Editorial

This issue of Psychoanalytic Psychotherapy, with papers from Germany, the UK and Italy, explores from a psychoanalytic perspective the concepts of trauma, depression and personality disorder, the relationships between them, and the limitations of conventional diagnostic categories. The first paper, ‘Childhood trauma from a patient and a psychoanalyst perspective: linking chronic depression to relational multiple trauma’ by Alexa Negele, Johannes Kaufhold and Marianne Leuzinger-Bohleber, examines the relationship between multiple childhood trauma, adversity and chronic depression. This is the second paper published in Psychoanalytic Psychotherapy by researchers from the LAC depression study, a major, multi-site, ongoing comparative study of outcomes of psychoanalytical and cognitive behavioural long-term treatments of chronically depressed patients conducted at the Sigmund Freud Institute in Frankfurt (see Leuzinger-Bohleber, Kallenbach, & Schoett, 2016). Findings from the LAC study showed that three quarters of participating patients reported clinically relevant histories of childhood trauma. This paper examines a subsample of patients in the larger LAC study, comparing patient self-ratings of trauma with their treating psychoanalysts’ perspectives, the results of which support the connection between multiple childhood trauma and chronic depression. These findings are illustrated with detailed clinical material from one of the patients who participated in the LAC study from the beginning of his therapy to five-year follow-up, which convincingly demonstrates how the patient was able to gain insight into the effects that his childhood traumatic experiences had on his adult relationships and mental health due to a psychoanalytic therapeutic process in which both the patient and the analyst worked together to reconstruct the meaning of traumatic experiences. The emerging findings from LAC study complement the results of the Tavistock Adult Depression Study (TADS) (Fonagy et al., 2015) which showed the efficacy of psychoanalytic psychotherapy in patients with treatment-resistant depression, and are of crucial importance in demonstrating to influential advisory bodies such as the National Institute for Health and Care Excellence (NICE) that psychoanalytic psychotherapy has been empirically shown to be effective for depression.

The second paper in this issue, ‘A new diagnosis of complex post-traumatic stress disorder (PTSD): A window of opportunity for the treatment of patients in the NHS?’ by Catherine Matheson, also focuses on trauma, and discusses the proposals and implications of changes in the taxonomy of post-traumatic stress-disorder (PTSD) with the inclusion of a new diagnostic category of ‘complex PTSD’ in the next revision of the World Health Organization’s International Classification of Diseases (ICD-11), due to be published next year. The author starts with a well-researched and comprehensive historical review of the diagnosis of PTSD, from psychoanalytic, medical, sociological and cultural perspectives. She then examines the ramifications of the new diagnosis of complex PTSD, including its possible aetiology, co-morbidity with personality disorders, and treatments that might be both effective and available in the National Health Service (NHS). Matheson goes on to movingly describe how psychodynamically informed group treatments that she and her colleagues have developed help to contain and support two severely traumatized groups: refugees from the war in Sri Lanka and women who have been sexually abused. Whilst this new diagnostic category may provide some benefits by highlighting the complex nature of traumatic illness, it also exposes the limitations of the current taxonomic systems in continuing to create more diagnostic categories which purport to be distinct from others but may actually share similar underlying pathological mechanisms. Thus it is likely, as Matheson notes, that many of the patients who will meet criteria for complex PTSD may have been previously diagnosed with borderline personality disorder, illustrating the complexity and severity of the psychopathology with which an ever greater proportion of patients present to secondary mental health services today.

The third paper, ‘The relationship between personality organization and sexual life in a community sample of men’ by Antonio Prunas, Rossella di Piero and Roberto Bernorio, explores the relationship between dimensions of Kernberg’s borderline personality organization, sexual functioning, quality of sexual life and paraphilias (unusual, perverse or deviant sexual practices). Research into the relationship between paraphilias and personality disorder is limited and is in fact one of the areas that my colleagues and I are currently researching at the Portman Clinic (a forensic out-patient clinic within the Tavistock and Portman NHS Foundation Trust in London). Unlike our patients at the Portman Clinic who seek help for their paraphilias and other problematic sexual behaviours, the sample in Prunas’ study was on 136 healthy adult Italian male volunteers who had responded to an invitation to take part in an online survey investigating the relationship between sexuality and personality characteristics. Level of personality organization, sexual functioning, quality of sexual life and the presence of paraphilias were obtained via self-report questionnaires, and the results showed that those men who could be classified as having a more disturbed, borderline, level of personality organization were significantly more likely to report sexual difficulties than the men with less disturbed personality features. The authors’ findings suggest that the assessment of personality function in patients referred for sexual difficulties is important for prognosis and treatment, and support our psychoanalytic understanding that paraphilias and personality disorders are not distinct diagnostic categories, but that problematic sexual fantasies and behaviours are symptoms of underlying personality difficulties and it is these which become the focus of treatment, rather than the behaviours themselves.

Finally, we pay tribute to Professor Gill McGauley in ‘Remembering Gill McGauley’ by Gill’s close friend and colleague, Gwen Adshead. Tragically, Gill died suddenly and unexpectedly in July of this year from cancer of the oesophagus. Gill was Professor of Medical Education and Forensic Psychotherapy at St George’s Hospital, London, and a valued contributor and reviewer of this journal, and was Guest Editor of the recently published Special Issues on Forensic Psychotherapy. As well as being a very accomplished clinician, teacher and researcher she was always warm, witty, kind, compassionate and loyal, as well as modest about her many achievements, and she leaves behind her cherished family, friends and colleagues who will miss her sorely.

Jessica Yakeley
Tavistock and Portman NHS Foundation Trust, London, UK
[email protected]