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The pathology of parents is thought to be associated with the emergence of Borderline Personality Disorder (BPD) among offspring by both genetic and environmental pathways (Links and Blum 1990). In an effort toward clearer delineation, not only reliable diagnoses of patients, but also direct study of families, are recommended (Gunderson 1990; Gunderson and Zanarini 1989; Links and Blum 1990; Ogata et al. 1990; Zanarini et al. 1990). With this in mind, we conducted a pilot, retrospective study of parental psychiatric status, developmental events, and family climate during the developmental years of 30 young women hospitalized for BPD, to be reported here. In studying these three dimensions of family life, we hoped to shed light on environmental underpinnings (Gunderson 1990; Gunderson and Zanarini 1989; Links 1992; Rutter and Quinton 1984). Even though our cohort is small and select, and the data on a comparison group not yet available, our research approach holds promise of yielding fresh insights.

In this article, the psycho-socio-biologically integrative concept of affect-logic, and its relevance for a comprehensive understanding and therapy of schizophrenia, is briefly presented. This concept has been developed by the author over the past 20 years, on the basis of the literature, of clinical experience and his own research into long-term evolution, rehabilitation, effects of milieu-therapy, and nonlinear evolutionary dynamics of the illness. It postulates, basically, that fundamental affective states (or emotions, feelings, moods) are continuously and inseparably linked to all cognitive functioning (or 'thinking' and 'logic' in a broad sense), and that affects have essential organizing and integrating effects on cognition. Schizophrenia is understood as an altered mode of affective-cognitive interaction based, possibly, on disturbed (loosened) affective-cognitive connections. This hypothesis leads to: 1) an integrative psycho-socio-biological model of long-term evolution of the illness; 2) a new understanding of psychopathological core phenomena such as ambivalence, incoherence, and emotional flattening; 3) an innovative therapeutic approach based on an emotion-relaxing milieu and style of care; and 4) the hypothesis that schizophrenia could basically be an affective (and not a cognitive) disease, of another kind than mania or melancholia, however.

Despite its fruitfulness, the concept of the ego has fallen into disuse in contemporary psychiatry. It is the aim of this paper to explore the phenomenon of the decline of the concept of the ego by looking at the psychoanalytic theory of schizophrenia in which the ego is central and the genetic/neurochemical theory in which the ego is absent. Kuhn's (1970) explication of the competition of explanatory paradigms is utilized to frame this investigation and some of the factors involved in the displacement of the ego-oriented theory with the genetic/neurochemical theory are elucidated. Each theory is reviewed as to its theoretic and epistemological assumptions and its overall explanatory power. The psychoanalytic theory centers on the role of regression to an early state of ego development, and utilizes an intersubjective mode of data collection to describe developmental determinants of pathognomonic ego deficits. The genetic/neurochemical theory rests on the therapeutic outcome of neuroleptic treatment and family clustering of the illness. In failing to take into account data derived from intrapsychic, interpersonal, and cultural influences, the genetic/neurochemical theory is limited in its ability to provide a comprehensive understanding of the nature of schizophrenia. The ego-oriented theory gains significance at the border of these limitations. The concept of the ego is capable of integrating a wide range of biologic, developmental, and social influences that can account for the clinical phenomena of schizophrenia and should be restored to a central position in etiologic theories.

This paper examines links between violent behavior, type and severity of psychopathology, substance abuse comorbidity, and community mental health treatment, using matched data from two surveys: the National Institute of Mental Health Epidemiologic Catchment Area project and the Triangle Mental Health Survey (a North Carolina study of adults with severe and persistent mental illness). Multivariate logistic regression analysis was used to model the risk of violent acts attributable to three domains of independent variables: sociodemographic characteristics, clinical diagnoses and symptomatology, and mental health services utilization. Findings include: (1) Symptom severity was significantly greater in the clinically-selected sample than in the community survey of respondents with comparable diagnoses who self-reported using mental health services; (2) Violence risk was related to psychoticism/agitation in a curvilinear form; (3) In a multivariable model, violence was significantly associated with substance abuse comorbidity, particular psychotic symptoms (perceived threat and loss of internal cognitive controls), and absence of recent contact with a community mental health provider; (4) The relationship between lack of treatment and higher odds of violence was less pronounced among respondents with substance abuse comorbidity; (5) When clinical and services-use variables were taken into account, sociodemographic predictors were not significantly related to violence.

MULTIPLE personality disorder (MPD) has been diagnosed with increasing frequency in the 1980s: according to one estimate 6,000 cases have now been diagnosed in North America (Coons 1986). The diagnosis of MPD can be difficult because patients usually present in a polysymptomatic fashion, and the specific features of their dissociative disorder may be difficult to elicit (Kluft 1985a, 1987). One of the most common presenting features consists of suicidal ideation and suicide attempts. Putnam et al. (1986), for instance, noted suicidality as a presenting symptom in nearly 70% of 100 cases of MPD reported to them by 92 clinicians throughout North America. We have collected a series of 236 cases of MPD reported to us by 203 clinicians throughout North America. Our results show that 72% of the patients attempted suicide. The purpose of this report is to compare 48 cases of MPD from this series with no previous suicide attempts to 167 cases that have attempted suicide to determine features that differentiate the patients who attempt suicide from those who do not.

THE therapeutic process is complex, and researchers and clinicians alike search for organizing principles or underlying structures that will reduce this complexity and thereby augment the efficacy of their respective endeavors. As other papers in this issue indicate, one such organizing principle is the concept of a recurring relationship theme that can be identified in the patient's descriptions of current and past relationships, as well as observed in the patient's interaction with the therapist. This concept has its origins in Freud's discovery of the transference phenomenon (1912), wherein the patient reenacts early relationships with significant others in the relationship with the analyst, and in Sullivan's interpersonal theory of psychiatry, with its central tenet that 'personality is the relatively enduring pattern of recurrent interpersonal situations which characterize a human life' (1953, pp. 110-11). In the psychoanalytic and interpersonal therapies, these recurrent interpersonal themes, associated with the patient's difficulty in living and characterized as self-defeating and self-perpetuating, can potentially serve three main purposes: diagnosing and describing patients' difficulties, focusing therapeutic interventions, and measuring change on an individual basis. However, until recently, research on transference and rigidity of interpersonal style has been hampered by the lack of objective and clinically relevant measures for quantifying this clinical phenomenon (Kiesler 1986; Luborsky and Spence 1978). Luborsky (1977) developed the first reliable method for operationalizing the transference concept. Since then, as the companion papers in this issue point out, several different methods have been developed (e.g., Gill and Hoffman 1982; Horowitz 1979; Schacht et al. 1984). Although these methods differ in the postulated structural composition or components of the transference theme or recurrent relationship theme, they operate from similar methods of assessment. This paper presents the results of an initial investigation into convergent validity (Cronbach and Meehl 1955) of two of the major relationship theme methods -- the Core Conflictual Relationship Theme (CCRT) of Luborsky and colleagues (Luborsky 1977), and the Cyclical Maladaptive Pattern (CMP: formerly called the 'dynamic focus') of the Vanderbilt group (Schacht et al. 1984; Schacht and Henry, in press). In our investigation, developers of the approaches independently applied their methods to the same interview with a depressed patient. (1) It was hypothesized that aside from differences due to the structural composition, the two methods would identify a similar relationship theme. (1) Originally, three methods were applied to the transcript and reported at the Wellesley SPR panel. The third method was for identifying structures of mental representation (Leeds and Bucci 1986); however, the semi-structured nature of the interview made application of this method difficult.

RECENT years have seen increasing interest in devising methods of studying psychodynamic phenomena. These efforts have had to confront difficulties, first, in specifying the data, the observation language, and rules of inference for psychodynamic propositions, and second, in determining the reliability and validity of the measures used. Given how 'fuzzy' traditional psychodynamic concepts are, it is no wonder that psychodynamic clinicians from Freud onward have achieved more success in generating new hypotheses than in testing their validity. As Reichenbach (1938) has observed, science requires that discovery be followed by systematic validation of all new propositions, regardless of their degree of popular acceptance. At the core of efforts to study psychodynamics have been methods to study ego functioning (Bellak and Goldsmith 1984), defense mechanisms (Perry and Cooper 1988), and psychodynamic conflicts. This paper reports on the reliability of the Idiographic Conflict Formulation (ICF), a guided method for formulating an individual's psychodynamic conflicts.

THE THEORY developed here locates mental illness in a biosocial context involving social bonds. Because of the inclusion of both social and emotional elements, light may be shed on how mental illness originates, the part played by family, agents of social control, and society. Labeling and stigma may rest on strong unacknowledged emotions, particularly shame and anger. The shame construct is used to provide a model of mental illness at the intra/interpersonal and societal levels, which involves a bilateral relationship between the labeled and the labelers. I use excerpts from a psychiatric interview to illustrate my model. Although preliminary, the findings point to the role of shame in mental illness; it may figure in both the formation of symptoms and their maintenance.

RECURRENT maladaptive interpersonal relationship patterns are a central characteristic of the personality disorders and the main focus in dynamic, cognitive, and family psychotherapies. In dynamic formulations the emphasis is on examining conflict in terms of opposing wishes, fears, and defenses. Such formulations can take place at various levels of information, involving ideas, emotions, self and objects. This paper presents a system for formulating intrapsychic conflicts at the level of person schemas (Horowitz 1988a). It uses units called Role-Relationship Models (RRM).

THIS STUDY examines mother-child communication as one factor in the development of conduct-disturbed/hyperactive boys. Three groups of school-age children were compared: a group including conduct-disturbed/hyperactive boys who had a significant insult in their perinatal/developmental history; a group of conduct-disturbed/hyperactive boys in whom no insult could be found; and a group of normally active/non-conduct-disturbed/hyperactive boys. It was hypothesized that disturbed communication between mother and son would be found in boys who were conduct-disturbed/hyperactive, whether or not there was a probable organic cause for their dysfunction, and this hypothesis was confirmed. In addition, it was found that the communication patterns in children who had a probable organic etiology for their disturbance were different from those found in the group lacking an organic etiology. However, both of these groups exhibited communication patterns that were more disturbed than the communication from mother to son in the normally active, non-conduct-disturbed group.

THE TRUE SELF is a central construct of psychotherapy, but its status as fact or fiction is uncertain. Much of the plausibility of the true self comes from the concept's ambiguity, since it encompasses several different kinds of mental entity. It may be construed as a person's belief about himself or herself, as the experience of the working of the mind, or as a characterological essence. The true self is composed of qualities borrowed from these quite disparate kinds of self, none of which, considered singly, readily fits the description. However, if the true self is viewed as a fantasy, grounded on fact, of whom the patient might become, it is an instrument that gives coherence and direction to psychotherapy.

WHY, one might reasonably query, do some narcissistic characters serve time as seemingly successful presidents of corporations while others serve time as seemingly impaired inpatients on psychiatric units? I will offer some observations on this unusual clinical phenomenon and suggest that it is useful to distinguish between two clinical presentations of narcissistic character psycholopathology, which I will call, for the sake of expeidence, Level 1 and Level 2. (1) I will then examine 1) how an understanding of the dimensins of emphatic abilities, paranoia, levels of depression, grandiosity, and defensive uses of denial and disavowal can lend a broad explanatory range to the understanding of these levels, and 2) how we can assess both successful and unsuccessful adaptation to the outer world and the inner world in narcissistic disorders. Moreover, it is important to distinguish between being well adapted and being emotionally healthy, which are quite different in meaning and intent. I use the term Level 1 to refer to the more poorly adapted presentation, and the term Level 2 to refer to the more successfully adapted narcissistic presentation. Characteristics of Level 1 narcissitic pathology dispose a patient to an adaptation that is similar to the description of the narcissistic patient who is often described as borderline; characteristics of Level 2 narcissistic pathology dispose a patient to a high-flying and superficially successful adaptation in which the patient can competently navigate the occupational and social demands of an external world despite the presence of severe object relational impairments. While a difference in adaptation is highlighted, emotional well-being is not within the exclusive province of either's characteristic adaptive skills.

EXTREMES in mood, thought and behavior-including psychosis-have been linked with artistic creativity for as long as man has observed and written about those who write, paint, sculpt or compose. The history of this long and fascinating association, as well as speculations about its reason for being, have been discussed by several modern authors and investigators, including Koestler (1975), Storr (1976), Andreasen (1978), Becker (1978), Rothenberg (1979), Richards (1981), Jamison (in press) and Prentky (in press). The association between extreme states of emotion and mind and creativity not only is fascinating but also has significant theoretical, clinical, literary and societal-ethical implications. These issues, more thoroughly reviewed elsewhere (Jamison et al. 1980; Richards 1981; Jamison, in press), include the understanding of cognitive, perceptual, mood and behavioral changes common to manic, depressive and creative states; and potential ability to lessen the stigma of mental illness; effects of psychiatric treatment (for example, lithium) on creativity; and concerns raised about genetic research on mood disorders. The current study was designed to ascertain rates of treatment for affective illness in a sample of eminent British writers and artists; to study differences in subgroups (poets, novelists, playwrights, biographers, artists); to examine seasonal patters of moods and productivity; and to inquire into the perceived role of very intense moods in the writers' and artists' work. One of the major purposes of this investigation was to look at possible similarities and dissimilarities between periods of intense creative activity and hypomania. Hypothesized similarities were based on the overlapping nature of mood, cognitive and behavioral changes associated with both; the episodic nature of both; and possible links between the durational, frequency and seasonal patterns of both experiences.

SUZANNE RETZINGER'S article, 'A Theory of Mental Illness,' provides further untangling of the complex links between social relationships and psychopathology. Those links have been demonstrated in such diverse areas as the impact of family relationships on relapse (e.g., Brown et al. 1972), the predictive importance of social relations to outcome (e.g., Strauss and Carpenter 1977), and the genetic connections between social relationship traits and vulnerability to psychopathology (Kendler et al. 1982). The research presented here focuses on social relationships with special emphasis on stigma in those relationships and its impact on disorder. It also has the valuable role of forging connections between the more abstract labeling theory and the actual behaviors of people as viewed in their interaction.