The therapeutic relationship is the factor which has most consistently shown an impact on psychotherapy outcome. While for other disorders, such as circumscribed phobias, the relationship seems to determine a smaller percentage of variance, for the treatment of patients with BPD it is crucial. This is accounted for by disorder specific elements also in manualized treatment (DBT) with the principle of validation. Validation can be conceptualized as criticizing behaviors while accepting motives.

In this paper it will be argued that this principle can be used even more systematically based on the concept of "Plan Analysis" by Grawe and Caspar. It will be shown how the functioning of patients can be analyzed and described in a hierarchical structure of Plans. Such a description serves as a basis for reflections about how to react in a complementary way to problematic patient behavior while avoiding reinforcement of maladaptive behavior.

It will then be elaborated and demonstrated that to the extent to which the individual motives of a patient are met with precision, it becomes realistic to satisfy them and to reduce the motivational basis of problem behavior. In contrast, if attention is given reluctantly and reactive to patient pressure, we have to expect the well known bottomless pit.

Dialectical Behavioral Therapy (DBT) was initially developed and evaluated as an outpatient treatment program for borderline personality disorder (BPD). Within the last few years, several adaptations have been developed. This study aims to evaluate a three-month DBT inpatient treatment program. Clinical outcomes, including changes on measures of psychopathology and frequency of self-mutilating acts, were assessed for 50 female patients meeting criteria for BPD. Thirty-one patients had participated in a DBT inpatient program, and 19 patients had been placed on a waiting list and received treatment as usual in the community. Post-testing was conducted four months after the initial assessment. The DBT group improved significantly more than participants on the waiting list on seven of the nine variables analyzed, including depression, anxiety, interpersonal functioning, social adjustment, global psychopathology and self-mutilation. Analyses based on Jacobson's criteria for clinically relevant change indicated that 42% of those receiving DBT had clinically recovered on a general measure of psychopathology. The effect sizes ranged between moderate and strong (see fig. 1). The data suggest that three months of inpatient DBT treatment is significantly superior to non-specific outpatient treatment. Within a relatively short time frame, improvement was found across a broad range of psychopathological features. Nine and 21 month follow-up data suggest stability of the recovery.

In modern psychiatry a main task is the exploration and explanation of the nature of mental disorders and its treatment. Post-modernity with its change of paradigms opens up new perspectives in diagnosis and treatment of mental disorders. Not only the nature of disorders but also the narratives creating our world of illnesses and the dialogue with the patient suffering from it becomes more and more the main interest of medical and psychotherapeutic measures. It is no longer the disorder itself but the human being suffering from it which will be the main target of diagnostic and therapeutic procedures. The human being is not only a disorder producing physico-psycho-social apparatus. In postmodern medicine the human being cannot be longer considered as a machine which can be explored and repaired; it is much more the expression of active and reactive processes. As individuums we are not only complex machines reacting to external and internal stimuli; we are on the contrary “doers”, “makers” and “creators”. As cosmopoets we constitute and design our world and ourselves. But this creation is not a creation out of nothing. Our patients suffering from mental disorders are thrown in a world not of their choosing; but nevertheless they are able to (re)construct their life and their narratives. As psychiatrists, it is our duty not only to analyze the conditions and nature of mental disorders but also to enter into a dialogue with the human being suffering from the disorders’ nature and its narratives.

This presentation will be introduced by the different disease conceptions between Europe and West African cultures.

The classical assumption of universality of neurological substrate will be discuss in confront with cultural relativist perspectives going back to nosology.

Some questions will be adress in the fields of compared subjectivity and phenomenology.

Some final remarks about the importance of Ethno-psychiatry will be done.

Since countries have relaxed immigration policies, mental health professionals have been confronted with clinical pictures necessitating a different reflection on their practice of psychiatry based on a western system of reference. Misdiagnosis can be the source of unnecessary hospitalization, harmful drug treatment and inadequate management of cases. From the perspective of migrating populations, they undergo a process of change with the necessity to cope with the host culture while preserving their previous cultural values. Sometimes migration awakens new hopes like the belief seen lately among Israeli Ethiopians that spirits won't migrate with them and won't anymore require their attention. It soon becomes apparent that the reality is different and Zar spirits pathology appear, provoking questions about its meaning. Beer-Yaacov Mental Health Center is located south of Tel-Aviv in an area where 20% of the Ethiopian community lives. Patients of Ethiopian origin, unresponsive to “traditional” Western treatment are referred to the hospital outpatient clinic for examination at the ethnopsychiatric consultation service. With the help of three clinical vignettes we will describe the psychopathology due to the issues of healers that can't heal or of people meant to be healers that couldn't fulfill their apprenticeship because of migration. We will show how an ethnopsychiatric-oriented interview combined with an ethnopsychiatric analysis of the clinical picture, allow a better diagnosis even in the context of a conventional institutional frame.

The research we are striving to foster in Italy, aims at identifying the nature of the spaces linking the well-known neurobiological paths of interpersonal experience and the less-known psychological and phenomenological paths of the intercultural relation. The challenge consists in understanding the experience of plurality and therefore how you can pass from a “relational” to a “multicultural” mind.

An approach, to be really multicultural, intercultural and transcultural, must be based on the dialogue between different disciplines. Therefore, if European psychiatrists will not be opened to cultural anthropologists, psychologists, sociologists, ethnologists, they will not progress and there will be the risk of closing themselves in a conclave detached from the interconnections of globalisation.

We hope that this first symposium between psychopathologists and cultural psychiatrists may prompt a debate between experts in the field of psychopathology and cultural anthropology to deconstruct Western culture seen as a repository of the “medical basic knowledge”.

Today, more than ever, it is increasingly important to consider not only the Western culture models (e.g. the neurobiological point of view) but also specific models of other cultures. The latter either disregard our medical background or they “do not let themselves be colonised”.

Those who work in the field of psychopathology are confronted to systems of thought different from the system of thought studied by Western psychopathologists. This makes to think that the right way to consider “psychopathology” is as a “cultural psychopathology”.

Gene-environment interactions (GEI) were recently found to contribute to the etiology of mood disorders and suicidal behavior in children adolescents and young adults. Childhood adversity may produce a biological and clinical diathesis for mood disorder and suicidality that endures into adulthood. Life events predict depression and suicidal ideation or a suicide attempt in children, adolescent and young adult carriers of the S allele of the 5-HTTLPR polymorphism. This finding was replicated in children, adolescents and young adults. We reported on a third functional allele in the serotonin transporter gene (A trialleleic polymorphism) that may give a new clue to the GEI in depression and suicide. Some new biological data supporting the validity of this interaction will be presented.

The antisaccade task is a model of the conflict between an unwanted reflexive response (which must be inhibited) and an appropriate volitional response (which must be generated). In this talk I will present a study of the neural correlates of these cognitive components separately using a delayed saccade paradigm to dissociate saccade inhibition from generation. Event-related functional magnetic resonance imaging (fMRI) was carried out in healthy human volunteers. It was found that the right supramarginal gyrus showed significantly greater activation during response inhibition compared to response generation, suggesting a role in saccade inhibition or stimulus detection. The right lateral frontal eye field and bilateral intraparietal sulcus showed evidence of selective involvement in antisaccade generation. Ventrolateral and dorsolateral prefrontal cortices showed comparable levels of activation in both phases of the task. These areas likely fulfil a more general supervisory role in the volitional control of eye movements, such as stimulus appraisal, task set, and decision making. The findings will be discussed in relation to data suggesting that antisaccade deficits constitute an endophenotype for schizophrenia and in relation to pharmacological studies of brain function during antisaccade eye movements.

Prepulse inhibition (PPI) refers to the attenuation of the amplitude of the startle reflex in response to sudden intense stimuli (pulse) if preceded by a weaker sensory stimulus (prepulse). PPI reflects sensorimotor gating i.e. the ability to filter out irrelevant information in the early stages of processing so that attention can be directed to more salient environmental features. Recent neuropsychological studies show greater PPI in healthy individuals with superior performance on tasks that rely on the integrity and efficiency of prefrontal cortical (PFC) function. The PFC is an important node in the cortico-striato-pallido-thalamic circuitry, which modulates PPI. PFC function has been examined in relation to the COMT Val158Met polymorphism, which determines basal PFC dopamine (DA) neurotransmission levels and consequently, performance on PFC DA-dependent cognitive tasks. Met/Met individuals have the best PFC performance or greater “efficiency” and the highest PPI, Val/Val the worst performance and the lowest PPI, and Val/Met intermediate performance and PPI. Consistent with the increasingly accepted model of an inverted U-shape relationship between PFC DA levels and PFC function, the COMT inhibitor tolcapone as well as attention-to-prepulse, increase PPI in Val/Val individuals, while Met/Met individuals are unaffected or get worse. These findings strongly suggest that inhibition at the early stage of information processing is modulated by the PFC DA activity in a “top-down” fashion and this may account for the normal inter-individual variability in PPI and in cognitive performance.

Schizophrenia patients exhibit impairments in prepulse inhibition (PPI) of the acoustic startle response (ASR). PPI is commonly used as an index of sensorimotor gating. Results of animal studies and some human data suggest that PPI deficits are in part genetically determined, such that PPI could be an endophenotypic indicator of risk for schizophrenia, Thus, PPI deficits should already be present prior to onset of psychosis. To test this assumption, we investigated PPI in individuals with prodromal symptoms of schizophrenia and patients with first-episode schizophrenia.

Startle reactivity, habituation, and PPI of ASR were assessed in 54 subjects with prodromal symptoms of schizophrenia (35 at an early prodromal stage, 19 at a late prodromal stage), 31 first episode schizophrenic patients (14 unmedicated, 17 medicated), and 28 healthy controls. Patients were also examined with the Positive and Negative Symptom Scale and the Global Assessment of Functioning Scale.

Prodromal subjects and unmedicated patients with first episode schizophrenia showed significant PPI deficits, whereas schizophrenic patients treated with risperidone had almost normal PPI. In contrast, startle reactivity decreased with severity of symptoms but was relatively unimpaired in the medicated patients. With respect to habituation, prodromal subjects and schizophrenic patients did not differ from healthy controls.

PPI disruption is present in subjects in a prodromal state likely to proceed to schizophrenia, supporting the hypothesis that PPI disruption is an endophenotype of schizophrenia. In contrast, startle reactivity and habituation deficits were not evident in the prodromal subjects, but only in unmedicated patients with diagnosis of schizophrenia.

A key feature of schizophrenia is the inability to screen out irrelevant sensory input. Prepulse inhibition (PPI) of the startle response, a cross-species measure of sensorimotor gating, provides a valuable opportunity to study this feature. Patients with schizophrenia, first-degree relatives of patients with schizophrenia, patients with schizotypal personality disorder and healthy individuals scoring high on psychometric measures of psychosis-proneness display reduced PPI. Animal models of disrupted PPI have proved valuable for the evaluation of existing and potential new treatments for schizophrenia. Animal studies have also shown that PPI is modulated by the cortico-striatal-pallido-thalamic circuitry involving the prefrontal cortex, thalamus, hippocampus, amygdala, nucleus accumbens, striatum, ventral pallidum, globus pallidus, and subpallidal efferents to the pedunculopontine nucleus. Recent neuroimaging data from our and other laboratories confirm the involvement of this circuitry in (a) normal PPI in healthy people, (b) deficient PPI in patients with schizophrenia and related conditions, and (c) the effects of pharmacological agents relevant to the treatment of schizophrenic illness.