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Anorexia nervosa (AN) is a severe and often chronic disorder with uncertain aetiology and poor prognosis. New approaches to the understanding of the disorder are needed in order to aid the development of more effective treatments. Several authors have suggested that AN has a considerable overlap with obsessive-compulsive disorder (OCD) and that this may reflect common neurobiological, genetic, or psychological elements. However, more recent studies have suggested that AN may have a closer relationship with obsessive-compulsive personality traits such as those found in obsessive-compulsive personality disorder (OCPD). In this paper, evidence for links between the three conditions is reviewed, suggestions for further research are outlined and possible implications for the treatment of AN are presented.

Objective: Utilization of mental health treatment was compared in patients with personality disorders and patients with major depressive disorder without personality disorder., Method: Semistructured interviews were used to assess diagnosis and treatment history of 664 patients in four representative personality disorder groups-schizotypal, borderline, avoidant, and obsessive-compulsive-and in a comparison group of patients with major depressive disorder., Results: Patients with personality disorders had more extensive histories of psychiatric outpatient, inpatient, and psychopharmacologic treatment than patients with major depressive disorder. Compared to the depression group, patients with borderline personality disorder were significantly more likely to have received every type of psychosocial treatment except self-help groups, and patients with obsessive-compulsive personality disorder reported greater utilization of individual psychotherapy. Patients with borderline personality disorder were also more likely to have used antianxiety, antidepressant, and mood stabilizer medications, and those with borderline or schizotypal personality disorder had a greater likelihood of having received antipsychotic medications. Patients with borderline personality disorder had received greater amounts of treatment, except for family/couples therapy and self-help, than the depressed patients and patients with other personality disorders., Conclusions: These results underscore the importance of considering personality disorders in diagnosis and treatment of psychiatric patients. Borderline and schizotypal personality disorder are associated with extensive use of mental health resources, and other, less severe personality disorders may not be addressed sufficiently in treatment planning. More work is needed to determine whether patients with personality disorders are receiving adequate and appropriate mental health treatments.

Compulsive buying disorder is characterised by excessive or poorly controlled preoccupations, urges or behaviours regarding shopping and spending, which lead to adverse consequences. Compulsive buying disorder has been estimated to affect from 2 to 8% of the general adult population in the US; 80 to 95% of those affected are female. Onset occurs in the late teens or early twenties, and the disorder is generally chronic. Psychiatric comorbidity is frequent, particularly mood, anxiety, substance use, eating and personality disorders. Treatment has not been well delineated, but individual and group psychotherapy, cognitive-behavioural therapy and 12-step programmes may be helpful. Debt consolidation and credit counselling will be appropriate for many individuals who have compulsive buying disorder. Serotonin (5-hydroxytryptamine; 5-HT) re- uptake inhibitors may help some patients regulate their buying impulses. Self-help books are also available.

The authors examined the relations among therapeutic alliance, outcome, and early-in-treatment symptomatic improvement in a group of 86 patients with generalized anxiety disorders, chronic depression, or avoidant or obsessive-compulsive personality disorder who received supportive-expressive dynamic psychotherapy. Although alliance at Sessions 5 and 10, but not at Session 2, was associated with prior change in depression, alliance at all sessions significantly predicted subsequent change in depression when prior change in depression was partialed out. The results are discussed in terms of the causal role of the alliance in therapeutic outcome.

Exposure treatment is efficient as a treatment for some anxiety disorders. Briefly described, it consists in letting the patient expose himself to an anxiety-inducing situation without running away from it. In the author's experience, this mode of treatment is too seldom used. This article exemplifies conditions in which this form of therapy can be useful. The method is easily learnt by general practitioners. The article describes the treatment of five patients with these psychiatric diagnoses: agoraphobia, social phobia, compulsive disorder, and post-traumatic stress disorder.

In the short-term therapy over 16 50-min. sessions of a compulsive personality, there were unanimous positive changes on 17 verbal measures, with no activity shown on one measure. The verbal measures of Mahl, Raimy, and Bugental were used, along with Bühler, Bühler, and Lefever's Basic Rorschach Score and a qualitative analysis of the Rorschach. There were indications of decreases in procrastination, narcissism, and disorderliness.

Obsessional slowness is regarded as an uncommon but severely disabling variant of obsessive-compulsive disorder. This paper examines the psychopathology, classification, pathophysiology and treatment of obsessional slowness. It argues that primary obsessional slowness does not require classification as a separate syndrome because it can be found to be secondary to recognised phenomena of obsessive-compulsive disorder or anankastic personality disorder. The treatment described in the literature is not thought to be successful in the long term, and controlled trials are required to evaluate new strategies and antidepressant medication.

Compulsive checking can be treated effectively through the use of in vivo exposure with response prevention. However, the clinical application of these procedures can become quite complex. The therapist must help teach the client new coping skills for managing anxiety. However, many compulsive clients report a substantial reduction in the urge to check whenever accompanied by another adult. Therefore, the therapist must not be so intrusive as to reduce the impact of the exposure. Treatment procedures used with two clients are described to show how prompting can be useful for facilitating the early stages of exposure and how fading is essential in promoting self-control. Portable electronic communication devices were used to bridge the gap between therapist-assisted and self-controlled exposure sessions. Therapy was successful in reducing the frequency of checking behaviors and the subjective urge to check.

Over the last 10 years, primary health care practitioners have seen an increase in their case loads of persons with chronic addictive illnesses (e.g., alcohol- and drug-related illnesses, eating disorders, spending addictions). The management of chronic illnesses usually is aimed at restoring a level of health and reinforcing a positive lifestyle so that a person can manage the illness rather than having it cured and its effects eradicated. Practitioners can apply the treatment modalities already being used in the management of chronic and addictive illnesses to treat the most newly emerging addictive illness--sexual addiction. Following the premise that a person needs to be involved with other people who have the illness, treatment and recovery are based on a 12-step recovery-group process. Additionally, sexually addicted clients need medical and emotional therapy. This article focuses on understanding the decision-making process involved in the care of patients with sexual addiction, and presents tools and resources to help in managing this illness.

This study explores the preference of patients for humorous or nonhumorous therapist interventions. Hysterical, obsessive, and depressive patients were presented with three functional kinds of humorous interventions: emotional confrontation, anxiety reduction and perspective development. The data indicate that the patients consistently favored the nonhumorous interventions, but the degree of this preference varied according to personality style. Obsessive patients stood out in their ardent repudiation of humorous interventions. The results suggest that the desirability of utilizing humor in therapy depends on a multiplicity of parameters.

Anxiety is identified with a state of high arousal. Agoraphobia is differentiated from specific phobias which are inherent responses to situations which threatened primitive man. In agoraphobia, attacks of high arousal are produced by situations which delay ongoing activity. It is hypothesised that such delays produce arousal by activating behavior completion mechanisms. Evidence is reviewed which indicates desensitization has a specific effect in agoraphobia but not in specific phobias. It is suggested that desensitization reduces the arousal produced by behavior completion mechanisms. -- Aversive therapy in homosexuality reduces the subjects' drive to carry out compulsive sexual behaviors but does not alter sexual orientation. It is suggested that the compulsive sexual behaviors are not activated by primary sexual drive but by behavior completion mechanisms. Aversive therapy reduces the arousal produced by the behavior completion mechanisms. -- A similar mode of action is advanced for desensitization and aversive therapy. Both inhibit arousal by establishing a focal experimental neurosis which results from alternation of excitatory and inhibitory impulses.

A pilot study is reported of costs and benefits from behavioural psychotherapy by nurse-therapists for selected neurotic problems. Figures are based on the treatment of 42 neurotics (mainly phobics and obsessive-compulsives) who completed treatment with nurse-therapists in a mean of 9 sessions (16 hours). The year before and after treatment was studied. Apart from significant and lasting reduction in patients' distress, economic benefits to them, their families and the community yielded a worthwhile internal rate of return when benefits from the cohort continue for 3 years, a reasonable assumption on available other evidence. Though untreated phobics did not improve elsewhere over 5 years follow-up, a controlled study would seem desirable.

A satisfactory psychoanalytic definition and theory of affects has not yet been evolved. In spite of this, analysts work with affects using, for practical purposes, a common-sense definition leading to a therapeutic advantage in coordinating affective and cognitive structures as they appear in the course of a prolonged analysis. Undoing of defenses facilitates this process, allowing the ego's integrative capacities to function more adequately and satisfactorily in relation to inner and outer reality. A developmental hierarchy of affects emerges in this way ranging from primitive--all or none--affective experiences to adult, modified expression of such ego experiences. A brief historical survey of the changing forms of the theory of affects is included, as are clinical vignettes illustrating the therapeutic aspects of dealing with affective expression in the psychoanalytic situation. The therapeutic gains of such work comes about through the integration of earlier affective experiences into more developed cognitive structures allowing a variety of ego functions greater control over adult experiences.

Some of the factors that influence an analyst to choose one construction rather than another are explored. Such choices may be based on the analyst's insights and development, or his biases, past training and personal pathology; or the patient's attempts to influence the analyst in a particular direction. Construction may overemphasize the part played by the patient's innate propensities or his environment. Freud's interpretation of the Oedipus myth is re-examined in the light of these thoughts. Reconstruction is considered to be of therapeutic value only through the analysis of the repetition compulsion in the transference. The clinical examples include consideration of the repetition of an early folie à deux phenomenon manifest in the transference. The nature of the internal objects that 'go with' the patient in exploration and distortion of truths is examined. New developments in analysis need to be integrated with creative constructions of the past, forming the foundation of new constructions. The view is held that in times of crisis patients revert to past systems; recognition of this factor implies that the work of reconstruction will be an on-going process after the analysis is terminated, and forms part of the patient's equipment for future self analysis.

The Quality Assurance Project is developing explicit and detailed treatment outlines for each of the major psychiatric disorders. Three sources of information are used: a meta-analysis of the treatment outcome literature, the opinions of a sample of practising psychiatrists, and the views of a panel of nominated experts. The recommendations for the treatment of obsessive-compulsive disorder were as follows: for those patients who have no significant personality disorder, either short-term dynamic psychotherapy or cognitive behaviour therapy is indicated if the illness has lasted less than a year or if obsessions are the predominant symptoms. When compulsions predominate, particularly when they have been present for more than a year, response prevention is the treatment of choice. Tricyclic antidepressants and cingulo-tractomy are also worthy of consideration in patients with persisting symptoms. Psychotherapy or cognitive behaviour therapy are the approaches recommended for compulsive personality disorder.

Quantitative ratings of transference and resistance were made at each session during four psychoanalyses. Ratings were then compared with the treating psychoanalysts' clinical impressions. The two relatively successful analyses showed rising transference and diminishing resistance. The two relatively less successful analyses showed more parallel curves: the long, difficult analysis showed closely associated transference and resistance curves; the failure in analysis revealed a high resistance curve, even while transference increased.

The author collected data on 15 patients for whom therapy was interrupted because of a move to a distant city by the analyst or the patient. He found that 14 of these patients refused to accept transfer to another analyst as urged by their analyst; instead, they continued contact by phone and/or correspondence with the analyst for long periods of time. Continuation of contact was not related to diagnosis but perhaps to a basic inability of these patients to face and work through separation or to some type of special patient-therapist relationship.

The cases of 40 consecutive patients, accepted for supervised psychoanalysis at the Treatment Center of The New York Psychoanalytic Institute, are reviewed. The process of the initial evaluation is examined as well as the nature of the patient group, the characteristics of the treatment, outcome, and follow-up data. A survey of a group of 42 patients from the private practice of a group of graduate analysts during the same period of time is also reported. Both studies are discussed in relation to methodological issues, and an approach is suggested for the study of assessment of analyzability and analyses through a systematic prospective study of analytic treatments conducted by experienced analysts.

In the management of patients it is often important to combine physical and psychotherapeutic treatment methods according to the individual patient's needs. In analytically oriented psychotherapy more attention can usefully be paid to the patient's bodily attitudes and behavior than has been customary. A psychosomatic approach which can be applied to the psychotherapeutic process is described, and theoretical considerations are discussed.

This is a study of two patients who had what might be considered classical examples of narcissistic transferences. They were both severely disturbed persons and one could decompensate into a disruptive psychosis. Consequently it is not surprising that their transference projections would be consonant with their primitive orientations. They projected hateful and hating parts of the self onto the analyst. But within all this hatred was a part of the self that had the potential to achieve good things for the patient. I believe the latter is a special feature of narcissistic transferences that has revieved very little emphasis and a feature that may cause us to view such patients and their projections somewhat more optimistically in terms of their potential for growth and treatability.

Clinical material is presented on a single case of impotence in a middle-aged black man. The symbolic meanings of the symptom in terms of the patient's aggression, feelings about his racial self-image, and the options that allow for male identity are discussed, along with some aspects of an interracial treatment situation in these changing times.

Obsessional defenses require a confronting, active therapist in order to break through the intellectualized, ritualized, and highly distracting productions of the patients. The tendency to obfuscate through details and rigid adherence to the instructions demands a loose, flexible, and direct interaction from a therapist who is not too obessional and willing to forego his own perfectionistic expectations from therapy.