100174576 Tania is 20 years old, and can’t sleep without the light shining in her room at night. She also has installed at her personal expense two extra locks on her room door in an apartment she shares with 2 other girlfriends. She feels she must be in before it gets dark, so her social life is very restricted. Tania also controls her food intake carefully, and though she isn’t under-weight, she consumes exactly 1800 calories each day. If she goes out to a meal she will attempt to fit in by eating, but will fast the next day. Tania’s parents are high achievers, and she is an only child. Because of their heavy work demands, Tania was raised from birth by a series of professionals. She has very little recollection of her childhood, but when prompted, denies any traumatic events or abuse.” From a Psychodynamic (PD) viewpoint, Tania (T) appears to suffer from a number of specific, situational phobias corresponding to a broad definition of a circumscribed Generalised Anxiety Disorder (Lydiard, 2000), which developed as a maladaptive response to the demands made upon her as a child. Sleep disturbances, eating disorders and excessive anxiety are crucially connected to early sexual memories in female samples (Fairburn et al., 1997; Fallon & Wonderlich, 1997; Pelekis et al., 2004), and we know from the work of Freud (2003/1920) and other PD theories, that an active unconscious is responsible for the repression and substitution of painful memories that threaten the status of the ego (MacLeod, 1998). Simply categorising T’s problems into an Axis I, Axis II or Cluster C disorder does not, however, provide the clearest approach to treatment. Psychodynamic Psychotherapies (PDPTs) are unlikely to use medical (DSM) diagnoses, preferring to formulate the problems within the theoretical landscape of traditional psychoanalysis. First, PD approaches to psychopathology will be discussed, with specific links to T’s symptoms, and an Affect Phobia Treatment will be described and suggested as a short-term dynamic treatment programme. PD models assume that psychic life takes place outside of conscious awareness and progression through the psychosexual stages of childhood crucially influence the development of the unconscious (MacLeod, 1998). Freud settled on the idea that anxiety was a warning that repressed sexual energy was on the verge of breaking through to consciousness, resulting in the unconscious, but purposeful, exclusion of painful, unacceptable thoughts from conscious awareness, by means of ego defences (MacLeod, 1998). Thus patients may not consciously remember childhood traumatic experiences. The goal of PDPT is to uncover the underlying problems of the patient by facilitating their insight into the nature of
their unconscious conflict, which requires bypassing defences which over the years have kept this material unconscious (Macleod, 1998). Within a PD setting, the positive relationship between the therapist and client is fundamental. As in all therapies, there is a danger of abuse on the part of the therapist, but the evidence for the effectiveness of short- and long-term PD treatments for a variety of anxiety disorders, (Rouillon, 2004; Knekt et al., 2007; Ferrero et al., 2007; Anderson & Lambert, 1995) far outweighs the dearth of literature suggesting otherwise (Eysenck, 1965). It has been said that the sheer comprehensiveness of PD theories make them difficult to test, but recent research has demonstrated that many of Freud’s theories have been and are being tested, providing new hope for psychoanalysis (PA) oriented, PD models (Solms, 2006). Fonagy, (2000) finds that brief dynamic PTs and other derivatives of PA provide considerable gains, superior to other therapies and no treatment and that PA consistently ‘helps’ patients overcome milder neurotic disorders. Many ideas central to PD approaches emerged from Freud’s ‘Affect-Trauma’ phase psychology. The emphasis on external traumatic events as instigators of pathology and the idea that repressed traumatic experience may lie behind patient psychopathology (PP), remain core to the treatment of neuroses, along with the notion of quantities of affect, held back in a ‘pent-up’ state. Other PD concepts of mental energy and its discharge, as well as ‘defences’, remain central to many PTs (Sandler et al., 1972). To understand PD theories it is important to conceive of ‘mental apparatus’ as representing the psychological organisation within which the processes of ‘damming up’ of frustrated libidinal (unconscious) energies and the ego’s defences (to threats to consciousness) occur. Development brings the ego into existence with a constitutional disposition for splitting off memories and ideas that are incompatible with consciousness, (Sandler, et al., 1972). The pathogenic process is seen as a particular adaptation to disequilibrium within the mental apparatus, caused by intense charges of affective energy associated with certain ideas (mental trauma or actual neurosis). Special emphasis is placed on sexual experiences that lead to a state of ‘dammed up’ affect which find psychopathological, unconscious expression, due to the egos defences (Sandler et al., 1972). Freud believed that the specific cause of anxiety neurosis was the accumulation of sexual tension, produced by abstinence or unconsummated sexual excitation (2003/1920).
Phobias do not ‘make sense’. They are irrational fears making them open to the science of the irrational. Phobic phenomena are typical during certain periods of childhood, and adult phobias can often be traced back to earlier forms that preceded them (Ward, 2001). Genetic arguments cannot however, account for the notable incapacity that overwhelms the phobic individual when faced with the object of their fear (Ward, 2001). Nyctophobia: “Tania…can’t sleep without the light shining in her room at night... She feels she must be in before it gets dark, so her social life is very restricted…” Simple phobias comprise of an intense fear of certain objects or situations and a corresponding desire to avoid being in their presence (Bergin & Garfield, 1994). Fears and anxiety that emerge during childhood are known to dissipate over time often with no long-term deleterious effects, but there are more extreme variations that seem to impair daily performance and are not likely to disappear over time. Social Phobia (Social anxiety disorder) is a disorder characterised by an intense fear of embarrassment or humiliation in social and performance settings. The higher number of fears held psychologically, socially and functionally, the more impaired people seem to be (Vriends et al, 2007). It is reasonable to imply that T’s fear of the dark reflects a simple (specific) part of a circumscribed social phobia (which includes her fear of eating in public). This fear could have been instigated in childhood after some kind of trauma occurring at night and in the dark. Freud would say that T had experienced some kind of sexual seduction or frustration in childhood, where she would have taken a passive role, carrying feelings of guilt around potentially enjoying the sexual stimulation (as would be expected of most curious young people, discovering the ‘pleasure principle’ behind their sexual organisms and impulses – the domain of the ‘id’). These statements are not necessarily predictions but within a PD framework, the possibility is allowed for, and with T’s visible risk, at being in the care of so many adults that were not her parents, it does seem plausible. Food: “Tania also controls her food intake carefully, and though she isn’t under-weight, she consumes exactly 1800 calories each day. If she goes out to a meal she will attempt to fit in by eating, but will fast the next day.”
Vriends et al., (2007) would see this behaviour as another aspect of a circumscribed Social phobia related to the performance-oriented situation of eating in public. From the information about T, it would seem that this specific phobia, is somewhat milder than her fear of the dark, because T does eat, but controls her calorific intake rigidly, indicating a classic maladaptation to an early sense of being out of control, and vulnerable (as is the case with most childhood sexual abuse – CSA cases). The additional fact that once facing her fear and eating in public, T feels that it is just a performance and later punishes herself by fasting and completely limiting her calorific intake, could be seen as an attempt to compensate for and ‘deal with’ the ensuing level of affective arousal achieved through the act of eating. Trying to ‘numb out’ through starvation suggests some underlying unconscious conflict that could reflect a maladaptation to some early trauma. This sort of pathological behaviour, from a PD perspective, is seen to be stemming from early experiences in life, when the psychic structures are not strong enough to process the input from the environment. Sclerophobia; She also has installed at her personal expense two extra locks on her room door in an apartment she shares with 2 other girlfriends. Schlerophobia is a PA term, seen as a fear of bad men, or burglars (Ward, 2001). This phobia may have been laid down in response to a very real threat of having personal space invaded (by a man) and further still, being penetrated or molested by such a man. This could support our hypothesis that it is possible T experienced some early CSA, which may have involved a man (though it could have been a woman) invading into T’s very personal space, and causing a serious trauma that required immediate repression or substitution. This repressed energy could, from a PA standpoint, lead to a desire to be sexually active in order to consciously deal with the frustration, hence the need for T to lock herself in. If the act of being sexual arose terrible feelings that your consciousness aims to keep at bay, barricading yourself inside would be seen as avoiding being out and about and vulnerable to attack, or temptation. This physical barrier that T routinely enforces (to an almost obsessional-compulsive degree) seems to act as a metaphor for T wanting to keep something out physically, mirroring a desire to keep certain ideas out of consciousness. This physical manifestation of barrier building symbolises the psychic ego-process of repression.
From a PD view, phobias represent a defence against anxiety, rooted in repressed impulses from the id: the source of instinctual drives (libido and thanatos); the 1 st structure to appear in infancy; operating with Freud’s ‘pleasure principle’ (Freud, 2003/1920). Anxiety is displaced onto something that has a symbolic relationship to the real object of anxiety. Generalised anxiety results from an unconscious conflict between the ego and id impulses that is not adequately dealt with because the person’s defence mechanisms have broken down (Freudians would say that primarily aggressive and sexual impulses have been either blocked from expression or punished upon expression, leading to anxiety). In phobias, defence mechanisms of repression or displacement are operative (Carlson et al., 2000). Parents/Caregivers: “Tania’s parents are high achievers, and she is an only child. Because of their heavy work demands, Tania was raised from birth by a series of professionals.” It is difficult to say at this stage whether T’s hypothesised early trauma (be it sexual or not), was brought about through simple separation anxiety, chronic disappointment about not really being raised by her parents, or actual CSA. The chances that high-achievers prioritise their attachments to their children appears to be contradictory to their goals as high-achievers (unless of course, they measured their success and wealth on the basis of a strong, secure, emotional attachment to their child). It would be safe to say that, being raised by a number of caregivers put T at substantial risk of developing insecure, ambivalent and avoidant attachments and of not forming very secure ones, not only to her parents, but to the multitude of ‘professionals’ her parents would hire to bring her up whilst they were busy with their careers. The work of Bowlby, (1980) supports this idea that a child ultimately benefits from building close, reliable and dependable connections to their parents, above and beyond the relationships they may form with other people who care for them, and that feeling a sense of separation, even rejection from parents, early on in life, is associated with a known constellation of risk factors for later mental health and attachment problems which could lead someone to isolate and fear intimacy. Attachment theory is crucial in explaining the consequences of childhood adversities on adulthood interpersonal functioning. In T’s case, her early, damaging and chronic separation from her parents and the subsequent feelings of powerlessness could be an aetiological factor in her developing circumscribed social phobias around eating, in a specific performance oriented situation, and controlling food intake in general. Indirectly, T’s problems may
be due to not her being or feeling connected to or protected by her parents early on in life, during whatever traumatic event may have instigated her nyctophobia and sclerophobia. It is also important to note that, CSA, is known to lead to eating control behaviours and sleep disturbances, so the proposition that T may have suffered some early abuse reflects a unique contribution of PD approaches to individual PP, in that this horrendous possibility, is allowed for and is able to be dealt with in therapy, even if there is some resistance on the part of the patient’s ego, to consciously look at these possible sources of disturbance. Memories: “She has very little recollection of her childhood, but when prompted, denies any traumatic events or abuse.” CSA is identified as a significant risk factor for mental disorders and interpersonal problems in women (Fairburn et al., 1997; Fallon & Wonderlich, 1997; Pelekis et al., 2004). The National Comorbidity Survey showed that CSA had an independent effect in 14 mood, anxiety and substance use disorders in women (Molnar et al, 2001). The relative contributions of CSA and Family Background Risk Factors on the development of mental disorder in adulthoods have aetiological and important therapeutic consequences (Mullen et al., 2000). The relationship to both mother and father was significantly worse in CSA group in Pelekis et als., (2004) study and the main finding was that women treated for anxiety disorders, with a history of CSA, have significantly higher load of all childhood adversities compared to those without CSA. Factors of interpersonal sensitivity and paranoid ideation were significantly worse than the norm in CSA patients (Pelekis et al., 2004). Finally, Ryon et al., (2000) suggested CSA was predictive of internalising problems (such as anxiety). It is assumed that CSA is a severely traumatic event that being exposed to early in life could result in some neurotic disturbances, typified in the case of T. T does not report any conscious memories of traumatic happenings but she also admits to not really remembering anything from her childhood altogether. This global amnesia, would indicate some sort of repression or occlusion of traumatic events; something that would be seen as a reasonable response, in order to protect T’s fragile ego and hold back, any disturbing or traumatic memories (that essentially need to be brought into conscious, if they are to release their pathological control over T’s behaviour and anxieties). The
fear of the dark, of being broken into, of eating in public, all point towards T being fundamentally unhappy, the fact that she can not remember any reason why she might manifest these symptoms, and the fact that she doesn’t remember very much at all, combined with the fact that she was put at considerable risk in her childhood, of forming numerous, potentially abusive relationships yet none with her actual parents, all seem to suggest that T’s symptoms are somewhat to be expected. This configuration stands out, alone, within the PD approach to individual PP.
Ward (2001) says that the phobic person does not really know why they are afraid, and that recognition of the irrationality makes little difference to its psychical reality. In the grip of a phobic reaction, the individual exists in a state of knowing something and not knowing it at the same time. Growing up not only offers opportunities and rewards but also entails significant losses, which require some degree of attention: phobia is seen as the result of an impasse to development; the construction of which may be a more permanent way to avoid the unwanted demands of reality from entering into consciousness (Ward, 2001). The possibility that traumatic experiences can be utterly forgotten due to repression and then somehow recovered intact later is thought to be relatively common (Carlson et al., 2000). Treatment:
PDPT focuses on individual personality dynamics deriving from a PA oriented perspective, following on from Freud’s fascination with thermodynamics (the underlying model relating the channelling and transformations that occur in the energy contained in human drives and motives) (Carlson et al., 2000). The interactional field of patient and therapist, their alliance and dyadic characteristics all have an impact on the outcome of therapy (Bergin & Garfield, 1994). PD oriented techniques aim to provoke, in the patient, limited psychogenetic understanding of the focal problem (Bergin & Garfield, 1994). A primary goal in T’s PDPT would be to establish if anxiety was present in childhood and if there are any occluded memories of trauma. PD Therapy is a dynamic, interactive process. Therapists have to decide whether the primary need for the client at any particular moment is to be contained and made to feel safe, to be understood or to be challenged. Containment, reflection and interpretation define the broad categories of types of responses therapists may make to their client in a session (Llewelyn & Hardy, 2001). McCullough’s Affect phobia therapy (APT) is based on the hypothesis that conflicts about feelings (affect phobias) are fundamental issues underlying many Axis I and Axis II disorders. Stepwise exposure and defence response prevention represent the fundamental agents of therapeutic change aimed at resolving affective conflicts within a PD framework (McCullogh & Andrews, 2001). Using Malan’s (1976) ‘two triangles’ as a blueprint for the PD formulation and intervention, a working hypothesis accelerates the process of defence restructuring, affect restructuring and the restructuring of inner images of self and other, which are interwoven through treatment in the form of therapist reflection and questioning. Endicott et als., (1976) Global Assessment of Functioning Scale (GAF) provides a good measure of appropriateness for this form of short-term treatment; patients with scores above 50 of the GAF, say McCullough & Andrews, (2001), benefit from this treatment. The APT therapist does not remain neutral or silent as in traditional Long-term options, meaning that the transference neurosis (exclusive to PD techniques) is not allowed to fully develop. APT encourages a collaborative, ‘emotionally-present’ stance, actively pursuing a healing connection through encouragement, guidance and direction, focussing on feelings of closeness and acceptance to create a ‘holding environment’ within which rapid growth and change may take place. This integrative model of Short-Term Dynamic Psychotherapy (STDP) builds on 50 years of research on STDPs by Malan, (1976) and at least 2 clinical trials have demonstrated it’s efficacy for treating Axis II and Cluster C disorders, resulting in significant character change in as few as
20-40 sessions (McCullough & Andrews, 2001).
T’s recommended treatment would be one similar to APT, if not APT itself. She requires a psychoanalytic space, within which she can build a therapeutic relationship with someone who can encourage her to explore the hidden meaning to her neurotic behaviours. It may take some time, but all the indicators point towards there being large elements of unconscious, repressed urges to her manifest symptomatology. Providing T scores above 50 on the GAF test, a process of interview and more traditional counselling (listening) type sessions, with active engagement from the therapist (whose goal is to assist T in developing a conscious understanding of the unconscious processes underlying her problems) could proceed. One problem anticipated here is that T sounds as though she may be resistant to these probes into the unknown, as illustrated by her admission of having no recall of traumatic experience. What the therapist should do, is help T to understand that, simply being separated so much from her parents was traumatic for her as a child, whether or not CSA occurred. Allowing for the possibility that there are some things T may not want to remember, may lead to charged reactions and even threats to cease treatment on T’s part, but by allowing her to express herself, and experiencing affectively, her responses to such infringements upon her ego’s status, would be seen as positive and necessary in this case. Castonguay, Goldfried, Wiser, Raue & Hayes (1996) reported that the level of affective experiencing was linked positively with outcome. The possibility that T may never reclaim her memories, or that she genuinely has no traumata to recall, is considered, hence the process of restructuring (through questioning and challenging) T’s defences, phobic affects and self-concept is seen as an additional benefit of APT that could provide substantial gains for T, whether or not, she manages to uncover the root of her anxieties. ←
←
T’s therapist would do well to focus on building a firm and trusting relationship before
attempting any depth work. Hovarth and Greenberg (1994) demonstrate that a good therapeutic alliance makes a major contribution to the therapeutic outcome. Gaston (1990) proposed a multidimensional model where the alliance is composed of the working alliance (patient’s capacity to purposefully work in therapy); the therapeutic alliance (affective bond between the dyad); the therapists empathic understanding and involvement and the dyadic agreement on the goals and tasks of treatment). Interestingly, the alliance was found to be unrelated to outcome in Cognitive therapy (Crits-Cristoph et al., 1988). Mortberg et al., (2007) argue for specific dimensions of improvement for social phobics with reductions in irrational harm avoidance and improvements in self-directedness being seen as crucial for success in treating phobias, so focussing on these dimensions should form a good deal of the therapists work during sessions with T. Conclusion: Gabbard, (1990) define PDPT as an approach to diagnosis and treatment characterised by a way of thinking about both patient and clinician that includes unconscious conflict, deficits and distortions of intrapsychic structures and internal object relations. Smith et al., (1980) found compelling evidence that brief PT is effective for patients with less severe problems such as anxiety disorder. Solms, (2006) agrees that Freud’s brushstroke organisation of the mind is destined to provide a template on which emerging details can be coherently arranged. Citing research that has identified unconscious memory systems that bypass the hippocampus (which generates conscious memories) and suggesting that current events routinely trigger unconscious remembrances of emotionally important past events, which cause conscious feelings that seem irrational (as may be the case with T’s phobias). Neuroscience has also demonstrated that the major brain structures essential for forming explicit memory are not functional during the first 2 years of life, providing elegant explanation of Freud’s ‘Infantile Amnesia’ and a further explanation for how early traumata can remain unconscious. Moreover, developmental neurobiologists now agree that early experiences, especially between mother and infant, influence the emerging pattern of brain connections in a way that fundamentally shapes later personality and mental health (Solms, 2006). And yet, none of these experiences can be consciously remembered, leaving a good deal of our mental activity unconsciously motivated. Jones & Pulos (1993) – found that when
CB therapists used more developmental (PD) techniques than rationalist techniques, outcome was better. However, The ‘dodo bird’ affect is alive and well in that there are mostly small and nonsignificant differences between the outcomes of different psychotherapies, emphasing their common factors as agents of change as opposed to their distinguishing features (Luborsky et al., 2002). There is, at least, interdisciplinary support for framing T’s case within a PD psychoanalytically-oriented perspective. Despite a non-uniform nomenclature, PD approaches remain capable and indeed superior to other therapies, in the sense that they are uniquely biased towards the patient uncovering unconscious conflicts and tracing them back to early trauma that may well have been occluded through repression or substitution over the years. This defense mechanism protects the developing ego from unbearable pain and must be bypassed through a positive therapeutic alliance in order to feel that pain, begin to heal and release of the pathogenic manifestation of pent up, frustrated energy (rooted in the early trauma), thus allowing the patient to forget these traumata consciously and with the support of an allied agent. The psychoanalytic undercurrents to the PD approach, not only strengthen its theoretical and practical arrangement, but allow for a dynamic contextualization of the patient and their interpersonal and intrapsychic patterns of adaptation that can highlight individual pathology and assist in formulating a therapeutic response that takes into account the possibility of unconscious motivations as aetiological factors in adult psychological problems such as phobias and anxieties, which seem to defy classical categorization. Based on the information in T’s vignette, the PD approach seems best suited to this level of conceptualization and most equipped to tackle the potential causal agents in her presented symptomatology. Specifically the APT approach, has been expounded as a good example of how a PD oriented therapy might treat someone like T.
References: Anderson, E, M. & Lambert, M. J. (1995). Short-term dynamically oriented psychotherapy: a review and meta-analysis. Clinical Psychology Review, 15, 503-514 Bergin, A. E. & Garfield, S. L. (1994). Handbook of Psychotherapy and Behaviour Change New England: Hamilton Printing. Bowlby, J. (1980) Attachment and Loss, III. Loss, sadness, and depression. New York: Basic Books Carson, R, C., Butcher, J, N. & Minkea, S. (2000). Abnormal Psychology and Modern Life. MA: Allyn & Bacon. ← Castonguay, L. G., Goldfried, M. R., Wiser, S.L., Raue, P. j. & Hayes, A. M. (1996). Predicting the effect of cognitive therapy for depression: A study of unique and common factors. Journal of Consulting and Clinical Psychology, 64, 497-504 ← Crits-Cristoph, P., Cooper, A. & Luborsky, L. (1988). The accuracy of therapists’ interpretations and the outcome of dynamic psychotherapy. Journal of Consulting and Clinical Psychology, 56, 490-495 ← Endicott, J., Spitzer, R. L., Fleiss, J. L. & Cohen, J. (1976). The Global Assessment Scale: A procedure for measuring overall severity of psychiatric disturbance. Archives of General Psychiatry, 33, 766-771 ← Eysenk, H. J. (1965). The effects of psychotherapy. International Journal of Psychiatry, 1, 99-178 Fairburn, C. G., Welch, S. L., Doll, H. A., Davies, B. A. & O’Connor, M. E. (1997). Risk factors for bulimia nervosa: A community based case-control study. Archives of general Psychiatry, 54, 509-517 Fallon, P. & Wonderlich, S. A. (1997). Sexual abuse and other forms of trauma. In Carson, Butcher & Mineka (Eds.). Ab. Psyche
Ferrero, A., Piero, A., Fassina., S., Massola, T., Lanteri, A., Daga, G, A. & Fassino, S. (2007). A 12-month comparison of brief psychodynamic psychotherapy and pharmacotherapy treatment in subjects with generalised anxiety disorders in a community setting. European Psychiatry, 22, 530-539 Fonagy, P. (2000). The outcome of psychoanalysis: The hope of a future. The Psychologist, 13, 620-623. ← Freud, S. (2003/1920). Beyond the Pleasure Principle and Other Writings. Wiltshire: Antony Rowe. ← ← Gabbard, G. O. (1990). Psychodynamic psychiatry in clinical practice. In Bergin, A. E. & Garfield, S. L. (1994). Handbook of Psychotherapy and Behaviour Change. ← Gaston, L. (1990). The concept of alliance and its role in psychotherapy: Theoretical and empirical considerations. Psychotherapy, 27, 143-153 ← Hovarth, A. O. & Greenberg, L. S. (1994). The working alliance: Theory, research and practice. New York: Wiley ← ← Jones, E. & Pulos, S. (1993). The role of therapeutic alliance in psychotherapy. Journal of Consulting and Clinical Psychology, 61, 306-316 Knekt, P., Lindfors, O., Laaksonnen, M. A., Raitasalo, R., Haaramo, P. & Jarvikoski, A. The Helsinki Psychotherapy Study Group. (2007). Effectiveness of short-term and long-term psychotherapy on work ability and functional capacity – A randomised clinical trial on depressive and anxiety disorders Journal of Affective Disorders, Llewelyn, S. & Hardy, G. (2001). Process research in understanding and applying psychological therapies. British Journal of Clinical Psychology, 40, 1-21 Luborsky, L., Rosenthal, R., Diguer, L., Andrusyna, T. P., Berman, J. S., Levitt, J. T, Seligman, D. A. & Krause, E. D. (2002). The Dodo Bird Verdict is Alive and Well – Mostly. American Psychological Association, D12, 2-13 Lydiard, R, B. (2000). An Overview of Generalized Anxiety Disorder: Disease State-Appropriate Therapy. Clinical Therapeutics, 22, x-y ← Malan, D. H. (1976). Toward the validation of dynamic psychotherapy: A replication. New York: Plenum press MacLeod, A. Therapeutic interventions. In Eysenck, M. (1998). Psychology an integrated approach. New York: Addison Wesley
McCullough, L. & Andrews, S. (2001). Assimilative Integration: Short-term Dynamic Psychotherapy for treating Affect Phobias. American Psychological Association, D12, 82-96. ← Molnar, B. E., Buka, S. L. & Kessler, R. C. (2001). Child sexual abuse and subsequent psychopathology: Results from the national Comorbidity Survey. American Journal of Public health, 91, 753-760 Mortberg, E., Bejerot, S. & Wistedt, A. A. (2007). Temperament and character dimensions in patients with social phobia: patterns of change following treatments. Psychiatry Research, 152, 81-90 ← Mullen, R. T. & Lemieux, K. E. (2000). Social support, attachment, and psychopathology in high risk formerly maltreated adults. Child Abuse and Neglect, 24, 883-900 Peleikis, D., Mykletun, A. & Dahl, A. A. (2004). The relative influence of childhood sexual abuse and other family background risk factors on adult adversities in female outpatients treated for anxiety disorders and depression. Child Abuse and Neglect, 28, 61-76 Rouillon, F. (2004). Long term therapy of generalised anxiety disorder. European Psychiatry, 19, 96-101 ← Ryon, K. D., Kilmer, R. P., Cauce, A. M., Wantanabe, H. & Hoyt, D. R. (2000). Psychological consequences of child maltreatment in homeless adolescents: Untangling the unique effects of maltreatment and family environment. Child Abuse and Neglect, 24, 333-352 Sandler, J., Holder, A. & Dare, C. (1972). Frames of reference in psychoanalytic psychology. IV. The affect-trauma frame of reference. British Journal of Medical Psychology, 45, 265-272. ← Smith, M. L., Glass, G. V, & Miller, T. I. (1980). The benefits of psychotherapy. In Bergin Solms, M. (2006). Freud Returns. Scientific American Mind, 28-34 Vriends, N., Becker, E. S., Meyer, A., Michael, T. & Margraf, J. (2007). Subtypes of social phobia: Are they of any use? Journal of Anxiety Disorders, 21, 59-75 Ward, I. (2001) Phobia: Ideas in psychoanalysis. Icon: Cambridge