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Anxiety and depressive disorders are both associated with abnormalities in the processing and regulation of emotion. However, little is known about the similarities and differences between anxiety and depression at the neural level. The authors examined emotional conflict processing using a salient stimulus associated with observable and interpretable behavioral outcomes and with activation in limbic and prefrontal regions implicated in anxiety and depression.Thirty-two healthy comparison subjects, 18 patients with generalized anxiety disorder only, 14 patients with major depression only, and 25 patients with comorbid generalized anxiety disorder and major depression were studied using functional MRI while they performed an emotional conflict task that involved categorizing facial affect while ignoring overlaid affect label words. The authors used behavioral and neural measures to compare trial-by-trial changes in conflict regulation, a test of implicit regulation of emotional processing.Behavioral data indicated that only patients with generalized anxiety (i.e., the anxiety-only and comorbid groups) failed to implicitly regulate emotional conflict. By contrast, deficits in activation and connectivity of the ventral anterior cingulate and amygdala, areas previously implicated in regulating emotional conflict, were found in all patient groups. Depression-only patients, however, compensated for this deficit by also activating the left and right anterior lateral prefrontal cortices, in which activity was correlated with behavioral evidence of successful implicit regulation, thus mediating the disorder-specificity of the behavioral phenotype.These data support the existence of a common abnormality in anxiety and depression in the ventral cingulate and the amygdala, which may be related to a shared genetic etiology. Compensatory engagement of cognitive control circuitry in depression illustrates how the complex nature of psychopathology arises from the interaction of deficits and compensation, all of which can occur at an implicit level.

The authors examined the risk that family disruption and low socioeconomic status in early childhood confer on the onset of major depression in adulthood.Participants were 1,104 offspring of mothers enrolled during pregnancy in the Providence, R.I., site of the National Collaborative Perinatal Project. Measures of childhood family disruption and socioeconomic status were obtained before birth and at age 7. Structured diagnostic interviews were used to assess respondents' lifetime history of major depressive episode between the ages of 18 and 39. Survival analysis was used to identify childhood risks for depression onset.Parental divorce in early childhood was associated with a higher lifetime risk of depression among subjects whose mothers did not remarry as well as among subjects whose mothers remarried. These effects were more pronounced when accompanied by high levels of parental conflict. Independent of the respondents' adult socioeconomic status, low socioeconomic status in childhood predicted an elevated risk of depression.Family disruption and low socioeconomic status in early childhood increase the long-term risk for major depression. Reducing childhood disadvantages may be one avenue for prevention of depression. Identification of modifiable pathways linking aspects of the early childhood environment to adult mental health is needed to mitigate the long-term consequences of childhood disadvantage.

This study tested the hypothesis that frontal error negative wave amplitude on EEG during Stroop test activation predict change in depressive symptoms in depressed elders.Twenty-two older patients with major depression received controlled treatment with citalopram at a target dose of 40 mg/day for 6 weeks. Paramedian error negative waves were recorded during Stroop activation before treatment.Nine subjects who remained symptomatic had larger left frontal error negative waves than the subjects who achieved remission. Left frontal error negative waves were correlated with percent change of depressive symptoms from baseline. Other paramedian error negative waves did not distinguish remitted from unremitted subjects. Left frontal error negative waves were negatively correlated with Mattis Dementia Rating Scale scores for initiation/perseveration; these scores were lower in unremitted than remitted patients.Increased left frontal error negative waves are associated with limited or slow change in depressive symptoms in elders receiving citalopram.

The author presents a new concept of the term "body image." He also introduces the term "extraneous body image," i.e., one's mental representation of others' appearance and behavior. The formation of one's own and extraneous body images and their role in the development of self-concept, concept of others, interpersonal relationships, and mind-body interactions, as well as their clinical implications, are discussed.

The authors suggest that addicts' use of opiates represents a unique and characteristic way of dealing with ordinary human problems and the real world around them. Through five case reports they illustrate how addicts resort to drugs because they have failed to develop symptomatic, characterologic, or other adaptive solutions to stress. In addition, they describe how the pseudoculture of the addict also plays a part infilling his social vacuum and providing an alternative to the establishment of meaningful attachments to other people. The implications for treatment are considered.

This study examines the different impact of work on the physical and psychological health of women and men: how men and women in business and managerial professions perceive the pressures of their work environments and what the consequences (e.g., depression, anxiety, somatic complaints, and drug and alcohol abuse) of these stresses are for the individual. The results indicate significant differences between the working men and women studied in job tension, coping strain, role conflict, and health status but not in styles of coping. (AmJ Psychiatry142:1174-1178, 1985) personal conflict, and the second related to the strain precipitated by attempts to integrate career and family responsibilities. We hypothesize that men and women differ in the way they perceive the stresses related to their jobs, how they respond to these stresses, and the physical and psychological manifestations of workrelated stress. This study, therefore, looks at the mdividuat’s perception of the pressures of work environments and the consequences of these pressures, such as depression, anxiety, somatic complaints, and drug and alcohol abuse.

Using the SCL-90, a self-administered symptom inventory, the authors evaluated 48 sexually asymptomatic male and female partners (invested partners) of sexually dysfunctional men and women. They found that the male invested partners showed significantly more psychological symptoms than the female invested partners but about the same symptom distress levels as sexually dysfunctional men. The authors hypothesize that the reason for this gender-specific difference in distress levels of invested partners is society's definition of the male's role as the responsibe partner regarding satisfaction in sexual relationships.

The authors propose that oscillations of attachment in borderline personality disorder stem from a central problem with regulation of interpersonal distance. This problem derives from borderline patients' conflicts between fears of abandonment and domination. When they move closer to others, they fear that they will be dominated; when they move away, they fear that they will be abandoned. Whichever direction they move, they experience negative feedback. This gives rise to recurrent oscillations between attachment to and detachment from others. Because the oscillations are reinforced by the ambivalent reactions of significant others and the involvement of third parties, family therapy is often indicated.

An angry conflict erupted between male and female psychiatric residents when 3 of 12 residents at a major training center become pregnant in the second year of training. The author explores the fantasies and feelings that fueled this conflict from the points of view of intrapsychic and group dynamics. Problems within the institution are seen as providing the context for the residents' conflicts aroused by the event of pregnancy.

As the family child-rearing life cycle unfolds, puberty sets in motion processes within the adolescent and the family that initiate an adolescent family developmental epicycle. An integral aspect of this epicycle is a temporary regression in sibling, marital, and family functioning, reflecting a creative return to earlier modes of experience and behavior. This normal regression provides the empathetic interpersonal framework within which family members get in touch with, share, and facilitate adolescent development—while at the same time growing themselves as individuals and as a family unit.

The author discusses ethical problems specific to practice with adolescents, a patient group which has special requirements in terms of their relations with authority figures and the kind and degree of external control they need. The psychiatrist who works with adolescents must be aware that his or her actions, attitudes, and personality can be crucial influences in the young person's development. Particular attention is needed in the areas of confidentiality, informed consent, and the impact of behavior control and other treatment techniques on adolescents.

The authors describe a modification of systematic desensitization that they developed which uses a psychodynamic formulation as the basis for treatment along behavioral lines. The technique, illustrated by the authors through case reports, involves efforts to relieve the patient's anxiety arising in connection with unacceptable impulses or with irrational prohibitions against these impulses.

The authors administered a questionnaire including statements regarding controversies in psychiatric education to 86 residents in six programs in the Washington, D.C./Baltimore, Md., area. The residents were asked for their opinions on educational policies, ideological issues in psychiatry, their identification with traditional areas of medicine, and future regulatory practices for psychiatry. The data gathered show some shifts in attitudes among first-second-, and third-year residents. They also show a marked inclination toward dynamic-analytically oriented psychotherapy. The authors conclude that substantial changes will be required in the core curriculum of residency education if the prediction that tomorrow's psychiatrist will be a complete psychobiologist is to be fulfilled.

Joint custody, with both divorced parents sharing childrearing functions, is a recent and controversial phenomenon. To the authors' knowledge there have been no published quantitative outcome studies establishing its efficacy. The authors present data on 414 consecutive custody cases in a Los Angeles court over a 2-year period, comparing relitigation rates (indicative of postdivorce parental conflict) of exclusive and joint custody. In those cases which were returns to court, the proportion of relitigation for joint custody families was one-half that of exclusive custody families, suggesting that joint custody is a more beneficial arrangement in terms of reduced parental conflict.

The author discusses the father-child relationship as it is influenced by divorce. Psychiatrists are often consulted by individuals considering dovorce who are concerned about its probable impact on their children. Data gathered from the treatment of fathers during divorce indicate that there can be positive changes in their parental bonds as a result of increased opportunities to relate to children in a conflict-free atmosphere. In such a setting, the father's nurturing experience provides him with a new perspective on parenting. Psychotherapeutic help can lead to a strengthening of parental bonds, with subsequent benefits to both father and child. The author encourages professionals to support men in improving their fathering during the postdivorce period.

The process of evaluating the professional competence of trainees in the mental health field is accompanied by complexities that are more extensive than in other professional fields. The authors draw on personal experiences with mental health trainees to delineate some of the rational and irrational components of the evaluation process. They describe dilemmas and conflicts for both the evaluator and the trainee and make a number of recommendations aimed at clarifying individual and institutional roles and responsibilities and minimizing personal and institutional distress.

Psychiatrists usually select therapeutic modalities for their patients on the basis of empirical and theoretical considerations. Only in special circumstances (e.g., psychosurgery) are ethical concerns primary. Yet every therapeutic decision involves questions of value and requires ethical justification. The author outlines four resources for ethical direction in therapy: a general systems or biopsychosocial formulation of the clinical problem, the historic ethical commitments of the medical profession, the patient's informed perspective, and the psychiatrist's own values. Finally, a method is proposed for the resolution of conflicts among these four perspectives in individual cases.

The author describes the influence of the feminist movement on the intellectual, social, and sexual behavior of feminist college students. The complex interrelationship between sexual political ideology and actual sexual behavior creates confusion and anxiety for some vulnerable students in their attempts to evolve a satisfactory sexual identity. A series of vignettes illustrates the struggle of such students, who initially expressed concern over actual or potential lesbianism and its connection to the movement, to resolve their conflicts concerning feminism and sexual preference.

Three patients experienced recurrent manic episodes while taking lithium at levels that previously had been effective. In each case, the patient's decompensation followed a life stress. These stresses, which had a striking similarity, involved conflictual situations in which the patient felt impelled to pursue activities contrary to his or her own interests and aspirations. The activities, often involving the patient's family, seemed impossible to avoid. These clinical examples, together with several reports from the literature, suggest that pharmacological, psychodynamic, and situational forces may need to be considered together to allow more accurate conceptualization and to prevent recurrence of mania.

The authors examine the ethical issues in choosing between individual and social unit (marital and family) therapies. Although usually neglected in the literature, these ethical questions are important and complex. A general systems perspective is used to provide a framework for ethical analysis. The core of the ethical problem is shown to be the interdependence and irreducible conflict inherent between the individual and social unit levels. The authors outline a general systems approach to identification and consideration of these ethical issues in clinical practice.

The author used a self-rating scale to assess marital happiness and sexual functioning in a sample of 20 couples referred to an outpatient family therapy unit. Evaluation of couples in structured interactions indicated important differences in the quality and intensity of relationship difficulties observed. Analysis of variance clearly showed that sexual dysfunction and marital distress may operate independently of one another. Thus effective treatment of marital discord may be neither a necessary nor sufficient condition for improvement in sexual functioning.

Interdisciplinary staff meetings with a group-process orientation are a common feature of inpatient psychiatric wards. In these meetings an attempt is made to elicit and resolve intrastaff conflicts. Often the hierarchy of administrative structure is suspended and a setting reminiscent of a therapy or T-group is created. Insufficient attention has been paid to the potential hazards of and varying indications for this process-oriented approach to staff meetings. The authors reassess the usefulness of these meetings in improving staff relations and clinical performance and suggest guidelines for tailoring their use to fit the ward's therapeutic objectives.

The author discusses the correlative nature of projection and introjection, their early roles in development and differentiation, and their later defensive uses. He describes how, in paranoid states, the interplay between projecting and introjecting leads to conflicted ambivalence between preserving and annihilating significant objects.

Patients on long-term hemodialysis are subjected to many psychological and social stresses. However, through the mechanism of secondary gain, such patients may obtain certain gratifications that they refuse to relinquish. The author presents two case reports that demonstrate various secondary gains and discusses the complications they presented to a hemodialysis unit.

The authors describe a technique for assessing police department candidates based on projective tests and an interview. They conclude that success or failure in a law enforcement career is not determined by unconscious conflict or the nature of the ego defenses alone, but is strongly influenced by the degree to which the ego has remained undistorted in response to those conflicts.

The author describes Israel's social structure and discusses some of its problems. Israeli society is based on a pioneering ideology, which is a source of strength and also of conflict as the nation evolves into a consumer culture. Waves of heterogeneous immigrants necessitate further social adjustment. She describes the Israelis' relationship to their own and to other nations and reviews some factors in the Mid-East conflict. The psychosocial barriers between the Israelis and the Arabs are constantly strengthened by external and internal political interests.

Although it is only the culmination of a more traumatic emotional upheaval in the family, the legal event of parental divorce presents acute problems for the very young child since it involves an abrupt change in his daily life. During the immediate period of parental divorce, ten of the 16 nursery school children discussed here showed dramatic changes in behavior, often characterized by impairment of the ability to master anxiety and depression through play. Preventive efforts channeled through the school at this time may ease the immediate shock for the child and help him to resume the normal tasks of maturation more quickly.

On the basis of his investigations of some aspects of interpersonal bonding in several widely different species and human cultures, the author suggests that high-intensity interpersonal bonding may be a prerequisite for various human behaviors, including cultural achievement, aggression, and mental illness. He further suggests that by increasing the degree of synergy in our society we may be able to reduce aggression and mental illness while maintaining a high level of cultural achievement.

Teaching sexual psychology to medical students must take into consideration their high degree of anxiety and conflict, common obsessive compulsive personality structure, lack of factual knowledge, and lack of awareness of the social class influences on sexual attitudes and behavior. A small group teaching method is presented that encourages the acquisition of knowledge and assists the student to reduce his own anxieties, increase his ease of communication, and broaden his sociocultural sensitivity.

The authors examine the implications of the women's liberation movement for current psychotherapeutic theory and practice in terms of the antifeminine Freudian position, the predominance of male therapists, the concept of role unhappiness as psychopathological, and the threat to the therapist's social power. Consideration of role conflict in sociological terms instead of the intrapsychic rubric is especially emphasized. The authors also discuss related issues concerning the training of therapists and propose a model using male and female cotherapists.

This overview describes five concepts of sexuality that run through Freud's writings—bisexuality, infantile sexuality and the Oedipus complex, libido theory, the primacy of the penis, and conflict—and tests each against recent advances in sex research.

A session ofthe annual meeting ofthe A merican Psvchiatric Association in Honolulu, Hawaii, on May 9, 1973, was devoted to ‘ ‘Should Homosexuality Be in the A PA Nomenclature?” The participants were.’ Rohertf. Stoller, M.D., Professor of Ps vchiatrv, University of Southern California School of Medicine, Los A ngeles. Judd Marmor, M.D., Fran: Alexander Professor of Psychiatry, University of Southern California School of Medicine, Los Angeles. Irving Bieher, M.D., Clinical Professor of Psychiatry, New York Medical College, New York Cliv. Ronald Gold, Gay Activists Alliance, New York City. Charles W. Socarides, M.D., Associate Professor of Psychiatry, Albert Einstein College of Medicine, New York City. Richard Green, M.D., Associate Professor of Psychiatry in Residence, University of Southern California School of Medicine, Los Angeles. Their papers are abstracted below. The session was organi:ed and chaired by Robert L. Spii:er, M.D.. Director, Evaluation Section. Biometrics Research, New York State Department of Mental Hygiene, 722 West /68 St.. New York, N. Y. 10032, and Associate Professor of Clinical Psychiatry, Department of Psychiatry, Columbia University. Hi.s paper, which is also abstracted below, was written after the meeting. Reprint requests should be directed to Dr. Spit:er.

The author describes the hysterical personality and hysterical psychosis and provides some examples, from the literature and from his practice, of the occurrence of hysterical psychosis in response to disrupted object relations, particularly in the case of disturbed marriages.

A 30-year-old man experienced episodes of acute recurrent pancreatitis; documented episodes were accompanied by a specific psychologic conflict and its specific affects of guilt, anger, and feelings of rejection. The author concludes that the pancreatitis occurred as a psychophysiologic response and as part of a total psychiatric disorder.

Although Benjamin Rush disclaimed any tendency toward superstitious belief in dreams, he seems in fact often to have fallen under the spell of his own dreams and to have been quite affected by them. A common theme in Rush's dreams was the attempt to reconcile a conflict he was then experiencing: the struggle between his humanitarian sentiments and his need to earn a living, for example, and the frequent incompatibility of his personal political ambitions with his role as a doctor.

There is a great need to deepen our understanding of the psychological forces which motivate individuals whose actions in the public sphere affect the lives of all of us. T. E. Lawrence, because of an extraordinary gift of psychological insight and a compelling need for introspection brought about by his emotional suffering in World War I, has proved to be an excellent subject for such study. In this essay the author concentrates on one aspect of his psychology, the problem of self-esteem, and the relationship between this problem and Lawrence's public actions.

A previously disregarded but consequential influence upon the conceptual model of dynamic psychiatry as evolved by Freud is that of military science. Thus many fundamental terms bear obvious milita...

The authors studied a pair of monozygotic twins who became discordant for mental and physical disorders late in life. Differences in the twins' early histories, earliest memories, and reactions to the loss of their mother when they were children suggest that their early interactions with their environment resulted in different modes of adaptation, which subsequently became internalized as different defensive and characterological patterns. The authors believe that the specific environmentally determined psychodynamic influences described in the paper serve to explain the twins' discordance for disease.

Thomas Jefferson achieved what the author considers an extraordinary mastery of his life, which was, however, not devoid of conflicts. Dr. Binger describes Jefferson's inner struggle relating to the separation of the colonies from Britain, his depressive withdrawal when his wife was seriously ill and their infant son died, his unhappiness and indignation following his censure by the Virginia legislature for failure to call out the militia during a period of emergency, and his and Alexander Hamilton's mutual hostility.

The APA Task Force on Women was created to study the special issues and problems of women, especially in relation to the practice of psychiatry, and the special concerns of women psychiatrists. In this paper, the author details the specific areas the task force is examining, summarizes the findings of some of the few reports in the literature, and outlines the projects the task force has undertaken.

The author presents two case reports of patients who, in their psychotic productions, were unusually preoccupied with death. These contrast with previously reported patients with sleep paralysis who were concerned with various conflicts. He suggests that anxiety accompanying sleep paralysis might be associated with several conflict situations and that the experience has no specific psychological meaning in itself. It may be interpreted differently by different patients, depending upon their individual makeup.

The author presents an approach to psychiatric consultation before abortion that attempts to determine the extent of the woman's ambivalence about the abortion by clarifying any unconscious motivations or conflicts. Other goals are an evaluation of the woman's capacity to cope and an assessment of the quality of life that would be available to the infant.

A department of psychiatry in Hawaii undertook an exploratory study of the motivational patterns of entering freshmen, relating these to problems of selection, performance, and the educational system itself. The authors, noting that the motivations of students seem to be changing and that a different value system is emerging, call for further study to more accurately assess the values and needs of prospective students and to reassess the educational process.