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The dreamer often portrays wishes, conflicts, or current problems in terms of visual-spatial representations and metaphors. The spatial dimensions of dreams frequently signify important affective themes of the dream. In doing so, they serve to continue or reflect processes of self-recognition in relation to the environment, processes that began in early childhood, when the developing child's experience of movement through space played a central role in organizing affect and motivation systems that contribute to emerging schemata of the self. Representations of that movement through space gradually grow to serve a broader symbolic function, as may be seen in the spatial dimensions of both play and dreaming. Spatial relations then become building blocks for aspects of metaphoric and abstract thinking. The resultant personal "geography," a constellation of physical imagery of a body moving through space, retains an important place in mental life as development unfolds. It is complemented and enhanced by the achievement of language, but it never recedes as a core aspect of self. Developmental and neurobiological observations suggest the clinical usefulness of heightened attention to this spatial aspect of dreams. Clinical examples illustrate how attention to the spatial arrangements of a dream and the dreamer's movement through space can enhance access to the affective tone and meaning of the dream.

The experience, imagery, and fantasy of self in motion play a central part in the dreams, aspirations, and affective life of individuals, and in their growth. Human infants are supplied with an intrinsic drive to move to, with, and against forces and objects in the natural world, for that action maps a developing self into the world. This striving is not derivative from some other drive; it is a motivational force in and of itself intertwined with other essential strivings of the developing individual. Clinical observations and recent findings of developmental and neurobiological studies demonstrate that positive aspects of a person's striving in the sphere of motor control imbue a person's sense of self with qualities of energy, agency, and mastery. And, when thwarted, distorted, or unbalanced in relation to other strivings, one's physicality may also be a locus for conflict and maladaptive defenses. Schemas of self in relation to the world at large and especially to significant others are often encoded in procedural modes of remembering and perceiving, where movement is central. When the analyst is attuned to the experience of motor action in the life of the person he or she seeks to know fully and to help, the appreciation of that person's motives, emotions, and sense of self is deepened and enhanced.

When movie-goers are thrilled by cinematic imagery portraying transcendent motor action, they are drawn into a world of imagination more often inhabited only in dreams of flying or of perfectly executed motion. The drive toward free and expansive movement which such dreams portray doesn't require explanation in terms of symbolic links to other aims, as has been common in the literature. The aim to achieve mastery in the locomotor sphere of action is a basic aim, in itself, integral to ego development. The developing child could not begin to organize perception, intention, and a coherent sense of self without this drive to move. This proposition is supported by emerging views of the ways the developing nervous system integrates systems mediating perception, action, and affect, which complement observations of the bodycentered development of mutual recognition in infants and their caregivers.

We describe an 81-year-old white man in whom a subepidermal bullous eruption developed that clinically resembled bullous pemphigoid. The eruption promptly responded to oral tetracycline and niacinamide and topical clobetasol. Histologic examination of perilesional skin revealed neutrophilic infiltration with formation of papillary microabscesses and subepidermal cleavage. Direct immunofluorescence showed linear deposition of IgG and C3 along the basement membrane zone. By indirect immunofluorescence, circulating IgG autoantibodies bound exclusively to the dermal side of salt-split normal human skin. Immunoblot analysis demonstrated that the patient's autoantibodies reacted with a 200 kd dermal protein that was different from type VII collagen, the epidermolysis bullosa acquisita autoantigen. This patient represents the first confirmed case from the United States with a recently reported novel autoimmune subepidermal bullous disease associated with IgG autoantibodies to a 200 kd dermal antigen.

The growth of investor-owned hospital-management companies represents the most dramatic change in the hospital industry in recent years. Whereas supporters of investor-owned chains suggest that their growth is attributable to operating efficiencies, critics suggest that it has resulted from pricing and marketing strategies. Using data supplied by the California Health Facilities Commission, we compared the economic performance of investor-owned and not-for-profit hospitals in California. There were three principal findings. First, during the study period both costs and charges were higher in for-profit than in not-for-profit hospitals, measured on the basis of either patient-days or admissions. Second, the for-profit chains have used aggressive marketing and pricing strategies to generate high rates of profitability and growth. Finally, the payer class of patients did not differ specifically according to the hospital-ownership category. We conclude that the recent dramatic growth of investor-owned hospital chains is attributable to the employment of managerial strategies that were well suited to the reimbursement system in effect during the period studied. As a result of recent changes in federal and state reimbursement, many of these reimbursement-maximization strategies have become obsolete. Whether the investor-owned chains will be able to adapt rapidly to this new reimbursement environment remains to be seen.

Rats trained on 16 two-odor discrimination problems showed rapid acquisition of a learning set and one-trial learning by the end of the problem series. Learning to sample odor cues before responding and adoption of a "win-stay, lose-shift" strategy probably accounts for the virtually errorless learning. Learning-set performance of rats trained with odor stimulus comparable to that reported for primates trained on visual cues.

The Boston Psychotherapy Study found no major differences in the effects of insight-oriented and supportive psychotherapies in the treatment of schizophrenia. The authors of the current study looked beyond the assignments to those treatment designations and used blindly rated transcripts of tape-recorded sessions to examine the relationship of therapist interventions and patient outcomes at 2 years. They found significant relationships between skillfully conducted psychodynamic exploration and greater improvements in negative symptom areas of schizophrenia. The authors note the limitations and implications of these findings for clinical practice and research.

This study compares the effects of exploratory, insight-oriented (EIO) and reality-adaptive, supportive (RAS) forms of psychotherapy on a sample of 95 schizophrenic patients. Analyses of 2-year outcomes revealed a complex interaction between the type of psychotherapy provided and the domain of psychopathology affected. RAS psychotherapy exerted clear preferential effects in the areas of recidivism and role performance. The EIO psychotherapy exerted preferential, albeit more modest, action in the areas of ego functioning and cognition. Overall, however, the magnitude of the differences was low. The results highlighted the need for more focused studies of subgroups, and of process and contextual influences on outcome.

A new agenda for the practice and study of psychotherapy of schizophrenia should focus not on the longstanding debate as to whether psychotherapy is effective, but on how it may be effective for particular groups of patients, and on combining psychotherapy with other interventions over the course of illness. Empirical studies have failed to substantiate claims for broadly superior outcome when patients are treated with psychotherapy, and practitioners of psychotherapy may need to have a narrower focus and more modest expectations for change. Research efforts should work toward developing guidelines for selective use of psychotherapy that are consistent with our recognition that schizophrenic patients show heterogeneity in their etiology, presenting symptoms, and clinical course. Intrapsychic, experiential, and interpersonal aspects of schizophrenia that are most resistant to other treatment approaches may be sensitive to psychotherapeutic intervention, and a psychodynamic approach to therapy offers the most direct help with a disordered inner world to the person struggling with schizophrenia.

Sixty-nine nonchronic schizophrenic patients who had dropped out of psychotherapy were studied with regard both to reasons for dropping out and their subsequent clinical course, assessed by means of a retrospective, semistructured interview. Their 2-year outcomes were compared with those of a group of similar patients who remained in psychotherapy. It was found that the patients who dropped out were markedly heterogeneous in terms of their reasons for dropping out, and their subsequent outcomes. As a group, they received an unexpectedly substantial amount of subsequent psychiatric treatment, and after 2 years did not generally differ from those remaining in psychotherapy on measures of social or occupational functioning.