioning.

The Cambridge Neuropsychological Test Automated Battery (CANTAB) is a computer-based cognitive assessment system that measures various cognitive functions such as attention, memory, and executive function. It is commonly used in research and clinical settings to assess cognitive impairment in patients with neurological disorders.

The Hayling-Brixton tests are neuropsychological tests that evaluate executive function, specifically response inhibition and initiation. These tests are often used to assess patients with brain injuries of neurological disorders.

The Luria-Nebraska Battery is a comprehensive neuropsychological battery that assesses various functions such as motor skills, memory, rhythm, reading, and writing. It is commonly used to evaluate patients with brain injuries of neurological disorders.

The Stanford-Binet test is an intelligence test that measures cognitive abilities such as verbal and nonverbal reasoning, spatial perception, and quantitative reasoning. It is commonly used in educational and clinical settings to assess intellectual functioning.

For further reading on these assessments, additional information can be found through Pearson, the publisher of the MCMI-III.

While adherence, compliance, and capacitance all refer to how well a patient follows a doctor’s instructions, they do not have the same meaning as concordance, which specifically refers to the agreement between patient and doctor on a treatment plan.

The Henderson hospital model exemplifies the four principles that underlie the therapeutic community, which include communalism, permissiveness, democratisation, and reality confrontation. These principles are reflected in the way staff and inmates interact, with a focus on mutual support and learning, tolerance of unpredictable behavior, shared decision-making, and open and honest communication about distortions from reality.

Assessment Tools:

Luria’s Test:
Luria’s test is a motor task designed by Alexander Luria, a Russian neuropsychologist. The test was developed based on his observation that individuals with significant frontal lobe damage were unable to modify their responses to a programmed motor task when the order of actions in the task was changed.

Geriatric Depression Scale:
The Geriatric Depression Scale is a screening tool used to identify depression in older adults. It is not designed to assess cognitive impairment.

Mini-Mental State Examination:
The Mini-Mental State Examination is a brief, 30-question screening tool used to assess cognitive impairment. It does not evaluate frontal lobe functions.

National Adult Reading Test:
The National Adult Reading Test is used to assess the premorbid level of intelligence in English-speaking patients.

Wechsler Adult Intelligence Scale:
The Wechsler Adult Intelligence Scale is a comprehensive assessment tool used to measure intelligence in adults and older adolescents.

Irvin Yalom identified 11 therapeutic factors that are unique to group therapy, including universality, altruism, instillation of hope, imparting of information, corrective recapitulation of the primary family group, development of socializing techniques, imitative behavior, group cohesiveness, existential factors, catharsis, and interpersonal learning. Group therapy has been practiced by various pioneers in the field, such as Bion at the Tavistock Clinic, Foulkes who developed group analysis, Moreno who is associated with psychodrama, and Pratt who was an early advocate of group therapy in the United States.

Behaviour change theories can be categorized into two main groups: social cognition models and stage models. Stage models involve progression through specific stages, while social cognition models focus on beliefs and attitudes as drivers of behaviour change. Examples of social cognition models include the health belief model, protection motivation theory, and self-efficacy theory.

The concept of recovery in mental disorder goes beyond symptom resolution and focuses on developing a rewarding and meaningful life while accepting the impact of mental distress on the self. Clinical remission, on the other hand, refers to the cessation of symptoms and is often measured through clinical outcome scales. Chronic psychosis is the ongoing experience of psychotic symptoms. Recovery in mental disorder is a rephrasing of the conventional medical definition of remission and recognizes the need for a holistic approach to treatment while still involving clinicians and allied professionals. For further reading, Anthony’s Recovery From Mental Illness and Davidson and Roe’s Recovery from versus recovery in serious mental illness offer valuable insights.

The recommended treatment for emotionally unstable personality disorder (borderline type) does not involve a single psychological therapy of drug treatment as a first line of defense. However, for women who prioritize reducing self-harm, DBT is recommended. Drug treatments may be considered for comorbid conditions. According to NICE guidelines on Borderline personality disorder (BPD) (CG78), a comprehensive dialectical behaviour therapy programme should be considered for women with borderline personality disorder who prioritize reducing recurrent self-harm. Brief psychological interventions of less than 3 months’ duration should not be used specifically for borderline personality disorder of for the individual symptoms of the disorder. Drug treatment should not be used specifically for borderline personality disorder of for the individual symptoms of behavior associated with the disorder, such as repeated self-harm, marked emotional instability, risk-taking behavior, and transient psychotic symptoms. If sedatives are used for crisis intervention in a patient with EUPD, they should be prescribed for a maximum period of one week.

Recent clinical trials have shown that various psychotherapy approaches do not differ significantly in terms of effectiveness. This particular trial aimed to prove that psychodynamic psychotherapy was not inferior to other modalities at 22 weeks and one year follow-up. While non-inferiority was observed at 22 weeks, it could not be conclusively demonstrated at one year, despite no significant difference between interventions. Interestingly, individuals who received CBT appeared to require more additional treatment during the year following therapy, although this trend was not statistically significant.

Frontal lobe pathology can result in the elicitation of frontal release signs, such as palmomental reflexes. Ataxia may be present in conditions like normal pressure hydrocephalus, while cogwheel rigidity is commonly found in extrapyramidal syndromes. Contralateral hemisphere dysfunction can lead to postural arm drift. These signs occur when the frontal lobe’s normal inhibition of these responses is released. For more information, see Kipps and Hodges’ article Cognitive assessment for clinicians.

Expressed emotion (EE) in schizophrenia was first introduced by Brown et al., which refers to the emotions exhibited by family members towards their loved one with the illness. The James-Lange theory is one of two fundamental theories of emotions, alongside the Cannon-Bard theory. Fromm-Reichmann coined the term ‘schizophrenogenic mother.’ Harris proposed a model of emotional development consisting of five stages. Plutchik identified eight primary emotions.

The term ‘schizophrenogenic mother’ was proposed by Fromm-Reichmann, a contemporary of Freud, who believed that defective parenting caused the disorder. However, this concept has since been proven to be unfounded. Lidz later examined the impact of parents’ socialization on a child’s psychological health, further exploring this concept. Bleuler is credited with coining the term ‘schizophrenia’, while Kraepelin had previously described ‘dementia praecox’.

It is estimated that around 10% of individuals diagnosed with borderline personality disorder will ultimately take their own lives. While there may be some variation in the findings of different studies, this figure is widely accepted as the general rate of completed suicide among this population over an extended period of time.

The culture of empowerment in a therapeutic community involves democratisation, which is demonstrated through voting, decision-making, and achieving seniority. This is essential in developing an individual’s sense of agency and ability to carry out meaningful actions. Rapoport’s four principles, which define the work of a therapeutic community, include permissiveness, democracy, reality confrontation, and communalism. These principles are updated by Haigh, with containment corresponding to permissiveness, communication to communalism, involvement to reality confrontation, and agency to democracy. Overall, the therapeutic community aims to provide support, establish rules and boundaries, confront reality, and foster a sense of shared responsibility among its members.

The Drug Attitude Inventory assesses the subjective effects of antipsychotic drugs in patients with schizophrenia. The ASK-20 Adherence Barrier Survey measures barriers to treatment adherence with 20 clinical items. The Brief Evaluation of Medication Influences and Beliefs (BEMIB) Scale is an eight-item Likert-type scale that evaluates the costs and benefits of medication use based on the health belief model. The Medication Adherence Rating Scale (MARS) is a 10-item self-report scale that combines elements of the Drug Attitude Inventory and Medication Adherence Questionnaire for use in patients with schizophrenia and psychosis. The Rating of Medication Influences (ROMI) Scale is a 20-item interviewer-rated scale that assesses adherence attitudes in psychiatric patients, particularly those with schizophrenia, with good inter-rater reliability.

Patients who are not informed about the potential side effects of a medication may initially agree to treatment, but are less likely to follow through if they experience adverse effects. To improve adherence, healthcare providers can implement various strategies. These include educating patients about the treatment, discussing the benefits and drawbacks of different options, and promoting insight into the importance of prophylactic treatment. Encouraging patients to be open about any side effects they experience, even if they are embarrassing, can also help. Regular reviews of the medication plan, including discussions about side effects and the possibility of stopping medication if necessary, can further improve adherence. Simplifying the medication regimen and choosing medications with tolerable side effect profiles can also be helpful. Communication between the patient and their GP should be clear and in writing. Finally, the use of depot antipsychotics may be considered as an option.

Harry Harlow conducted controversial experiments with rhesus macaque monkeys and surrogate ‘mothers’ made of inanimate objects, revealing that the infants preferred comfort and warmth over food.
Mary Ainsworth created the Strange Situation classification to categorize infants’ attachment behaviors.
John Bowlby coined the term ‘attachment’ to describe a child’s bond with their mother.
Konrad Lorenz studied imprinting in geese that were hatched in incubators.
Mary Main played a role in the development of the Adult Attachment Interview, which evaluates an individual’s early attachment experiences.

Strategic systemic therapy incorporates reframing and the domino effect. Haley’s approach assumes that symptoms are perpetuated by attempts to suppress them, and reframing involves giving negative emotions of behaviors a positive connotation. The domino effect refers to the improvement of additional problems after resolving an initial issue. Bowen’s family systems approach emphasizes the patient’s ability to maintain their individuality amidst familial tension. The Milan systemic approach uses circular questioning among family members, while Bateson’s paradoxical therapy involves intentionally engaging in undesirable behaviors. Minuchin’s structural model prioritizes the family hierarchy, rules, and boundaries.

The psychosocial theory of development, as described by Erikson, involves eight stages that continue into adulthood and require the resolution of a crisis at each stage. Bowlby is known for attachment theory and maternal deprivation, while Freud focused on psychosexual development. Kohlberg studied moral development, and Piaget developed the cognitive model of development.

The recommended treatment options for obsessive-compulsive disorder and body dysmorphic disorder, according to NICE guidelines, include the use of selective serotonin reuptake inhibitors (SSRIs) of cognitive behavioural therapy (CBT), of a combination of both. Other therapies such as cognitive analytical therapy, interpersonal therapy, and psychodynamic psychotherapy have not been found to have sufficient evidence to support their use in managing OCD. Additionally, referral to an anxiety management group would not provide targeted treatment for OCD.

René Spitz’s Study on Anaclitic Depression in Children

René Spitz conducted a study on children who were deprived of their primary caregiver and found that they experienced a type of depression known as anaclitic depression. This type of depression is characterized by a lack of interest in the environment, a decrease in physical activity, and a failure to thrive. Spitz’s study highlights the importance of a primary caregiver in a child’s development and the negative effects of deprivation on their emotional and physical well-being. The study emphasizes the need for children to form secure attachments with their caregivers to promote healthy development.

The reverse-learning theory, which explains how the brain eliminates unnecessary information, was introduced by Crick and Mitchison. Foulkes believed that dreams reflect a person’s current preoccupations, while Freud viewed them as a means of expressing repressed thoughts and desires, famously calling them the royal road to the unconscious. Hobson and McCarley proposed the activation-synthesis theory. Jung was known for his work on dreams and symbolism, and his autobiography was titled Memories, Dreams, Reflections.

The health belief model is a social cognition model that aims to predict and understand health-related behaviors. It consists of four main constructs: perceived susceptibility, perceived severity, perceived benefits, and perceived barriers. Perceived severity refers to an individual’s understanding of the seriousness of a disease. Perceived susceptibility, also known as perceived vulnerability, refers to an individual’s perception of their risk of contracting the disease if they continue with their current behavior. Perceived benefits refer to an individual’s perception of the advantages of adopting a different course of action, including the extent to which it reduces the risk of the disease of its severity. Perceived barriers refer to an individual’s perception of the disadvantages of adopting the recommended action, as well as any obstacles that may hinder its successful implementation.