What is a Paced Auditory Serial Addition Test?

Introduction

Paced Auditory Serial Addition Test (PASAT) is a neuropsychological test used to assess capacity and rate of information processing and sustained and divided attention.

Background

Originally the test was known as the Paced Auditory Serial Addition Task (PASAT). The subjects are given in the version used as part of the Multiple Sclerosis Functional Composite a number every 3 seconds and are asked to add the number they just heard with the number they heard before. This is a challenging task that involves working memory, attention and arithmetic capabilities. Versions with numbers presented every 2 seconds are also available. The original version presented the numbers every 2.4 seconds with 0.4 decrements for subsequent trials. The PASAT was originally developed for use in evaluating patients with head injury. The advantage in this population was supposed to be minimal practice effects. This test has been widely used in other conditions besides traumatic brain injury.

Multiple Sclerosis

It has become widely used in the testing of patients with multiple sclerosis as patients with this disease frequently have an impaired performance on this test. The PASAT was included in the Multiple Sclerosis Functional Composite as a cognitive measure. However, the use of the PASAT in clinical trials in MS it has shown to be problematic as there are significant practice effects over repeated measures; typically the effect of treatment is reflected by a larger improvement on the test compared to the control group.

What is the International Association for Suicide Prevention?

Introduction

The International Association for Suicide Prevention (IASP) is an international suicide prevention organisation.

Background

Founded by Erwin Ringel and Norman Farberow in 1960, IASP, which is in an official relationship with the World Health Organisation (WHO), is dedicated to preventing suicidal behaviour and providing a forum for mental health professionals, crisis workers, suicide survivors and other people in one way or another affected by suicidal behaviour. The organisation now consists of professionals and volunteers from over 50 countries worldwide.

The IASP also co-sponsors, with the WHO, World Suicide Prevention Day on 10 September every year.

IASP Congresses

The IASP holds international congresses every two years. XXIX World Congress of the IASP will be organised in Kuching (Malaysia) in 2017.

Past Congresses

  • 2021 Queensland, Australia.
  • 2019 Derry-Londonderry, Northern Ireland.
  • 2017 Kucjing, Malaysia.
  • 2015 Montreal, Canada.
  • 2013 Oslo, Norway.
  • 2011 Beijing, China.
  • 2009 Montevideo, Uruguay.
  • 2007 Killarney, Ireland.
  • 2005 Durban, South Africa.
  • 2003 Stockholm, Sweden.
  • 2001 Chennai, India.
  • 1999 Athens, Greece.
  • 1997 Adelaide, Australia.
  • 1995 Venice, Italy.
  • 1993 Montreal Canada.
  • 1991 Hamburg, Germany.
  • 1989 Brussels, Belgium.
  • 1987 San Francisco, US.
  • 1985 Vienna, Austria.
  • 1983 Caracas, Venezuela.
  • 1981 Paris, France.
  • 1979 Ottawa, Canada.
  • 1977 Helsinki, Finland.
  • 1975 Jerusalem, Israel.
  • 1973 Amsterdam, Netherlands.
  • 1971 Mexico City, Mexico.
  • 1969 London, England.
  • 1967 Los Angeles, US.
  • 1965 Basel, Switzerland.
  • 1963 Copenhagen, Denmark.
  • 1960 Vienna, Austria.

Awards

The IASP provides awards for those who have contributed in a significant way to the furthering of the aims of the Association. Awards are presented at the IASP biennial conference.

The Stengel Research Award has been provided since 1977 and is named in honour of Professor Erwin Stengel, one of the founders of the IASP. This award is for outstanding research in the field of suicidology, and nominations can be made by any member of IASP.

The Ringel Service Award was instituted in 1995 and honours Professor Erwin Ringel, the founding President of the Association. This award is for distinguished service in the field of suicidology, and nominations can be made by National Representatives of IASP.

The Farberow Award was introduced in 1997 in recognition of Professor Norman Farberow, a founding member and driving force behind the IASP. This award is for a person who has contributed significantly in the field of work with survivors of suicide, and nominations can be made by any IASP member.

The De Leo Fund Award honours the memory of Nicola and Vittorio, the children of Professor Diego De Leo, IASP Past President. The Award is offered to distinguished scholars in recognition of their outstanding research on suicidal behaviours carried out in developing countries.

Journal

The Association’s journal, Crisis – The Journal of Crisis Intervention and Suicide Prevention, has been published since 1980.

Website

http://www.iasp.info/

What is Emotional Dysregulation?

Introduction

Emotional dysregulation is a term used in the mental health community that refers to emotional responses that are poorly modulated and do not lie within the accepted range of emotive response.

Refer to Emotional Self-Regulation.

Emotional dysregulation can be associated with an experience of early psychological trauma, brain injury, or chronic maltreatment (such as child abuse, child neglect, or institutional neglect/abuse), and associated disorders such as reactive attachment disorder. Emotional dysregulation may be present in people with psychiatric disorders such as attention deficit hyperactivity disorder, autism spectrum disorders, bipolar disorder, borderline personality disorder, complex post-traumatic stress disorder, and foetal alcohol spectrum disorders. In such cases as borderline personality disorder and complex post-traumatic stress disorder, hypersensitivity to emotional stimuli causes a slower return to a normal emotional state. This is manifested biologically by deficits in the frontal cortices of the brain.

Possible manifestations of emotional dysregulation include extreme tearfulness, angry outbursts or behavioural outbursts such as destroying or throwing objects, aggression towards self or others, and threats to kill oneself. Emotional dysregulation can lead to behavioural problems and can interfere with a person’s social interactions and relationships at home, in school, or at place of employment.

Etymology

The word “dysregulation” is a neologism created by combining the prefix “dys-” to “regulation”. According to Webster’s Dictionary, dys- has various roots and is of Greek origin. With Latin and Greek roots, it is akin to Old English tō-, te- “apart” and in Sanskrit dus- “bad, difficult.” It is frequently confused with the spelling “disregulation” with the prefix “dis” meaning “the opposite of” or “absence of”.

Child psychopathology

There are links between child emotional dysregulation and later psychopathology. For instance, ADHD symptoms are associated with problems with emotional regulation, motivation, and arousal. One study found a connection between emotional dysregulation at 5 and 10 months, and parent-reported problems with anger and distress at 18 months. Low levels of emotional regulation behaviours at 5 months were also related to non-compliant behaviours at 30 months. While links have been found between emotional dysregulation and child psychopathology, the mechanisms behind how early emotional dysregulation and later psychopathology are related are not yet clear.

Symptoms

Smoking, self-harm, eating disorders, and addiction have all been associated with emotional dysregulation. Somatoform disorders may be caused by a decreased ability to regulate and experience emotions or an inability to express emotions in a positive way. Individuals who have difficulty regulating emotions are at risk for eating disorders and substance abuse as they use food or substances as a way to regulate their emotions. Emotional dysregulation is also found in people who have an increased risk of developing a mental disorder, in particularly an affective disorder such as depression or bipolar disorder.

Early Childhood

Research has shown that failures in emotional regulation may be related to the display of acting out, externalizing disorders, or behaviour problems. When presented with challenging tasks, children who were found to have defects in emotional regulation (high-risk) spent less time attending to tasks and more time throwing tantrums or fretting than children without emotional regulation problems (low-risk). These high-risk children had difficulty with self-regulation and had difficulty complying with requests from caregivers and were more defiant. Emotional dysregulation has also been associated with childhood social withdrawal. Common signs of emotional dysregulation in early childhood include isolation, throwing things, screaming, lack of eye contact, refusing to speak, rocking, running away, crying, dissociating, high levels of anxiety, or inability to be flexible.

Internalising Behaviours

Emotional dysregulation in children can be associated with internalizing behaviours including:

  • Exhibiting emotions too intense for a situation.
  • Difficulty calming down when upset.
  • Difficulty decreasing negative emotions.
  • Being less able to calm themselves.
  • Difficulty understanding emotional experiences.
  • Becoming avoidant or aggressive when dealing with negative emotions.
  • Experiencing more negative emotions.

Externalising Behaviours

Emotional dysregulation in children can be associated with externalizing behaviours including:

  • Exhibiting more extreme emotions.
  • Difficulty identifying emotional cues.
  • Difficulty recognizing their own emotions.
  • Focusing on the negative.
  • Difficulty controlling their attention.
  • Being impulsive.
  • Difficulty decreasing their negative emotions.
  • Difficulty calming down when upset.

Protective Factors

Early experiences with caregivers can lead to differences in emotional regulation. The responsiveness of a caregiver to an infant’s signals can help an infant regulate their emotional systems. Caregiver interaction styles that overwhelm a child or that are unpredictable may undermine emotional regulation development. Effective strategies involve working with a child to support developing self-control such as modelling a desired behaviour rather than demanding it.

The richness of an environment that a child is exposed to helps the development of emotional regulation. An environment must provide appropriate levels of freedom and constraint. The environment must allow opportunities for a child to practice self-regulation. An environment with opportunities to practice social skills without over-stimulation or excessive frustration helps a child develop self-regulation skills.

Emotional Dysregulation and Substance Use

Several variables have been explored to explain the connection between emotional dysregulation and substance use in young adults, such as child maltreatment, cortisol levels, family environment, and symptoms of depression and anxiety. Vilhena-Churchill and Goldstein (2014) explored the association between childhood maltreatment and emotional dysregulation. More severe childhood maltreatment was found to be associated with an increase in difficulty regulating emotion, which in turn was associated with a greater likelihood of coping by using marijuana. Kliewer et al. (2016) performed a study on the relationship between negative family emotional climate, emotional dysregulation, blunted anticipatory cortisol, and substance use in adolescents. Increased negative family emotional climate was found to be associated with high levels of emotional dysregulation, which was then associated with increased substance use. Girls were seen to have blunted anticipatory cortisol levels, which was also associated with an increase in substance use. Childhood events and family climate with emotional dysregulation are both factors seemingly linked to substance use. Prosek, Giordano, Woehler, Price, and McCullough (2018) explored the relationship between mental health and emotional regulation in collegiate illicit substance users. Illicit drug users reported higher levels of depression and anxiety symptoms. Emotional dysregulation was more prominent in illicit drug users in the sense that they had less clarity and were less aware of their emotions when the emotions were occurring.

Treatment

While cognitive behavioural therapy is the most widely prescribed treatment for such psychiatric disorders, a commonly prescribed psychotherapeutic treatment for emotional dysregulation is dialectical behavioural therapy, a psychotherapy which promotes the use of mindfulness, a concept called dialectics, and emphasizes the importance of validation and maintaining healthy behavioural habits.

When diagnosed as being part of ADHD, norepinephrine and dopamine reuptake inhibitors such as methylphenidate (Ritalin) and atomoxetine are often used.

References

Kliewer, W., Riley, T., Zaharakis, N., Borre, A., Drazdowski, T.K. & Jäggi, L. (2016) Emotion Dysregulation, Anticipatory Cortisol, and Substance Use in Urban Adolescents. Personality and Individual Differences. 99, pp.200-205. doi:10.1016/j.paid.2016.05.011. PMC 5082236. PMID 27795602.

Prosek, E.A., Giordano, A.L., Woehler, E.S., Price, E. & McCullough, R. (2018) Differences in Emotion Dysregulation and Symptoms of Depression and Anxiety among Illicit Substance Users and Nonusers. Substance Use & Misuse. 53(11), pp.1915-1918. doi:10.1080/10826084.2018.1436563. PMID 29465278. S2CID 3411848.

Vilhena-Churchill, N. & Goldstein, A.L. (2014) Child Maltreatment and Marijuana Problems in Young Adults: Examining the Role of Motives and Emotion Dysregulation. Child Abuse & Neglect. 38(5), pp.962-972. doi:10.1016/j.chiabu.2013.10.009. PMID 24268374.

Who was Hans Asperger?

Introduction

Johann Friedrich Karl Asperger (18 February 1906 to 21 October 1980) was an Austrian physician.

Noted for his early studies on atypical neurology, specifically in children, he is the namesake of the autism spectrum disorder Asperger syndrome. He wrote over 300 publications on psychological disorders that posthumously acquired international renown in the 1980s. His diagnosis of autism, which he termed “autistic psychopathy”, has also garnished controversy. Further controversy arose during the late 2010s over allegations that Asperger referred children to a Nazi German clinic responsible for murdering disabled patients, although his knowledge and involvement remains unknown.

Hans Asperger with a young patient, University Paediatric Clinic, Vienna c. 1940.

Personal Life

Hans Asperger was born in Hausbrunn, Austria, and raised on a farm not far from the city. The eldest of three sons, Asperger had difficulty finding friends and was considered a lonely, remote child. He was talented in language; in particular, he was interested in the Austrian poet Franz Grillparzer, whose poetry he would frequently quote to his uninterested classmates. He also liked to quote himself and often referred to himself from a third-person perspective.

As a youth, he joined the Wandering Scholars of the Bund Neuland, a conservative Catholic organisation within the German Youth Movement. He considered this a formative experience, later stating: “I was molded by the spirit of the German youth movement, which was one of the noblest blossoms of the German spirit.”

Asperger studied medicine at the University of Vienna under Franz Hamburger and practiced at the University Children’s Hospital in Vienna. He earned his medical degree in 1931 and became director of the special education section at the university children’s clinic in Vienna in 1932. He joined the Austrofascist Fatherland Front on 10 May 1934, nine days after Chancellor Engelbert Dollfuss passed a new constitution making himself dictator. Asperger married in 1935 and had five children.

Career

During World War II, he was a medical officer, serving in the Axis occupation of Yugoslavia; his younger brother died at Stalingrad. Near the end of the war, Asperger opened a school for children with Sister Viktorine Zak. The school was bombed and destroyed, Viktorine was killed, and much of Asperger’s early work was lost.

Georg Frankl was Asperger’s chief diagnostician until he moved from Austria to America and was hired by Leo Kanner in 1937.

Asperger published a definition of autistic psychopathy in 1944 that resembled the definition published earlier by a Russian neurologist named Grunya Sukhareva in 1926. Asperger identified in four boys a pattern of behaviour and abilities that included “a lack of empathy, little ability to form friendships, one-sided conversations, intense absorption in a special interest, and clumsy movements”. Asperger noticed that some of the children he identified as being autistic used their special talents in adulthood and had successful careers. One of them became a professor of astronomy and solved an error in Newton’s work he had originally noticed as a student.  Another one of Asperger’s patients was the Austrian writer and Nobel Prize in Literature laureate, Elfriede Jelinek.

In 1944, after the publication of his landmark paper describing autistic symptoms, Hans Asperger found a permanent tenured post at the University of Vienna. Shortly after the war ended, he became director of a children’s clinic in the city. It was there that he was appointed chair of pediatrics at the University of Vienna, a post he held for twenty years. He later held a post at Innsbruck. Beginning in 1964, he headed the SOS-Kinderdorf in Hinterbrühl. He became professor emeritus in 1977, and died three years later. AS was named after Hans Asperger and officially recognised in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1994; it was removed from DSM-5 in 2013.

Posthumous Developments

Asperger Syndrome Diagnosis

Asperger died before his identification of this pattern of behaviour became widely recognised. This was in part due to his work being exclusively in German and as such it was little-translated; medical academics, then as now, also disregarded Asperger’s work based on its merits or lack thereof. English researcher Lorna Wing proposed the condition Asperger’s syndrome in a 1981 paper, Asperger’s syndrome: a clinical account, that challenged the previously accepted model of autism presented by Leo Kanner in 1943. It was not until 1991 that an authoritative translation of Asperger’s work was made by Uta Frith; before this AS had still been “virtually unknown”. Frith said that fundamental questions regarding the diagnosis had not been answered, and the necessary scientific data to address this did not exist. Unlike Kanner, who overshadowed Asperger, the latter’s findings were ignored and disregarded in the English-speaking world in his lifetime.

In the early 1990s, Asperger’s work gained some notice due to Wing’s research on the subject and Frith’s recent translation, leading to the inclusion of the eponymous condition in the International Statistical Classification of Diseases and Related Health Problems 10th revision (ICD-10) in 1993, and the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders 4th revision (DSM-IV) in 1994, some half a century after Asperger’s original research.

Despite this brief resurgence of interest in his work in the 1990s, AS remains a controversial and contentious diagnosis due to its unclear relationship to the autism spectrum. In 2010 there was a majority consensus to subsume AS into the diagnosis “Autistic Spectrum Disorder” in the 2013 DSM-5 diagnostic manual. The World Health Organisation’s ICD-10 Version 2015 describes AS as “a disorder of uncertain nosological validity”.

In his 1944 paper, as Uta Frith translated from the German in 1991, Asperger wrote, “We are convinced, then, that autistic people have their place in the organism of the social community. They fulfil their role well, perhaps better than anyone else could, and we are talking of people who as children had the greatest difficulties and caused untold worries to their care-givers.” Based on Frith’s translation, however, Asperger initially stated: “Unfortunately, in the majority of cases the positive aspects of autism do not outweigh the negative ones.” Psychologist Eric Schopler wrote in 1998:

Asperger’s own publications did not inspire research, replication, or scientific interest prior to 1980. Instead, he laid the fertile groundwork for the diagnostic confusion that has grown since 1980.

Since 2009, Asperger’s birthday, 18 February, has been declared International Asperger’s Day by various governments.

Nazi Involvement

Edith Sheffer, a modern European history scholar, wrote in 2018 that Asperger cooperated with the Nazi regime, including sending children to the Spiegelgrund clinic which participated in the euthanasia programme. Sheffer wrote a book further elaborating on her research called Asperger’s Children: The Origins of Autism in Nazi Vienna (2018).

Another scholar and historian from the Medical University of Vienna, Herwig Czech concluded in a 2017 article in the journal Molecular Autism, which was published in April 2018:

Asperger managed to accommodate himself to the Nazi regime and was rewarded for his affirmations of loyalty with career opportunities. He joined several organisations affiliated with the NSDAP (although not the Nazi party itself), publicly legitimised ‘race hygiene’ policies including forced sterilisations and, on several occasions, actively cooperated with the child ‘euthanasia’ programme.

Dean Falk, American anthropologist from Florida State University, questioned Herwig Czech’s and Edith Sheffer’s allegations against Hans Asperger in a paper in Journal of Autism and Developmental Disorders. Czech’s reply was published in the same journal. Falk defended her paper against Czech’s reply in a second paper.

In May 2019, Ketil Slagstad, a Norwegian doctor and historical scholar, added his interpretation of both Sheffer’s and Czech’s work, in his article “Asperger, the Nazis and the children – the history of the birth of a diagnosis”, in which he describes the nuances of the situation. He offers an alternative explanation of Asperger’s involvement: citing the challenges of war, a desire to protect his career, and protection of the children for whom he was caring. Slagstad concludes:

The story of Hans Asperger, Nazism, murdered children, post-war oblivion, the birth of the diagnosis in the 1980s, the gradual expansion of the diagnostic criteria and the huge recent interest in autism spectrum disorders exemplify the historical and volatile nature of diagnoses: they are historic constructs that reflect the times and societies where they exert their effect.

Critically, Slagstad noted “Historical research has now shown that he [Asperger] was…a well-adapted cog in the machine of a deadly regime. He deliberately referred disabled children to the clinic Am Spiegelgrund, where he knew that they were at risk of being killed. The eponym Asperger’s syndrome ought to be used with awareness of its historical origin.”

What is Experiential Avoidance?

Introduction

Experiential avoidance (EA) has been broadly defined as attempts to avoid thoughts, feelings, memories, physical sensations, and other internal experiences – even when doing so creates harm in the long-run.

The process of EA is thought to be maintained through negative reinforcement – that is, short-term relief of discomfort is achieved through avoidance, thereby increasing the likelihood that the behaviour will persist. Importantly, the current conceptualisation of EA suggests that it is not negative thoughts, emotions, and sensations that are problematic, but how one responds to them that can cause difficulties. In particular, a habitual and persistent unwillingness to experience uncomfortable thoughts and feelings (and the associated avoidance and inhibition of these experiences) is thought to be linked to a wide range of problems.

Background

EA has been popularised by recent third-wave cognitive-behavioural theories such as acceptance and commitment therapy (ACT). However, the general concept has roots in many other theories of psychopathology and intervention.

Psychodynamic

Defence mechanisms were originally conceptualised as ways to avoid unpleasant affect and discomfort that resulted from conflicting motivations. These processes were thought to contribute to the expression of various types of psychopathology. Gradual removal of these defensive processes are thought to be a key aspect of treatment and eventually return to psychological health.

Process-Experiential

Process-experiential therapy merges client-centred, existential, and Gestalt approaches. Gestalt theory outlines the benefits of being fully aware of and open to one’s entire experience. One job of the psychotherapist is to:

“explore and become fully aware of [the patient’s] grounds for avoidance” and to “[lead] the patient back to that which he wishes to avoid”.

Similar ideas are expressed by early humanistic theory:

“Whether the stimulus was the impact of a configuration of form, color, or sound in the environment on the sensory nerves, or a memory trace from the past, or a visceral sensation of fear or pleasure or disgust, the person would be ‘living’ it, would have it completely available to awareness…he is more open to his feelings of fear and discouragement and pain…he is more able fully to live the experiences of his organism rather than shutting them out of awareness.”

Behavioural

Traditional behaviour therapy utilises exposure to habituate the patient to various types of fears and anxieties, eventually resulting in a marked reduction in psychopathology. In this way, exposure can be thought of as “counter-acting” avoidance, in that it involves individuals repeatedly encountering and remaining in contact with that which causes distress and discomfort.

Cognitive

In cognitive theory, avoidance interferes with reappraisals of negative thought patterns and schema, thereby perpetuating distorted beliefs. These distorted beliefs are thought to contribute and maintain many types of psychopathology.

Third-Wave Cognitive-Behavioural

The concept of EA is explicitly described and targeted in more recent CBT modalities including acceptance and commitment therapy (ACT), dialectical behaviour therapy (DBT), functional analytic psychotherapy (FAP), and behavioural activation (BA).

Associated Problems

  • Distress is an inextricable part of life; therefore, avoidance is often only a temporary solution.
  • Avoidance reinforces the notion that discomfort, distress and anxiety are bad, or dangerous.
  • Sustaining avoidance often requires effort and energy.
  • Avoidance limits one’s focus at the expense of fully experiencing what is going on in the present.
  • Avoidance may get in the way of other important, valued aspects of life.

Empirical Evidence

  • Laboratory-based thought suppression studies suggest avoidance is paradoxical, in that concerted attempts at suppression of a particular thought often leads to an increase of that thought.
  • Studies examining emotional suppression and pain suppression suggest that avoidance is ineffective in the long-run. Conversely, expressing unpleasant emotion results in short-term increases in arousal, but long-term decreases in arousal.
  • Exposure-based therapy techniques have been shown to be effective in treating a wide range of psychiatric disorders.
  • Numerous self-report studies have linked EA and related constructs (avoidance coping, thought suppression) to psychopathology and other forms of dysfunction.

Relevance to Psychopathology

Seemingly disparate forms of pathological behaviour can be understood by their common function (i.e., attempts to avoid distress). Some examples can be seen in the Table below.

DiagnosisExample BehavioursTarget of Avoidance
Major Depressive DisorderIsolation/suicideFeelings of sadness, guilt, and/or low self-worth.
PTSDAvoiding trauma reminders, hypervigilanceMemories, anxiety, concerns of safety.
Social PhobiaAvoiding social situationsAnxiety, concerns of judgement from others.
Panic DisorderAvoiding situations that might induce panicFear, physiological sensations.
AgoraphobiaRestricting travel outside of home or other ‘safe areas’Anxiety, fear of having symptoms of panic.
Obsessive-Compulsive DisorderChecking/ritualsWorry of consequences (e.g. contamination).
Substance Use DisordersAbusing alcohol/drugsEmotions, memories, withdrawal symptoms
Eating DisordersRestricting food intake, purgingWorry about becoming ‘overweight’, fear of losing control.
Borderline Personality DisorderSelf-harm (e.g. cutting)High emotional arousal.

Relevance to Quality of Life

Perhaps the most significant impact of EA is its potential to disrupt and interfere with important, valued aspects of an individual’s life. That is, EA is seen as particularly problematic when it occurs at the expense of a person’s deeply held values. Some examples include:

  • Putting off an important task because of the discomfort it evokes.
  • Not taking advantage of an important opportunity due to attempts to avoid worries of failure or disappointment.
  • Not engaging in physical activity/exercise, meaningful hobbies, or other recreational activities due to the effort they demand.
  • Avoiding social gatherings or interactions with others because of the anxiety and negative thoughts they evoke.
  • Not being a full participant in social gatherings due to attempts to regulate anxiety relating to how others are perceiving you.
  • Being unable to fully engage in meaningful conversations with others because one is scanning for signs of danger in the environment (attempting to avoid feeling “unsafe”).
  • Inability to “connect” and sustain a close relationship because of attempts to avoid feelings of vulnerability.
  • Staying in a “bad” relationship to try to avoid discomfort, guilt, and potential feelings of loneliness a break-up might entail.
  • Losing a marriage or contact with children due to an unwillingness to experience uncomfortable feelings (e.g. achieved through drug or alcohol abuse) or symptoms of withdrawal.
  • Not attending an important graduation, wedding, funeral, or other family event to try to avoid anxiety or symptoms of panic.
  • Engaging in self-destructive behaviours in an attempt to avoid feelings of boredom, emptiness, worthlessness.
  • Not functioning or taking care of basic responsibilities (e.g. personal hygiene, waking up, showing up to work, shopping for food) because of the effort they demand and/or distress they evoke.
  • Spending so much time attempting to avoid discomfort that one has little time for anyone or anything else in life.

Measurement

Self-Report

The Acceptance and Action Questionnaire (AAQ) was the first self-report measure explicitly designed to measure EA, but has since been re-conceptualised as a measure of “psychological flexibility”. The 62-item Multidimensional Experiential Avoidance Questionnaire (MEAQ) was developed to measure different aspects of EA. The Brief Experiential Avoidance Questionnaire (BEAQ) is a 15-item measure developed using MEAQ items, which has become the most widely used measure of experiential avoidance.

What is Avoidance Coping?

Introduction

In psychology, avoidance coping is a coping mechanism and form of experiential avoidance.

It is characterized by a person’s efforts, conscious or unconscious, to avoid dealing with a stressor in order to protect oneself from the difficulties the stressor presents. Avoidance coping can lead to substance abuse, social withdrawal, and other forms of escapism. High levels of avoidance behaviours may lead to a diagnosis of avoidant personality disorder, though not everyone who displays such behaviours meets the definition of having this disorder. Avoidance coping is also a symptom of post-traumatic stress disorder (PTSD) and related to symptoms of depression and anxiety. Additionally, avoidance coping is part of the approach-avoidance conflict theory introduced by psychologist Kurt Lewin.

Literature on coping often classifies coping strategies into two broad categories: approach/active coping and avoidance/passive coping. Approach coping includes behaviours that attempt to reduce stress by alleviating the problem directly, and avoidance coping includes behaviours that reduce stress by distancing oneself from the problem. Traditionally, approach coping has been seen as the healthiest and most beneficial way to reduce stress, while avoidance coping has been associated with negative personality traits, potentially harmful activities, and generally poorer outcomes. However, avoidance coping can reduce stress when nothing can be done to address the stressor.

Measurement

Avoidance coping is measured via a self-reported questionnaire. Initially, the Multidimensional Experiential Avoidance Questionnaire (MEAQ) was used, which is a 62-item questionnaire that assesses experiential avoidance, and thus avoidance coping, by measuring how many avoidant behaviours a person exhibits and how strongly they agree with each statement on a scale of 1-6. Today, the Brief Experiential Avoidance Questionnaire (BEAQ) is used instead, containing 15 of the original 62 items from the MEAQ.

Treatment

Cognitive behavioural and psychoanalytic therapy are used to help those coping by avoidance to acknowledge, comprehend, and express their emotions. Acceptance and commitment therapy, a behavioural therapy that focuses on breaking down avoidance coping and showing it to be an unhealthy method for dealing with traumatic experiences, is also sometimes used.

Both active-cognitive and active-behavioural coping are used as replacement techniques for avoidance coping. Active-cognitive coping includes changing one’s attitude towards a stressful event and looking for any positive impacts. Active-behavioural coping refers taking positive actions after finding out more about the situation.

What is Self Psychology?

Introduction

Self psychology, a modern psychoanalytic theory and its clinical applications, was conceived by Heinz Kohut in Chicago in the 1960s, 70s, and 80s, and is still developing as a contemporary form of psychoanalytic treatment.

In self psychology, the effort is made to understand individuals from within their subjective experience via vicarious introspection, basing interpretations on the understanding of the self as the central agency of the human psyche. Essential to understanding self psychology are the concepts of empathy, selfobject, mirroring, idealising, alter ego/twinship and the tripolar self. Though self psychology also recognises certain drives, conflicts, and complexes present in Freudian psychodynamic theory, these are understood within a different framework. Self psychology was seen as a major break from traditional psychoanalysis and is considered the beginnings of the relational approach to psychoanalysis.

Origins

Kohut came to psychoanalysis by way of neurology and psychiatry in the 1940s, but then ’embraced analysis with the fervor of a convert … [and as] “Mr Psychoanalysis”‘ took on an idealising image of Freud and his theories. Subsequently, “in a burst of creativity that began in the mid-1960s … Kohut found his voice and explored narcissism in new ways that led to what he ended up calling a ‘psychology of the self'”.

Major Concepts

Self

Kohut explained, in 1977, that in all he wrote on the psychology of the self, he purposely did not define the self. He explained his reasoning this way: “The self…is, like all reality…not knowable in its essence…We can describe the various cohesive forms in which the self appears, can demonstrate the several constituents that make up the self … and explain their genesis and functions. We can do all that but we will still not know the essence of the self as differentiated from its manifestations.”

Empathy

Kohut maintained that parents’ failures to empathize with their children and the responses of their children to these failures were ‘at the root of almost all psychopathology’. For Kohut, the loss of the other and the other’s self-object (“selfobject”) function (see below) leaves the individual apathetic, lethargic, empty of the feeling of life, and without vitality – in short, depressed.

The infant moving from grandiose to cohesive self and beyond must go through the slow process of disillusionment with phantasies of omnipotence, mediated by the parents: ‘This process of gradual and titrated disenchantment requires that the infant’s caretakers be empathetically attuned to the infant’s needs’.

Correspondingly, to help a patient deal in therapy with earlier failures in the disenchantment process, Kohut the therapist ‘highlights empathy as the tool par excellence, which allows the creation of a relationship between patient and analyst that can offer some hope of mitigating early self pathology’.

In comparison to earlier psychoanalytic approaches, the use of empathy, which Kohut called “vicarious introspection”, allows the therapist to reach conclusions sooner (with less dialogue and interpretation), and to create a stronger bond with the patient, making the patient feel more fundamentally understood. For Kohut, the implicit bond of empathy itself has a curative effect, but he also warned that ‘the psychoanalyst … must also be able to relinquish the empathic attitude’ to maintain intellectual integrity, and that ’empathy, especially when it is surrounded by an attitude of wanting to cure directly … may rest on the therapist’s unresolved omnipotence fantasies’.

The conceptual introduction of empathy was not intended to be a “discovery.” Empathic moments in psychology existed long before Kohut. Instead, Kohut posited that empathy in psychology should be acknowledged as a powerful therapeutic tool, extending beyond “hunches” and vague “assumptions,” and enabling empathy to be described, taught, and used more actively.

Selfobjects

Selfobjects are external objects that function as part of the “self machinery” – ‘i.e. objects which are not experienced as separate and independent from the self’. They are persons, objects or activities that “complete” the self, and which are necessary for normal functioning. ‘Kohut describes early interactions between the infant and his caretakers as involving the infant’s “self” and the infant’s “selfobjects”‘.

Observing the patient’s selfobject connections is a fundamental part of self psychology. For instance, a person’s particular habits, choice of education and work, taste in life partners, may fill a selfobject-function for that particular individual.

Selfobjects are addressed throughout Kohut’s theory, and include everything from the transference phenomenon in therapy, relatives, and items (for instance Linus van Pelt’s security blanket): they ‘thus cover the phenomena which were described by Winnicott as transitional objects. Among “the great variety of selfobject relations that support the cohesion, vigor, and harmony of the adult self … [are] cultural selfobjects (the writers, artists, and political leaders of the group – the nation, for example – to which a person feels he belongs)”.

If psychopathology is explained as an “incomplete” or “defect” self, then the self-objects might be described as a self-prescribed “cure”.

As described by Kohut, the selfobject-function (i.e. what the selfobject does for the self) is taken for granted and seems to take place in a “blindzone”. The function thus usually does not become “visible” until the relation with the selfobject is somehow broken.

When a relationship is established with a new selfobject, the relationship connection can “lock in place” quite powerfully, and the pull of the connection may affect both self and selfobject. Powerful transference, for instance, is an example of this phenomenon.

Optimal Frustration

When a selfobject is needed, but not accessible, this will create a potential problem for the self, referred to as a “frustration” – as with ‘the traumatic frustration of the phase appropriate wish or need for parental acceptance … intense narcissistic frustration’.

The contrast is what Kohut called “optimal frustration”; and he considered that, ‘as holds true for the analogous later milieu of the child, the most important aspect of the earliest mother-infant relationship is the principle of optimal frustration. Tolerable disappointments … lead to the establishment of internal structures which provide the basis for self-soothing.’

In a parallel way, Kohut considered that the ‘skilful analyst will … conduct the analysis according to the principle of optimal frustration’.

Suboptimal frustrations, and maladaptations following them, may be compared to Freud’s trauma concept, or to problem solution in the oedipal phase. However, the scope of optimal (or other) frustration describes shaping every “nook and cranny” of the self, rather than a few dramatic conflicts.

Idealising

Kohut saw idealising as a central aspect of early narcissism. “The therapeutic activation of the omnipotent object (the idealized parent image) … referred to as the idealizing transference, is the revival during psychoanalysis” of the very early need to establish a mutual selfobject connection with an object of idealisation.

In terms of “the Kleinian school … the idealizing transference may cover some of the territory of so-called projective identification”.

For the young child, “idealized selfobjects “provide the experience of merger with the calm, power, wisdom, and goodness of idealized persons””.

Alter Ego/Twinship Needs

Alter ego/twinship needs refer to the desire in early development to feel alikeness to other human beings. Freud had early noted that ‘The idea of the “double” … sprung from the soil of unbounded self-love, from the primary narcissism which holds sway in the mind of the child.’ Lacan highlighted ‘the mirror stage … of a normal transitivism. The child who strikes another says that he has been struck; the child who sees another fall, cries.’ In 1960, ‘Arlow observed, “The existence of another individual who is a reflection of the self brings the experience of twinship in line with the psychology of the double, of the mirror image and of the double”.’

Kohut pointed out that ‘fantasies, referring to a relationship with such an alter ego or twin (or conscious wishes for such a relationship) are frequently encountered in the analysis of narcissistic personalities’, and termed their transference activation ‘the alter-ego transference or the twinship’.

As development continues, so a greater degree of difference from others can be accepted.

The Tripolar Self

The tripolar self is not associated with bipolar disorder, but is the sum of the three “poles” of the body:

  • “grandiose-exhibitionistic needs”.
  • “the need for an omnipotent idealized figure”.
  • “alter-ego needs”..

Kohut argued that ‘reactivation of the grandiose self in analysis occurs in three forms: these relate to specific stages of development … (1) The archaic merger through the extension of the grandiose self; (2) a less archaic form which will be called alter-ego transference or twinship; and (3) a still less archaic form … mirror transference’.

Alternately, self psychologists ‘divide the selfobject transference into three groups: (1) those in which the damaged pole of ambitions attempts to elicit the confirming-approving response of the selfobject (mirror transference); (2) those in which the damaged pole of ideals searches for a selfobject that will accept its idealisation (idealising transference); and those in which the damaged intermediate area of talents and skills seeks … alter ego transference.’

The tripolar self forms as a result of the needs of an individual binding with the interactions of other significant persons within the life of that individual.

Cultural Implications

An interesting application of self psychology has been in the interpretation of the friendship of Freud and Jung, its breakdown, and its aftermath. It has been suggested that at the height of the relationship “Freud was in narcissistic transference, that he saw in Jung an idealised version of himself”, and that conversely in Jung there was a double mix of “idealization of Freud and grandiosity in the self”.

During Jung’s midlife crisis, after his break with Freud, arguably “the focus of the critical years had to be a struggle with narcissism: the loss of an idealized other, grandiosity in the sphere of the self, and resulting periods of narcissistic rage”. Only as he worked through to “a new sense of himself as a person separate from Freud” could Jung emerge as an independent theorist in his own right.

On the assumption that “the western self is embedded in a culture of narcissism … implicated in the shift towards postmodernity”, opportunities for making such applications will probably not decrease in the foreseeable future.

Criticism

Kohut, who was “the center of a fervid cult in Chicago”, aroused at times almost equally fervent criticism and opposition, emanating from at least three other directions: drive theory, Lacanian psychoanalysis, and object relations theory.

From the perspective of drive theory, Kohut appears “as an important contributor to analytic technique and as a misguided theoretician … introduces assumptions that simply clutter up basic theory. The more postulates you make, the less their explanatory power becomes.” Offering no technical advances on standard analytic methods in “his breathtakingly unreadable The Analysis of the Self”, Kohut simply seems to blame parental deficit for all childhood difficulties, disregarding the inherent conflicts of the drives: “Where the orthodox Freudian sees sex everywhere, the Kohutian sees unempathic mothers everywhere – even in sex.”

To the Lacanian, Kohut’s exclusive “concern with the imaginary”, to the exclusion of the Symbolic meant that “not only the patient’s narcissism is in question here, but also the analyst’s narcissism.” The danger in “the concept of the sympathetic or empathic analyst who is led astray towards an ideal of devotion and samaritan helping … [ignoring] its sadistic underpinnings” seemed only too clear.

From an object relations perspective, Kohut “allows no place for internal determinants. The predicate is that a person’s psychopathology is due to unattuned selfobjects, so all the bad is out there and we have a theory with a paranoid basis.” At the same time, “any attempt at “being the better parent” has the effect of deflecting, even seducing, a patient from using the analyst or therapist in a negative transference … the empathic analyst, or “better” parent”.

With the passage of time, and the eclipse of grand narrative, it may now be possible to see the several strands of psychoanalytic theory less as fierce rivals and more “as complementary partners. Drive psychology, ego psychology, object relations psychology and self psychology each have important insights to offer twenty-first-century clinicians.”

Combat Stress and The Royal Navy and Royal Marines Charities Partnership to Deliver Mental Health Support

The Royal Navy and Royal Marines Charity has worked in partnership with Combat Stress for many years to support Royal Navy veterans with complex mental health conditions.

In 2020 the RNRMC began a three-year funding agreement with Combat Stress as part of the RNRMC’s Health and Wellbeing Support Programme. This partnership ensures that Royal Navy veterans, like Jim, will continue to receive vital support. Jim had wanted to join the Royal Navy since he was nine years old. When he was 18 that dream came true, but unfortunately his time in the services was not what he imagined.

After joining the Navy, Jim was quickly identified as a promising rugby player and spent much of his time on the rugby pitch. Playing rugby took him to several ships and shore bases over the course of 18 months, but Jim’s life was about to change forever. “In March 1992, after joining the HMS Illustrious, my life was totally changed when I was the victim of a random unprovoked attack shortly after going ashore,” he said. “My attacker, who pushed me through a plate glass window, was later charged with attempted murder. I sustained life-changing physical and mental injuries.
“Due to the nature of my injuries, I had to remain awake, un-anesthetised during surgery and I watched as the medical staff brought a priest in to administer the last rites as they didn’t think I would make it. “But I did, and once my physical injuries were stabilised, I was moved by the Royal Navy to a mental health ward where in June of 1992 I was diagnosed with PTSD. “I spent four weeks undertaking a PTSD awareness course. One element of the course was art therapy and I found painting helped me – in fact, I was encouraged to continue painting and remain busy in order to keep my PTSD at bay. I was also told not to think or talk about my trauma.

“For over 25 years I continued to paint as a way of coping and never spoke about the attack.
“After the course, I was sent back to HMS Dryad, and despite all I had been through, was encouraged to get back to rugby; however, when it came to my first match back, I was convinced I would sustain further injuries and didn’t play. “Shortly afterwards, I was offered a medical discharge which could take several months to arrange, or I could take an honorable discharge based on the exceptional circumstances which would take just 24 hours. I took the second option allowing me to leave as quickly as I could. “I left and got on with life, often travelling extensively with work in order to remain busy. I followed the instruction to keep busy, but I know now this was the wrong choice and wasn’t working.

“I used to relive seeing the priest at the end of my bed at night – just like during surgery. I also used to feel like the blood was pumping out of the scar on my head, just as it did after I’d been attacked. “It was when I was confronted by my daughter, telling me she’d come into my bedroom one night to tell me to turn the telly off that I knew I had to do something. The television wasn’t on –it was me shouting and screaming in my sleep. I knew I used to do this – I had to move into a mess of my own in the Navy because of it – but when I knew it was affecting my family, I decided to do something.”

Jim went to his GP initially and explained that he had been diagnosed with PTSD. However, he didn’t receive the support that he needed. Then in 2017 he reached out to Combat Stress. Finally, Jim started his journey towards recovery. “It wasn’t easy. I was embarrassed to call the helpline. I thought I’d been dealing with my problems but really, I’d just been told to keep busy and push everything to the back of my mind. I felt like a failure.

By working with the specialist team at Combat Stress Jim began to learn management techniques and coping strategies for his mental health issues such as hyperarousal and flashbacks. “I learnt about grounding, mindfulness and did much more art therapy. I received CBT & EMDR treatment which has significantly helped with the reliving. I no longer see the priest. Thanks to CBT/EMDR and the art therapists, I understand why I have these memories and have begun to process them. “I also found the education sessions invaluable – learning about how memories work and how the brain processes them really helped me. The peer support has also played important part of my recovery too, supporting me as I returned back to a Royal Navy shore base and the place of trauma. “Combat Stress also encouraged me to reengage with the veteran community. I hadn’t engaged in anything military since leaving the Navy.

“In 2019 I was selected to attend the Cenotaph on Remembrance Sunday. Since leaving Combat Stress, I had further medical support and discovered through a brain scan that I sustained brain injuries as a result of my attack. This injury was contributing to the sensation of blood pumping, but with medication, this is manageable. “What I learnt at Combat Stress has made a massive difference to me. I know now I needed to process my memories, not just bury them or push them away. I owe my life to the team who were on duty at the Royal Naval Hospital Stonehouse – thank you! Also, a huge thanks to Combat Stress for improving my health and knowledge, enabling me to look forward to a better future.”

If you would like to find out more about Combat Stress or how to access their support, please visit their website, or call their 24 hour helpline on 0800 138 1619.

Reference

Navy News. (2021) Jim’s Journey Out of the Darkness. Navy News. July 2021, pp.33.

What is World Mental Health Day (2021)?

Introduction

World Mental Health Day (10 October) is an international day for global mental health education, awareness and advocacy against social stigma.

Background

It was first celebrated in 1992 at the initiative of the World Federation for Mental Health, a global mental health organisation with members and contacts in more than 150 countries.

This day, each October, thousands of supporters come to celebrate this annual awareness programme to bring attention to mental illness and its major effects on peoples’ lives worldwide.

In some countries this day is part of an awareness week, such as Mental Health Week in Australia.

Brief History

World Mental Health Day was celebrated for the first time on 10 October 1992, at the initiative of Deputy Secretary General Richard Hunter. Up until 1994, the day had no specific theme other than general promoting mental health advocacy and educating the public.

In 1994 World Mental Health Day was celebrated with a theme for the first time at the suggestion of then Secretary General Eugene Brody. The theme was “Improving the Quality of Mental Health Services throughout the World”.

World Mental Health Day is supported by WHO through raising awareness on mental health issues using its strong relationships with the Ministries of health and civil society organizations across the globe. WHO also supports with developing technical and communication material.

On World Mental Health Day 2018, Prime Minister Theresa May appointed Jackie Doyle-Price as the UK’s first suicide prevention minister. This occurred while as the government hosted the first ever global mental health summit.

World Mental Health Day Themes

  • 1994 – Improving the Quality of Mental Health Services throughout the World.
  • 1996 – Women and Mental Health.
  • 1997 – Children and Mental Health.
  • 1998 – Mental Health and Human Rights.
  • 1999 – Mental Health and Aging.
  • 2000-2001 – Mental Health and Work.
  • 2002 – The Effects of Trauma and Violence on Children & Adolescents.
  • 2003 – Emotional and Behavioural Disorders of Children & Adolescents.
  • 2004 – The Relationship Between Physical & Mental Health: co-occurring disorders.
  • 2005 – Mental and Physical Health Across the Life Span.
  • 2006 – Building Awareness – Reducing Risk: Mental Illness & Suicide.
  • 2007 – Mental Health in A Changing World: The Impact of Culture and Diversity.
  • 2008 – Making Mental Health a Global Priority: Scaling up Services through Citizen Advocacy and Action.
  • 2009 – Mental Health in Primary Care: Enhancing Treatment and Promoting Mental Health.
  • 2010 – Mental Health and Chronic Physical Illnesses.
  • 2011 – The Great Push: Investing in Mental Health.
  • 2012 – Depression: A Global Crisis.
  • 2013 – Mental health and older adults.
  • 2014 – Living with Schizophrenia.
  • 2015 – Dignity in Mental Health.
  • 2016 – Psychological First Aid.
  • 2017 – Mental health in the workplace.
  • 2018 – Young people and mental health in a changing world.
  • 2019 – Mental Health Promotion and Suicide Prevention.
  • 2020 – Move for mental health: Increased investment in mental health.
  • 2021 – Mental Health in an Unequal World.