clinical case study of psychoanalytic

• DOI: 10.3389/fpsyg.2017.00108
• Corpus ID: 16589413

Clinical Case Studies in Psychoanalytic and Psychodynamic Treatment

• J. Willemsen , Elena Della Rosa , S. Kegerreis
• Published in Frontiers in Psychology 2 February 2017

26 Citations

Mapping the psychoanalytic literature on bipolar disorder: a scoping review of journal articles, learning from past practices: an overview of criticisms for psychoanalytic case studies, becoming a researcher: psychotherapists’ experience of starting a professional doctorate, methods used for evaluation of psychotherapy treatment. evaluation of psychotherapy, from clinical encounter to knowledge claims: epistemological guidelines for case studies in psychotherapy, conflicted anger as a central dynamic in depression in adolescents—a double case study, the > uncommon < factor in psychotherapy and the role of negative skills: why and how psychoanalysis offers an important contribution for mental health practice today, psychoanalytic perspectives on the psychological effects of stillbirth on parents: a protocol for systematic review and qualitative synthesis, is psychotherapy fundamentally threatened, with the demise of published case studies, to become neither an art and/ nor a science, narcissistic trauma, 47 references, the ‘inseparable bond between cure and research’: clinical case study as a method of psychoanalytic inquiry.

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Beyond Clinical Case Studies in Psychoanalysis: A Review of Psychoanalytic Empirical Single Case Studies Published in ISI-Ranked Journals

Reitske meganck.

1 Department of Psychoanalysis and Clinical Consulting, Ghent University, Ghent, Belgium

Ruth Inslegers

Juri krivzov.

2 Department of Experimental, Clinical and Health Psychology, Ghent University, Ghent, Belgium

Liza Notaerts

Single case studies are at the origin of both theory development and research in the field of psychoanalysis and psychotherapy. While clinical case studies are the hallmark of psychoanalytic theory and practice, their scientific value has been strongly criticized. To address problems with the subjective bias of retrospective therapist reports and uncontrollability of clinical case studies, systematic approaches to investigate psychotherapy process and outcome at the level of the single case have been developed. Such empirical case studies are also able to bridge the famous gap between academic research and clinical practice as they provide clinically relevant insights into how psychotherapy works. This study presents a review of psychoanalytic empirical case studies published in ISI-ranked journals and maps the characteristics of the study, therapist, patient en therapies that are investigated. Empirical case studies increased in quantity and quality (amount of information and systematization) over time. While future studies could pay more attention to providing contextual information on therapist characteristics and informed consent considerations, the available literature provides a basis to conduct meta-studies of single cases and as such contribute to knowledge aggregation.

Introduction

Single case studies are at the origin of both theory development and research in the field of psychotherapy in general and psychoanalysis in particular ( McLeod, 2010 , 2013 ). Increasingly, empirical case studies made their entrance in the field and are recognized as important sources of evidence to address the complexity of psychotherapeutic processes ( Goodheart, 2005 ; American Psychologcial Association [APA], 2006 ; McLeod and Elliott, 2011 ). Systematic meta-studies of single cases moreover allow knowledge aggregation and as such could enhance the scientific merits of case studies ( Iwakabe and Gazzola, 2009 ). We argue that in order to explore the full potential of empirical single cases in the field of psychoanalysis, it is important to map the existing field of such cases and get an overview of their characteristics, strengths and weaknesses. The goal of the current review is to provide this information and delineate points of interest for future case studies and context for meta-studies in the field.

From its origin, the clinical case study was the dominant research method in psychoanalysis. Sigmund Freud, the founding father of psychoanalysis, is still both famous and notorious for his elaborate clinical case studies through which he developed his theoretical framework during the course of his life. Famous because of the richness of his case presentations and because of the resulting theoretical and clinical advancements that up until this day permeate the whole psychotherapeutic and cultural field. Notorious because the scientific merit of this method received increasing criticism and is mostly relegated to the scientific trash can ( Bornstein, 2005 ).

While empirical research continues to be a major source of debate and controversy in psychoanalysis (e.g., Aron, 2012 ; Benecke, 2014 ; Mills, 2015 ), the questioning of its scientific credibility and therapeutic efficacy gave rise to a wealth of (group level) research indicating the efficacy of psychoanalytic psychotherapy (e.g., Leichsenring et al., 2015 ). Nevertheless, the case study has a privileged place in the field of psychoanalysis. Indeed, the clinical case study is still very common, however, increasingly, empirical case studies appear to see the light of day.

Critiques on the subjective bias of therapists’ retrospective reports, the anecdotal quality and uncontrollable nature of clinical case studies ( Spence, 2001 ) influenced the emergence of systematic (quantitative and qualitative) approaches to conduct single case studies that are no longer (solely) dependent on the interpretation of the therapist. Methodological articles on single-case experimental designs (for a review see Smith, 2012 ), case-based time series analysis ( Borckardt et al., 2008 ), case comparison methods ( Iwakabe, 2011 ), and theory-building case studies ( Stiles, 2008 , 2010 ) are but a few examples of the increased recognition of the potential value of empirical case-based research to build knowledge ( Edwards et al., 2004 ; McLeod and Elliott, 2011 ). In the entire field of psychology, such idiographic approaches are increasingly considered to be important tools to bridge the science-practitioner gap and address the lack of alignment between the object of study and the method that is often criticized in mainstream evidence-based practice research (e.g., Westen et al., 2004 ; Desmet, 2013 ).

Despite this recognition of empirical case study methods, an important critique on generalizability problems remains. A way to address this and build knowledge resulting from single case studies is to conduct meta-studies on published single case studies or as Dattilio et al. (2010 , p. 436) state “One observation or one case offers only a small piece of evidence, but repeated observation […] across a series of cases provides a way of constructing a database of evidence on which clinical theory can be built.” Currently the potential for knowledge aggregation across cases surely remains unexplored despite the existence of methodological tools to do so, for example, meta-synthesis methods ( Finfgeld, 2003 ; Willemsen et al., 2015 ) and case comparison methods ( Iwakabe and Gazzola, 2009 ). A preliminary requirement to facilitate meta-studies, however, is a well-organized database that gathers published case studies ( Fishman, 2005 ; Iwakabe and Gazzola, 2009 ). The single case archive (SCA; Desmet et al., 2013 ) provides such a tool for psychoanalytic single cases published in ISI ranked journals. 1 Such a tool allows gathering cases on a specific topic and conducting meta-studies. Nevertheless, an overview of the nature of existing empirical case studies would provide important contextual information when considering a meta-study, yet this is currently lacking in the literature.

This study attempts to address this need and explores the following questions concerning empirical case studies in the field of psychoanalysis: ‘Which studies have been done?’; ‘What is the nature of these case studies?’; and ‘What are their merits and weaknesses?’ We investigate this through a review of empirical case studies published in ISI-ranked journals.

Cases were selected through the original SCA ( Desmet et al., 2013 ), which comprises psychoanalytic and psychodynamic case studies, published in ISI-ranked journals between 1955 and 2011. Cases were selected starting from a search on ISI Web of Knowledge using the search terms (psychoanal ∗ OR psychodynam ∗ ) AND (case OR vignette). This search provided 2760 results, which after screening for title, abstract, and if necessary the full text of the article, resulted in 445 articles presenting psychoanalytic or psychodynamic treatment of an original single case (no comments on already published cases). For this study, all English case studies of this dataset that were classified as either experimental (i.e., N = 1 subject experiments, testing hypotheses in an experimental design) or (naturalistic) systematic case studies (i.e., case studies using data from sources other than the therapist’s report and where data are investigated by one or more researchers other than the therapist) 2 were selected (52 articles discussing 55 cases). Moreover, for this study, the same search procedure was followed for the period of 2012–2017 to update the sample with empirical case studies from these more recent years. Screening the 1093 search results resulted in 31 articles discussing 38 empirical cases. All empirical cases were screened with the Inventory for Basic Information in Single Cases (IBISC; Desmet et al., 2013 ), which inventories basic descriptive information on study characteristics [design, type of data, type of analysis, presence of clinical (process) description, presence of informed consent], therapist (gender, age, education, experience) and patient (gender, age, diagnostic information) characteristics, and therapy characteristics (duration, number of sessions, session frequency, therapy outcome).

In the screened period (1955–2017), 83 articles were identified that comprise 93 cases using empirical case designs. The selected manuscripts included one to three case studies. Figure ​ Figure1 1 depicts the number of case studies for each year empirical cases could be identified and indicates an increase of published empirical case studies over time.

Number of cases per year.

Study Characteristics

Of the empirical case studies, five cases (5.4%) were experimental designs and 88 were naturalistic systematic case studies (94.6%) following the definition of Iwakabe and Gazzola (2009) . Analysis of the case was mostly based on one type of data (44.1%); 25.8% used two types of data, 14% three types, and 3.2% four or more types of data. The amount of different types of data was not spread equally across time: before 2000 only one study mentioned more than one type of data, between 2000 and 2010 there were regular studies mentioning two types of data; while starting from 2010 studies start to appear that mention three and four or more types of data. The type of data most commonly used were audio recordings (or videotapes) (64.5%), followed by self-report or observer rated scales (36.6%) and interviews (35.5%). In 14% of cases (also) other types of data were used like behavioral measures, notes of the therapist, patient, or relatives, or biological measures.

Different ways of analyzing the data were used, from purely quantitative (21.5%) to purely qualitative (17.2%). Yet, in most studies mixed approaches (56%) were used combining for example clinimetric methods (e.g., ratings of session material using the Shedler Westen Assessment Procedure-200 (SWAP-200; Westen and Shedler, 1999 ) with clinical, qualitative, or quantitative approaches.

A clinical description of the patient and/or therapy process was provided in 73.1% of the cases. In 24.7% of the cases such a description was lacking, while in two cases there was somewhat of a clinical description through a patients’ retrospective report in one case and a qualitative description of specific analyzed sessions in the other case.

Informed consent (IC) was mentioned in 45.2% of the cases, meaning it was not mentioned in more than half of the cases. Before 2000, IC was mentioned in 4 out of 18 cases, between 2000 and 2010 it was mentioned in 13 out of 35 cases, and between 2011 and 2017 it was mentioned in 25 out of 40 cases. In this last period, of the cases not mentioning IC, four cases did mention an ethical approval, which might indicate that there was also an informed consent on the patient’s side.

Therapist Characteristics

In most studies information about the therapist was almost entirely lacking. We inventoried information about gender, age, education and experience, yet in 34.4% of the cases there was no information at all. In 10.8% of the cases information about only one of these variables was provided (mostly the therapist’s gender), while in 18.3, 29, and 7.5% of the cases information was provided about 2, 3, and 4 variables respectively.

Concerning gender, 24.7% were female therapists and 36.6% were male therapists. In one case there was both a male and a female therapist involved in therapy. For the remaining 37.8% of cases gender of the therapist was not mentioned. Age was mentioned in only 17.2% of the cases. Education was mentioned in 44.1% of the cases and included all kinds of degrees/description with psychologist, psychotherapist, social worker, and psychiatrist as the most common terms. Experience was mentioned in 57% of the cases, with 10.8% novice therapists (<5 years of experience), 21.5% experienced therapist (6–15 years of experience), and 10.8% senior therapists (>15 years of experience).

Patient Characteristics

Generally, more information was provided about the patient. There was consistent information about the patients’ gender with 68.8% female and 31.2% male patients. Concerning age, almost always (98.9% of cases) information was present with 6.5% children (2–11 years), 6.5% adolescents (12–17 years), 12.9% young adults (18–24 years), and 73.1% adults (25–65). There were no cases discussing elderly patients.

There was no information about diagnosis in three cases; all other cases provided diagnostic information. The descriptive terms used in the manuscript are included in the SCA database, however, they differ tremendously across cases. This is illustrated by the observation that in 49.5% of the cases there was no diagnostic system mentioned. In other cases, one or more diagnostic systems were used: 34.5% used a version of the DSM, 10.8% used a version of the ICD, 4.3% used the OPD or PDM, and 8.8% used another system (e.g., SWAP-200, AAI). Therefore, when diagnostic information was available, this was categorized into the main DSM-IV-R categories (multiple categories could apply) to be able to get an overview. Prevalence of diagnostic categories is presented in Figure ​ Figure2 2 . Clearly mood and anxiety disorders were the most common.

Primary diagnosis of cases per DSM-IV-R category.

Therapy Characteristics

In considering the characteristics of therapy we see that mostly at least some information is provided about objective characteristics and outcome.

The duration of investigated therapies consisted of 15.1% therapies shorter than 5 months, 12.9% lasting between 6 and 11 months, 32.3% lasting between 1 and 3 years, 18.3% lasting longer than 3 years, and 21.5% of cases were duration was not mentioned. Related to the duration of therapy, the number of sessions was mentioned in 66.7% of cases with 10.8% of therapies comprising less than 20 sessions, 22.6% between 21 and 50 sessions, 12.9% between 51 and 200 sessions, and 20,4% more than 200 sessions.

Session frequency ranged from less than once a week (2.2%), over once a week (35.5%), two to three times a week (17.2%) to a classical analytic setting of four to seven times a week (18.3%) and was not mentioned in 26.9% of the cases.

To inventory therapeutic outcomes the description of the authors was followed and categorized into successful (53.8%), failure (3.2%), or mixed (33.3%). In 9.7% of the cases no information about outcome was provided. Clearly, the description of authors/researchers starts from different frames of reference (e.g., in a long-term analysis success appears to require change at more levels than in studies on short-term psychodynamic psychotherapy who tend to conceptualize success more often as symptom decrease on a symptom rating scale) and consequently any appreciation of outcome is relative to these frames of reference.

Mapping psychoanalytic empirical case studies published in ISI-ranked journals showed that they, while still remaining scarce, clearly increased in quantity and quality throughout the last decennia. The increase in quality is shown in the results of our review that indicate a larger amount of information provided in more recent studies, a broader use of different sources of data and analysis methods, and more explicit informed consent considerations. However, also when reading the articles to rate the IBISC, it was clear that generally there is more attention for a detailed description of the study, its methods, the patient and his or her therapeutic process. Especially, in the last decennium a remarkable increase could be seen in the amount of published cases and the systematic nature of these cases that increasingly include multiple sources of data and combine different methods of analysis. These include both instruments and methods developed within the field of psychoanalysis [e.g., the Core Conflictual Relationship Theme method ( Luborsky and Crits-Christoph, 1998 ) or Reflective Functioning ratings ( Bucci, 1997 )] and more generic methods that allow the connection to broader psychological research (e.g., the Beck Depression Inventory; Beck et al., 1996 ).

When considering systematic case studies in the broader field of psychoanalytic case studies – which remain to be mainly clinical case studies – it is clear that they provide much more descriptive information than clinical case studies, which mostly pay little attention to giving comprehensive descriptive information, despite the rich clinical description they provide ( Desmet et al., 2013 ). Nevertheless, information about certain topics remains generally absent. Especially a description of the therapist is often omitted, which might however, be important contextual information if one intends to compare or aggregate different cases. As the role of the therapist in explaining outcome is increasingly recognized (e.g., Kraus et al., 2011 ) and because of the inherently interactive nature of the therapeutic encounter (e.g., Strupp, 2008 ), its importance can hardly be overestimated.

The range of diagnoses, short- and long-term therapies, and successful and unsuccessful cases investigated in empirical case studies, however, provide a myriad of possibilities for meta-studies. Moreover, while we noticed a wide array of methods, there also are trends and recurring methods indicating that meta-studies are feasible. For example, methods like Reflective Functioning or the SWAP-200 are used in different studies and should allow for good quality meta-studies. On the other hand, we noticed that studies focusing on purely quantitative methods often omit a clinical description of the patient and the therapy process. In our opinion, this is throwing away the baby with the bathwater. While critiques on the anecdotal nature of clinical case studies may be apt, discarding a clinical or qualitative description altogether is to disown the essence and the strength of the psychoanalytic single case study. Moreover, with respect to clinical relevance and to possible meta-studies, this clinical contextual information is quintessential.

Concerning ethical considerations of research in such delicate circumstances as the psychotherapeutic setting, it appears that even more attention could be paid to informed consent. While informed consent was mentioned much more than was found in the overall archive ( Desmet et al., 2013 ) – where it was mentioned in only 9% of cases – still more than half of the studies did not provide information about informed consent despite their explicit research context.

Surely, our review has certain limitations. Using other search criteria for example, might result in other cases and probably more empirical psychoanalytic cases exist. Also, the inclusion of cases published in books might be a valuable addition. Nevertheless, we think a representative and large sample of systematic case studies could be retrieved through this method. If this is the case, surely future research should aim to investigate age groups that are currently underrepresented in the field as most case studies focus on (young) adults.

We conclude that psychoanalytic empirical case studies, although they were adopted somewhat later than in other orientations, are of increasing and high quality. Moreover, journals currently provide more clear guidelines as to what comprises an eligible case study. High quality cases, for example Gazillo et al. (2014) , Mauck and Moore (2014) and Cornelis et al. (2017) , set the tone for a future where case aggregation based on scientifically sound cases that include triangulated data and analysis methods while not disregarding clinical context becomes increasingly possible. This attention for the clinical context is of crucial importance in the field of psychotherapy ( Spence, 2001 ). Psychotherapy is and always will consist of a unique encounter between patient and therapist, a complex interaction that cannot be easily disentangled ( Strupp, 2008 ). While systematically investigating what happens in this process is crucial for the advancement of the psychotherapeutic endeavor, this should not come at the cost of the clinical richness of these ever-singular encounters that comprise the magic of the psychotherapeutic profession.

Author Contributions

RM: conception of the study, contribution to data collection, data-analysis and interpretation, main author of the manuscript; RI: contribution to conception of the study, contribution to data collection, main reviewer of the manuscript; JK: contribution to data collection, data-analysis and interpretation, reviewer of the manuscript; LN: contribution to data collection, data-analysis, reviewer of the manuscript. All authors read and approved the final version of the manuscript.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We want to thank Mattias Desmet and Jochem Willemsen for the cooperation on the foundation of the SCA.

Funding. This project was partly supported by Flanders Research Foundation (FWO, Belgium; grant number: AUGE/15/15 – G0H3116N).

1 The original single case archive ( www.singlecasearchive.com ) comprises 445 articles between 1955 and 2011. Currently, there is an ongoing project to elaborate the SCA with cases from other theoretical orientations that should be finished at the end of 2018.

2 For more information on the types of case studies and their definition, see Iwakabe and Gazzola (2009) or the IBISC manual available through http://www.singlecasearchive.com/downloads/IBISC%20manual3.pdf .

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A clinical case study of a psychoanalytic psychotherapy monitored with functional neuroimaging

Affiliation.

• 1 Institute of Psychology, University of Innsbruck Innsbruck, Austria.
• PMID: 24167481
• PMCID: PMC3805951
• DOI: 10.3389/fnhum.2013.00677

This case study describes 1 year of the psychoanalytic psychotherapy using clinical data, a standardized instrument of the psychotherapeutic process (Psychotherapy process Q-Set, PQS), and functional neuroimaging (fMRI). A female dysthymic patient with narcissistic traits was assessed at monthly intervals (12 sessions). In the fMRI scans, which took place immediately after therapy hours, the patient looked at pictures of attachment-relevant scenes (from the Adult Attachment Projective Picture System, AAP) divided into two groups: those accompanied by a neutral description, and those accompanied by a description tailored to core conflicts of the patient as assessed in the AAP. Clinically, this patient presented defense mechanisms that influenced the relationship with the therapist and that was characterized by fluctuations of mood that lasted whole days, following a pattern that remained stable during the year of the study. The two modes of functioning associated with the mood shifts strongly affected the interaction with the therapist, whose quality varied accordingly ("easy" and "difficult" hours). The PQS analysis showed the association of "easy" hours with the topic of the involvement in significant relationships and of "difficult hours" with self-distancing, a defensive maneuver common in narcissistic personality structures. In the fMRI data, the modes of functioning visible in the therapy hours were significantly associated with modulation of the signal elicited by personalized attachment-related scenes in the posterior cingulate (p = 0.017 cluster-level, whole-volume corrected). This region has been associated in previous studies to self-distancing from negatively valenced pictures presented during the scan. The present study may provide evidence of the possible involvement of this brain area in spontaneously enacted self-distancing defensive strategies, which may be of relevance in resistant reactions in the course of a psychoanalytic psychotherapy.

Keywords: attachment; fMRI; psychoanalysis; psychotherapy process Q-Set; single case studies.

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Clinical Case Studies in Psychoanalytic and Psychodynamic Treatment.

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1st Edition

Clinical Psychoanalytic Case Studies with Complex Patients Watching Experience at Work

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Description

Clinical Psychoanalytic Case Studies with Complex Patients is a collection of key case studies that provides a rich resource of information and inspiration for clinicians working psychoanalytically with complex and disturbed patients in a range of contexts. The book is presented in six parts, each introduced with commentary that puts the material into context. It covers a range of topics including autism, violence and perversion, psychosomatics, hysteria, dementia, psychosis and assessment of gender dysphoria. Each chapter presents either a single case study or a selection of case vignettes, examines necessary context and presents additional detail about subsequent treatment. The depth and range of the cases presented provide key insight into and detailed consideration of risk assessment, safe settings and other important preliminary issues. Clinical Psychoanalytic Case Studies with Complex Patients will be of great interest to psychoanalysts in practice and in training, psychoanalytic psychotherapists and other clinicians seeking an introduction to psychoanalytic work.

Table of Contents

Anne Zachary is a psychoanalyst and retired consultant psychiatrist in psychotherapy based in the UK. She trained in medicine and psychiatry at the Royal Free Hospital and Friern Hospital and specialised in psychotherapy at the Cassel Hospital. She was locum consultant at the Maudsley Hospital before becoming a consultant at the Portman Clinic and consulted to medium secure units and Broadmoor Hospital. She has a specialist interest in acting out behaviours and risk and a sustained interest in female sexuality. She has a private psychoanalytic practice in SW London.

Critics' Reviews

"Clinical work is at the heart of the many-faceted creature we call psychoanalysis. Psychoanalysis is full of ideas, and ideas about psychoanalytic ideas, its meta-psychology. But again, and again its abstractions need to be earthed in the actual practice of psychoanalytic encounters between analysts and patients. It is this real, human encounter which contains, ultimately, the most moving, interesting and important dimensions of psychoanalysis, nowhere more so than when analysts are challenged by human cases which are enormously difficult to engage with and understand. Often psychoanalysis is the last chance for highly disturbed patients, which ups the ante for patient and analyst alike. Anne Zachary has, therefore, done us all an immense favour in putting together this book of expert clinical work with complex cases, a book that will inform and inspire many different types of readers - patients, analysts, psychologists, psychiatrists, all mental health workers, and those who are simply interested in psychoanalysis and the human spirit. I endorse the book whole-heartedly." - Francis Grier, Training Analyst & Supervisor, British Psychoanalytic Society, Editor-in-Chief, The International Journal of Psychoanalysis. "Psychoanalytic Clinical Case Studies with Complex Patients: Watching experience at work edited by Anne Zachary includes a wide spectrum of difficult to treat cases. If you buy this book you will learn about the tragic consequences of the tensions between management in NHS trusts and the front-line clinical personnel. Three chapters convey the hard-won understanding that emerges in the treatment of autistic children and adults. The psychosomatic and hysterical reactions to intergenerational trauma feature in another chapter. The reader will be able to follow the analysis of interlocking psychopathologies within a parental couple that enabled the father to move away from longstanding psychotic functioning. The technical difficulties of working with patients who present with gender dysphoria are examined in another chapter. This book will take the reader through the differential diagnosis of the underlying diseases that contribute to dementia, and a treatment that acknowledged the demented patient’s pain and insight. The reader will also learn about psychoanalytic work with patients who exercise ruthless and/or sadistic violence, and how the clinicians managed their anxieties when working with these patients. I strongly recommend this honest, straightforward book about the disturbing emotional, intellectual and clinical realities encountered when working psychoanalytically with complex patients." - Donald Campbell is a Distinguished Fellow, Training Analyst and Past President of the British Psychoanalytic Society

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A clinical case study of a psychoanalytic psychotherapy monitored with functional neuroimaging

2013, Frontiers in human neuroscience

This case study describes 1 year of the psychoanalytic psychotherapy using clinical data, a standardized instrument of the psychotherapeutic process (Psychotherapy process Q-Set, PQS), and functional neuroimaging (fMRI). A female dysthymic patient with narcissistic traits was assessed at monthly intervals (12 sessions). In the fMRI scans, which took place immediately after therapy hours, the patient looked at pictures of attachment-relevant scenes (from the Adult Attachment Projective Picture System, AAP) divided into two groups: those accompanied by a neutral description, and those accompanied by a description tailored to core conflicts of the patient as assessed in the AAP. Clinically, this patient presented defense mechanisms that influenced the relationship with the therapist and that was characterized by fluctuations of mood that lasted whole days, following a pattern that remained stable during the year of the study. The two modes of functioning associated with the mood shifts...

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In this pilot study, we followed 22 patients during their psychoanalytic psychotherapy to monitor changes in the quality of their object representations (father, mother, partner/best friend, self) and level of psychopathology (OQ-45). The Differentiation-Relatedness Scale (DR-S) was used in two semi-structured interviews: Object Relation Inventory (ORI) and two questions of the Adult Attachment Interview (AAI). Results showed that the DR-S ratings are comparable in both interviews for father and mother, with significant changes during therapy for father using the ORI and mother using the AAI. The level of psychopathology also changed significantly during treatment. Despite some shortcomings, the DR-S in combination with the ORI and AAI-questions seems a useful instrument for clinicians to monitor structural change in personality functioning during psychoanalytic psychotherapy.

Journal of Psychology and Neuroscience

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This study sets out to investigate the mechanisms by which psychoanalytical psychotherapy can induce neurobiological changes. From Neuroscience which, in accordance with his thinking at the time, Freud never disregarded, the concepts of neuronal plasticity, enriched environment and the neurobiological aspects of the attachment process. From Psychoanalysis, the theory of transference, M. Mahler’s psychological evolution model, the concept of the regulating function of the self-objects and Winnicott’s holding environment concept. Together these provide a useful bridge toward the understanding of the neurobiological changes resulting from psychoanalytical psychotherapy. One concludes that psychoanalytical psychotherapy, through transference, acts as a new model of object relation and learning which furthers the development of certain brain areas, specifically, the right hemisphere, and the prefrontal and limbic cortices, which have a regulating function on affects.

Annals of The New York Academy of Sciences

Hans-Peter Hartmann

The chapter starts with a historical overview of the subject of narcissism in psychoanalysis. Some sociophilosophical definitions of narcissism are explained and the connection to self psychology is described. It is especially referred to Honneth's Struggle for Recognition, which is related to the need for selfobject experiences. An outline of different concepts concerning narcissism, especially in the European psychoanalytic tradition, follows and leads to a clearer understanding of Kohut's conception of the self and its selfobjects. Because self psychology can often be understood as applied developmental psychology, useful links to attachment research are described and the move to the level of representation by mentalization is clarified. Further development of self psychology in the direction of intersubjectivity helps to supply connections to systems theory. Recently developed theories of empathy with reference to neurobiological findings provide a dynamic perspective of the activation of empathy. Thus, empathy seems to be better understood as a sort of contagion on which cognitive cortical processes are superimposed. Finally, the therapeutic process in psychoanalytic self psychology is portrayed. This process implies a disruption and repair process by which transmuting internalization can take place. More current theories of self psychology view this process in its essence intersubjectively as a co-construction between patient and analyst. The paper concludes with some hints for a paradigm shift in the direction of a more holistic understanding of the self.

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Psychotherapy Research

Madeline Carrig , Gregory Kolden

Trends in Psychiatry and Psychotherapy

Diogo Machado

Psychology and Psychotherapy: Theory, Research and Practice

Rosemary Cogan

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The Woman Behind Freud’s First Case Study

The case of anna o. showed that psychoanalysis worked. did freud tamper with it.

There is perhaps no one more devoted to the cause than a convert, and there is no one more violent toward it than a person who has lost their faith. The faithful turned faithless take up the act of crusade, but in reverse: new atheists confronting the world with secular eyes, children who learn that their parents aren’t omnipotent. They have suffered the loss of an organizing principle, the very thing they built their life around. Now, they may seek revenge on the object that caused an earlier delusion. The commitment doesn’t end—it just takes on new guises.

Beyond the reactions of former lovers and former zealots, we see this in the history of psychoanalysis, perhaps because the practice attracts and demands those same qualities of immersion and devotion. Many have justly loved psychoanalysis, and many have justly despaired of it. This includes the very founders of rational emotive behavioral therapy and cognitive behavioral therapy, who brought about a sea change in mental health care, and the critics Frederick Crews, Jeffrey Masson, and Philip Rieff, who turned against Freud even after he had been unthroned as king of the twentieth century. This hatred can feel quasi-personal, aimed at the originator, their father figure, Sigmund Freud.

This loss of faith looms over Gabriel Brownstein’s book, The Secret Mind of Bertha Pappenheim: The Woman Who Invented Freud’s Talking Cure . On its face, the book is a study of the first analytic patient (although she didn’t exactly receive psychoanalytic treatment), Bertha Pappenheim. Pappenheim, who was treated by Freud’s mentor Josef Breuer in Vienna, was the subject of one of Breuer’s case studies and was much discussed by Freud throughout his own career. The book’s stated aim is to offer a full portrait of someone flattened and circulated as a specimen. For Pappenheim is best known by another name—Anna O.—and is best known not as her full person, who left a legacy of feminist and activist patronage, but as the world’s most famous hysteric.

But quietly, this is also a book about the birth and death of psychoanalysis—which is to say that the narrative of Freud’s ascendance and betrayal is the engine that drives the book. Brownstein argues, sometimes contradictorily, that Freud’s brilliance and his drive to make his way as a medical doctor propelled him to tamper with Bertha’s story.

Given that Pappenheim’s stunning cure is the origin story of psychoanalysis, Brownstein seeks to denigrate the whole endeavor on these grounds. If the Anna O. case was a fraud, so, too, would the cure be that she discovered.

Hysteria, much like psychoanalysis, has a storied past, one with a powerful crescendo followed by a caesura. Though the term “hysteric” is now assumed in common speech to be either a pejorative epithet, synonymous with performative hyper-emotionality ( he was hysterical ), or a historical diagnosis made up by misogynistic doctors (like, some argue, Breuer and Freud), the condition was once quite common. For the uninitiated, hysteria is an illness where the body speaks, where neurotic symptoms appear in and on it. It was treated by an array of cures, from gynecological massage (prescribed orgasm), hypnotism, rest, and drugging, to change of scenery, and, yes, for a very few patients, starting in the late nineteenth century, Breuer and Freud’s cathartic method. This eventually became psychoanalysis. This was, it must be said, a treatment that seems preferable to the other options.

Bertha Pappenheim was in many ways a typical hysterical patient, and an extraordinary woman. When she went to see Breuer in 1880, she presented with the typical hysterical complaints: partial paralysis, disturbances of appetite and language, pain. She couldn’t recall her native German and only spoke in English. She wouldn’t drink water. She had fallen ill while nursing her father, and her condition deteriorated upon his death. She was treated both in her home and in an asylum, often with high doses of drugs. What marks her case as special is that Pappenheim was the first person on Earth to be treated by the cathartic method, in large part because she invented it. Anytime you hear someone say “talking cure,” they’re using the very term Pappenheim ascribed to the yearslong experiment she undertook, morning and night, with her doctor. As she chattered on, as she engaged in the “chimney sweeping” of her mind—so the story goes—she felt better.

Freud and Breuer went on to co-write the groundbreaking Studies on Hysteria , published in 1895. The two doctors, one senior and one junior, open the book with a co-written introduction and end it with a pair of stand-alone essays (Freud’s undermining Breuer’s) in which the nascent theories of repression, defense, catharsis, and abreaction first appear. Each supplied case material of hysteric women treated by this nascent cathartic method. Freud wrote up four cases, and Breuer only contributed the case of Pappenheim, now disguised and named “Anna O.” The two detailed the symptoms of their patients and how each was aided, if not outright cured, by this new talking protocol.

In Breuer’s write-up of Anna O., which only runs about 25 pages, he elaborates on the case study, telling his readers how ill Anna was, when, and why. He then goes on to describe his therapeutic practice of sitting with her at night, and how, while Anna O. was under hypnosis, the two came to “develop a therapeutic technique” of linking each of her symptoms to the moment it appeared. The water she will not drink, for instance, is linked to a moment she saw her English ladies’ companion let a little dog drink from her glass. After the connection is revealed under hypnosis, Breuer tells us, Anna O. drinks water once more. The process repeated until there were no symptoms left, and Anna O.’s mental state presumably returned to normal.

The problem is—and basically all historians of psychoanalysis agree on this point—that even though Breuer and Freud reported a miracle cure, Anna O. didn’t get better. In fact, she got worse and was put in a sanatorium. The question is why. Brownstein, following the anti-Freud tradition, attributes this failure to the treatment. Freud, of course, attributed this failure to the person who offered the treatment—Breuer—not because he couldn’t cure her, but because he didn’t finish doing so.

Like all origin myths, the case has been subject to endless interpretation and reinterpretation. Even the original case study is retrospective: Breuer didn’t write up the Anna O. case at the time of treatment. He did so at Freud’s urging, so that the two might document this new technique of psychotherapy. Anna O. thus became the first patient of psychoanalysis only after the fact, and even though her treatment has just about nothing in common with psychoanalysis today, she is celebrated as such. Freud then revised the case multiple times across his life (in private letters, then in publications in 1910 and 1914), often to diminish Breuer’s role in the origin of psychoanalysis. This is in part due to what Freud thought of privately as Breuer’s failure: When Anna O. showed Breuer she had transferred onto him—by fantasizing about having his baby—Breuer ran away. Breuer could have invented psychoanalysis had he stayed in the room—but he didn’t dare. And thus Anna remained ill, but, in Freud’s understanding, psychoanalysis was not at fault.

Once Freud died, others revised the case in their own ways. Stacks of books can be called up in any research library by those who either defend or revile Freud—and nearly all of them, at one point, turn to Anna O. These studies often seek to collate and correlate Breuer’s flattened write-up of the case with historical reality, trying to reconstruct both Anna O.’s illness and her medical treatment. Some are feminist rereadings of the case, arguing that Anna O. was sick with patriarchy; others center squarely on Freud’s obsession with the case, excavating his letters about Anna O. to various ends.

What’s plain as day: Pappenheim has become the Rorschach test for the field. What we see in her case tends to be run through our feelings about psychoanalysis. The great historian of psychoanalysis John Forrester has argued that the baby that Anna O. spoke of wanting to have with Breuer was psychoanalysis—something she conceived with Breuer, even though he wouldn’t stick around and take responsibility for it. Anti-Freudian Mikkel Borch-Jacobsen sees Anna O.’s case as entirely fabricated, a young woman taken in by her handsome doctor and given huge quantities of drugs; if she invented psychoanalysis, she was the first to be duped by it. As the late Peter Gay observed, “There are contradictions and obscurities in successive versions of the case, but this much is more or less beyond dispute: In 1880, when Anna O. fell ill, she was twenty-one.”

But because very little besides Breuer’s documents is known of her life at the time of treatment, we project what we want onto her, and we can, for her history is a mere fragment. That we continue to do so makes exquisite sense: Psychoanalysis teaches us we must go back to our origins to go forward. And the treatment of Anna O. by Breuer is one way—a decent way—to conceptualize the start of Freud’s theory of mind.

Brownstein’s main critique of Freud’s use of Anna O. is this: that he took her case for his own material ends (though, by the same token, we might ask after Brownstein’s book advance). Freud was a broke young doctor; he needed to get married, and, to do so, he needed to press Breuer into writing Studies on Hysteria so that he could practice this new treatment with a kind of paternal authorization, styling himself as a doctor of “the cathartic method of J. Breuer.”

Brownstein agrees with anti-Freudians like Borch-Jacobsen and Crews that Anna O.’s treatment was a dismal failure. And even though that would make the lie—that Anna O. was cured—Breuer’s, Brownstein argues it was Freud who metaphorically had a gun to his mentor’s head and forced him to write it. More softly, Brownstein argues that Anna O. obscures Bertha Pappenheim, whom Brownstein now promises to deliver to us. Here’s the problem: Brownstein wants to make Freud the (very) bad guy of a story that had little to do with him, even if he had a great deal to do with the case becoming a story. So much so that Brownstein treats the possibility of Freud seeing Bertha Pappenheim at a party years after the treatment as corroborating evidence for some kind of misdeed.

Brownstein thus rewrites up the notorious case, with his chatty, negative asides and interpretations taking center stage. His first close reading from the book is, appropriately, from the first page. He argues that, though Studies purports to be “about the sex lives and sex drives of young bourgeois women,” it “begins by announcing that, for the purposes of propriety, any discussion of their actual intimate lives will be avoided.” Brownstein argues that this is a cover—that Breuer and Freud are maliciously withholding evidence for their theory because there isn’t any and because the doctors wanted to appear respectable. But if we read the first page of Studies , here’s what Breuer and Freud actually wrote: “It would be a grave breach of confidence to publish material of this kind, with the risk of patients being recognized and their acquaintances becoming informed of facts which were confided only to the physician.” There is a deep truth to what Freud and Breuer argue: They were working in a small coterie of largely wealthy Viennese Jewish patients. Everyone knew one another (hence, the great possibility of Freud running into Pappenheim). If you circulated reports of the ills of a young woman’s “marriage bed” or lack thereof, it would have meant no father would refer his daughter to Breuer or Freud, let alone the greater ethical considerations Brownstein says are gestured to half-heartedly.

Elsewhere, Brownstein accuses Freud of having a faulty memory and disguising the patient (despite the authors’ own opening warning to the reader not to go looking for biographical information of Pappenheim). To cover over the lack of details about her, Brownstein freely narrativizes the case, turning it into a historical fiction. At other times, Brownstein seems furious that Freud tends to write beautifully—Brownstein takes this as a sign of fudging the facts—while he then turns to close reading it like a literary critic.

By the end, we know from Brownstein that we’re supposed to find Breuer largely unobjectionable, but in the grips of a young Freud. The cardinal sin for Brownstein, though, is that Anna O. wasn’t made better. (Brownstein believes that she was in fact suffering from a functional neurological disorder, a contemporary diagnosis that overlaps with hysteria.) She was transported back to the asylum, so ill that Breuer reportedly told Freud his beloved patient might be better off dead, so that she might be free of suffering. Yet we might pause and say something did indeed happen in that treatment: Pappenheim was ultimately able to recover enough. By 1889, at 29 years of age, she was able not only to get out of bed, to talk, but to work in a soup kitchen. From this year on, she published—first anonymously and then pseudonymously, under the name Paul Berthold. Soon, Pappenheim was finally known not as Anna O., not as Berthold, but as herself. She also became famous as herself, a powerful, feminist leader, founding the Jewish Women’s Association and centralizing Jewish women’s organizing toward both employment and charity.

Why a book about Bertha Pappenheim now? One answer: With its claim that it will deliver readers Pappenheim in full, Brownstein’s book sits on that ever-expanding shelf of nonfiction books that seek to tell the stories of women who have been relegated to the margins of history, returning them to their larger, unobfuscated import. The book, too, in trying to bring Pappenheim’s story up to the present by rediagnosing her with functional neurological disorder, joins the book market for explorations of contested illness. Yet this book isn’t exactly proper to either of these subgenres. Instead, we might make sense of it as a work of backlash: Just as a range of analysts and writers have turned once more to Freud (as The New York Times proclaimed in an article not quite aptly titled “Not Your Daddy’s Freud”), so have others returned to maligning him. Brownstein has offered us, perhaps, the first book of the Freud Wars 2.0.

Brownstein, in fact, inherits the role of Freud skeptic from an earlier generation. His father, Dr. Shale Brownstein, was a prominent New York psychiatrist and psychoanalyst with a Rolodex of famous patients. Sometime in the 1980s, Dr. Brownstein became disillusioned with psychoanalysis and became an anti-Freudian—though we are never quite told why. One night, when Brownstein went to visit his father, he found him in his underwear, speaking wildly. The subject: Bertha Pappenheim. His father held a thick envelope filled with scientific and historic papers, newspaper clippings, reviews of books, and his own essay on the subject.

His father gave him the manila envelope. The younger Brownstein went home to Brooklyn, and the next day his father was dead. As if in a novel, Brownstein then becomes fixated on the envelope and its contents only to discover he has misplaced it. His own book is as much an attempt to decipher his father’s theory about Bertha Pappenheim as to understand his father’s turn against Freud. Brownstein makes clear that his father was a devoted doctor, and treated luminaries in downtown New York, including Peter Hujar and Richard Serra. Dr. Brownstein tended to babies with HIV in the 1980s who languished otherwise in their cots, when others wouldn’t dare go near. Dr. Brownstein gave everything to psychoanalysis, but then something changed. We don’t quite know what, but his father became so disillusioned that he burned all 24 volumes of Freud’s Standard Edition .

Was it the homophobia of mainstream psychoanalysis that rightfully made him repudiate his training? Was it indeed the legacy of Anna O.? I wish we knew what Brownstein felt as he wrestled with Freud via his father. As author and son, Brownstein is overwhelmed by the research subject he must now try to understand and, more importantly, terribly overwhelmed by the pain of being alive when life is most brutal. Shortly after his father’s death, his wife is diagnosed with terminal pancreatic cancer, and when the global pandemic arrives, Brownstein must weather it without them.

While Brownstein seemingly hates Freud, he, like many others, can’t escape him. Early in the book, he disparages two Freudian terms: “secondary gain,” which can be described as the unconscious advantage patients acquire through their illness (stereotyped here as attention), and “ la belle indifférence ,” a calm character in the face of crisis. But toward the book’s close, Brownstein suddenly tips his hand: He comes to a form of self-understanding through these concepts. In not getting treated for a heart problem, he says he has a case of la belle indifférence . In writing the book, he self-analyzes, he can be understood as having a case of secondary gain—after all, Brownstein was quite literally paid for producing it.

But Brownstein uses these concepts defensively—to show his reader he is in on the joke. The book itself, more movingly, is a testament to yet another set of Freudian concepts: the return of the repressed, as evidenced by his return to the use of Freud; working through (here, loss of his father, his wife); and, indeed, sublimation. Writing the book then might be an act of Freudian sublimation; it is also an act of devotion. This article has been updated.

Hannah Zeavin is an assistant professor of history at UC Berkeley. She is the author of The Distance Cure: A History of Teletherapy .

• Open access
• Published: 22 June 2024

Correlation between the incidence of inguinal hernia and risk factors after radical prostatic cancer surgery: a case control study

• An-Ping Xiang 1 , 2 ,
• Yue-Fan Shen 1 ,
• Xu-Feng Shen 1 &
• Si-Hai Shao 1  

BMC Urology volume  24 , Article number:  131 ( 2024 ) Cite this article

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The incidence of recurrent hernia after radical resection of prostate cancer is high, so this article discusses the incidence and risk factors of inguinal hernia after radical resection of prostate cancer.

This case control study was conducted in The First People’s Hospital of Huzhou clinical data of 251 cases underwent radical resection of prostate cancer in this hospital from March 2019 to May 2021 were retrospectively analyzed. According to the occurrence of inguinal hernia, the subjects were divided into study group and control group, and the clinical data of each group were statistically analyzed, Multivariate Logistic analysis was performed to find independent influencing factors for predicting the occurrence of inguinal hernia. The Kaplan-Meier survival curve was drawn according to the occurrence and time of inguinal hernia.

The overall incidence of inguinal hernia after prostate cancer surgery was 14.7% (37/251), and the mean time was 8.58 ± 4.12 months. The average time of inguinal hernia in patients who received lymph node dissection was 7.61 ± 4.05 (month), and that in patients who did not receive lymph node dissection was 9.16 ± 4.15 (month), and there was no significant difference between them ( P  > 0.05). There were no statistically significant differences in the incidence of inguinal hernia with age, BMI, hypertension, diabetes, PSA, previous abdominal operations and operative approach ( P  > 0.05), but there were statistically significant differences with surgical method and pelvic lymph node dissection ( P  < 0.05). The incidence of pelvic lymph node dissection in the inguinal hernia group was 24.3% (14/57), which was significantly higher than that in the control group 11.8% (23/194). Logistic regression analysis showed that pelvic lymph node dissection was a risk factor for inguinal hernia after prostate cancer surgery (OR = 0.413, 95%Cl: 0.196–0.869, P  = 0.02). Kaplan-Meier survival curve showed that the rate of inguinal hernia in the group receiving pelvic lymph node dissection was significantly higher than that in the control group ( P  < 0.05).

Pelvic lymph node dissection is a risk factor for inguinal hernia after radical resection of prostate cancer.

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Prostate cancer is a common malignant tumor in urology, which occurs in the prostate epithelial tissue, There are an average of 190,000 new cases of prostate cancer each year and about 80,000 deaths worldwide each year [ 1 , 2 ]. In recent years, the incidence of prostate cancer has increased year by year, seriously affecting the health and quality of life of patients [ 3 ]. Worldwide, the incidence of prostate cancer is second only to lung cancer, and its death rate ranks 7th among male cancer causes [ 4 ]. Radical resection of prostate cancer (RP) is the main means for the treatment of prostate cancer, and the surgical methods are generally divided into open radical resection of prostate cancer (RRP) and minimally invasive radical resection of prostate cancer, the latter including laparoscopic radical resection of prostate cancer (LRP) and robot-assisted laparoscopic radical resection of prostate cancer (RALP) [ 5 , 6 , 7 ].

Inguinal hernia (IH) is a relatively common disease in clinic, which is caused by increased abdominal pressure, thinning of abdominal wall, and bulging of abdominal organs. Inguinal hernias include direct hernias, oblique hernias and femoral hernias [ 8 ]. At the onset, lumps protruding outward from the inguinal region can be seen. If the intestines cannot return to the abdominal cavity in time, it is easy to cause intestinal necrosis, intestinal obstruction, intestinal perforation and other complications, which may endanger the life safety of patients in severe cases [ 9 , 10 ].

With the extensive development of radical resection of prostate cancer in various hospitals, the problem of postoperative inguinal hernia has gradually attracted the attention of urologists. The previously reported incidence of IH after radical prostate cancer surgery was approximately 13.7% [ 11 ]. A study by Nagatani S et al. showed that the incidence of inguinal hernia after radical prostate cancer surgery was 7-21%, most of which occurred within 2 years after surgery [ 12 ]. A study by Stranne J et al. showed that the cumulative risk of IH occurrence within 48 months in open radical resection for prostate cancer group and non-surgical group was 12.2% and 5.8%, respectively [ 13 ]. Most cases of IH require surgery due to pain, discomfort, and incarceration and are considered an advanced complication of radical resection of prostate cancer. The adhesion after radical resection of prostate cancer also increases the difficulty of hernia repair. Therefore, urologists need to be concerned not only about the risk of urinary incontinence and erectile dysfunction after radical resection of prostate cancer, but also about the occurrence of IH.

In recent 10 years, many scholars around the world have studied the risk factors of inguinal hernia after radical prostate cancer surgery. Currently, most of the studies believe that anastomotic stenosis, previous history of inguinal hernia, and patent processus vaginalis are risk factors, However there is no consensus on the risk of lymph node dissection. For example, Niitsu H et al. believed that pelvic lymph node dissection during radical prostate cancer operation might damage the pectineal foramina, thereby increasing the risk of inguinal hernia [ 14 ]. Contrary to the results of Johan Stranne’s study, the author suggested that previous incidence of inguinal hernia and advanced age increased the risk of inguinal hernia after radical prostate cancer surgery, and pelvic lymph node dissection was not a significant risk factor [ 15 ]. There is also no consistent conclusion on the influence of BMI, age and surgical method.

Therefore, in order to further investigate the risk factors of inguinal hernia after radical prostate cancer surgery, especially the correlation between pelvic lymph node dissection and inguinal hernia, this study was conducted. This study retrospectively analyzed the clinical data of 251 patients who underwent radical resection of prostate cancer in our hospital from March 2019 to May 2021, and investigated the risk factors of postoperative inguinal hernia. It is reported as follows:

Research objectives

The objective of this study was to explore the incidence and risk factors of inguinal hernia after radical resection of prostate cancer, which provides reference for further research and guide the clinician to choose the appropriate surgical method according to the patient’s condition.

Research methods

The patient was also examined by B-ultrasound every 3 months at the outpatient PSA review to verify the occurrence of inguinal hernia. The subjects were divided into the inguinal hernia group (study group) and the non-inguinal hernia group (control group), If the diagnosis of inguinal hernia occurred, the follow-up was completed, and the type and time of inguinal hernia were recorded; otherwise, the follow-up was 2 years, and the relevant clinical parameters of each group were statistically analyzed (age, BMI, hypertension, diabetes mellitus, PSA value, previous abdominal operations, operation methods, operative approach, pelvic lymph node dissection)and the correlation between these parameters and the occurrence of inguinal hernia was analyzed, and the risk factors of inguinal hernia were found by Logistic regression analysis. According to the occurrence and time of inguinal hernia, Kaplan-Meier survival curve was drawn to compare the differences between the two groups.

The content of this study has been approved by the Ethics Committee of our hospital(approval number, 2,018,137). All patients signed informed consent forms. This is the protocol was registered on the Chinese Clinical Trial Registry. The study is planned to begin in mid-March 2019 and is planned to end by May 2021.

Inclusion criteria

Patients who received radical surgery for prostate cancer in Huzhou First People’s Hospital from March 2019 to May 2021; PSA was reviewed every 3 months after surgery, and check the inguinal area for protruding masses. Complete the 2-year follow-up plan.

Exclusion criteria

Patients with inguinal hernia before operation; patients with prior inguinal hernia surgery.

Statistical methods

SPSS 21.0 statistical software was used for statistical processing, the research data followed normal distribution, and the measured data were represented by X ± S. P  < 0.05 was considered statistically significant.

From March 2019 to May 2021, 318 cases of radical prostatectomy were performed in our hospital, during the follow-up period, a total of 28 cases died of other diseases, a total of 39 cases were lost to follow-up or clinical data were incomplete, and a total of 251 cases were finally followed up. There were no significant differences in age, BMI, hypertension, diabetes, PSA, previous abdominal operations and operative approach between the two groups ( P  > 0.05), while there were significant differences in surgical method and pelvic lymph node dissection ( P  < 0.05). The incidence of pelvic lymph node dissection in the inguinal hernia group 24.3% (14/57) was significantly higher than that in the control group 11.8% (23/194). See Table  1 for details.

Multivariate Logistic regression analysis of risk factors showed that pelvic lymph node dissection was a risk factor for inguinal hernia after prostate cancer surgery (OR =0.413, 95%Cl: 0.196-0.869, P  = 0.02). There was no statistical significance in age, BMI, hypertension, diabetes, PSA value, previous abdominal operations, operation method, operative approach were not risk factors for inguinal hernia ( P  > 0.05). See Table  2 for details.

The cases of inguinal hernia were grouped according to whether or not they had received pelvic lymph node dissection. The incidence and time of inguinal hernia in the two groups were recorded, and the Kaplan-Meier survival curve was drawn. The overall incidence of inguinal hernia after radical resection of prostate cancer was 14.7% (37/251), There were 26 cases with indirect hernia, accounting for 70.2% (26/37), 21.6% (8/37) with direct hernia, 8.2% (3/37) with oblique hernia and direct hernia, and the mean time of occurrence was 8.58 ± 4.12 months. The average time of inguinal hernia was 7.61 ± 4.05 (month) for those who received lymph node dissection and 9.16 ± 4.15 (month) for those who did not receive lymph node dissection, and there was no significant difference between them ( P  > 0.05). The incidence of inguinal hernia in the group receiving pelvic lymph node dissection was significantly higher than that in the control group ( P  < 0.05). See Fig.  1 for details.

Survival curve of pelvic lymph node dissection and inguinal hernia (month)

In recent years, the incidence of prostate cancer has increased year by year, seriously affecting the health and quality of life of patients, the complications after radical prostate cancer surgery mainly include urinary incontinence and sexual dysfunction, but inguinal hernia is also one of the common complications [ 16 ]. Liu L et al. found that open radical resection for prostate cancer technique and advanced patient age, especially those over 80 years old, are associated with a higher incidence of IH. Appropriate prophylaxis during surgery should be evaluated in high-risk patients [ 17 ].In some regional studies, low BMI has been identified as a risk factor for IH, and the risk threshold for BMI has not been determined, which is about BMI < 25 kg/m2 [ 18 ]. However, a number of studies have found that low BMI does not increase the risk of postoperative IH [ 19 , 20 ]. At present, there is no uniform conclusion on the risk of IH between open radical resection for prostate cancer and laparoscopic radical prostatectomy. The study of Alder R scholars believed that the incidence of IH after laparoscopic radical prostatectomy was relatively low [ 21 ], while Otaki T’s study shows that the incidence of IH after laparoscopic radical prostatectomy is 7.3% and that of open radical resection for prostate cancer is 8.4%, showing no statistical difference between them [ 20 ]. There is no consensus on whether pelvic lymph node dissection is a risk factor for inguinal hernia [ 14 , 15 ]. In short, the specific mechanism of inguinal hernia after radical prostate cancer surgery is unclear.

This study retrospectively analyzed the clinical data of 251 cases treated in our hospital, and found that the overall incidence of inguinal hernia was 14.7% (37/251), which was consistent with most of the current research results. We also found that the average time of occurrence of inguinal hernia after surgery was 8.58 ± 4.12 months, which provided certain guidance for our postoperative follow-up time.

In this study, through Logistic multivariate analysis, it was found that pelvic lymph node dissection was a risk factor for inguinal hernia after prostate cancer surgery (OR = 0.413, 95%Cl: 0.196–0.869, P  = 0.02). There was no statistical significance in age, BMI, hypertension, diabetes, PSA value, previous abdominal operations, operation method, operative approach and the occurrence of inguinal hernia after prostate cancer surgery ( P  > 0.05),but there were statistically significant differences with surgical method and pelvic lymph node dissection ( P  < 0.05). Therefore, the advantages and disadvantages of pelvic lymph node dissection should be reasonably evaluated for low-medium-risk prostate cancer patients, so as to avoid the occurrence of inguinal hernia. By drawing Kaplan-Meier survival curve, it was found that the rate of inguinal hernia in the group receiving pelvic lymph node dissection was significantly higher than that in the control group. Some studies believe that pelvic lymph node dissection during radical resection of prostate cancer operation will cause postoperative scar contraction in the inguinal region, resulting in an increase in abdominal pressure outward and downward, resulting in an increase in the incidence of inguinal hernia. Lodding P designed a comparative study between the group of radical resection of prostate cancer plus pelvic lymph node dissection, the group of pelvic lymph node dissection and the group without operation. They found that the incidence of inguinal hernia in the three observation groups was 13.6%, 7.6% and 3.1%, respectively, and the difference between the prostatectomy group and the group without operation was statistically significant. There was no significant difference between the group and pelvic lymph node dissection group. This result implies that pelvic lymph node dissection is an important factor in the development of inguinal hernia [ 22 ]. Another Sun M study compared the incidence of inguinal hernias after radical prostate cancer surgery and pelvic lymph node dissection alone, and showed that the risk of inguinal hernias increased by 6.8% and 7.8% at 5 and 10 years, respectively, in the radical prostate cancer resection group compared with the pelvic lymph node dissection group [ 23 ]. Niitsu H et al. believed that pelvic lymph node dissection during radical resection of prostate cancer might damage the pectineal foramina, while inguinal hernia originated from the defective pectineal foramina [ 14 ].

Shimbo M et al. found that due to prostatectomy and vesicourethral anastomosis, preoperative and postoperative sagittal MRI images showed that the rectovesical excavation (RE) was moved downward by about 2 to 3 cm [ 24 ]. Accordingly, they speculated that due to the displacement of RE, the peritoneum and vas deferens after urethrovesical anastomosis were pulled, which further pulled the opening of the inner ring and caused it to shift medially, which led to the occurrence of postoperative IH. Based on this theory, many scholars have prevented the occurrence of hernia after operation by reducing the tension of peritoneum and vas deferens at the inner ring and ligation and rupture of sheathing process. Several other articles have reported the role of preserving the retropubic space (RS) in preventing IH after radical resection of prostate cancer. Chang KD et al. found that robot-assisted laparoscopic radical prostatectomywith retained Retzius space significantly reduced the incidence of postoperative IH compared with standard robot-assisted laparoscopic radical prostatectomy [ 25 ]. In addition, the study of Matsubara et al. also showed that compared with standard open radical resection for prostate cancer, the incidence of IH after transperineal radical resection of prostate cancer with retained anatomical structures such as the Retzius space was lower [ 26 ]. Therefore, urological surgeons can take some effective measures in the operation to prevent the recurrence of inguinal hernia.

In this study, we identified risk factors for inguinal hernia after pelvic lymphadenectomy for prostate cancer. Other risk factors such as age, BMI, hypertension, diabetes mellitus, PSA value, history of abdominal surgery, operative method, operative approach were not significant in multivariate analysis, which was inconsistent with the results of Iwamoto H et al [ 27 ]. They found that dilatation of the right internal inguinal ring and different manipulation of the medial peritoneal incision of the ventral femoral ring were independent risk factors for IH after laparoscopic radical prostatectomy. The reason why postoperative IH occurs more often on the right side is not known. Alder R et al. found that the incidence of IH after open radical prostate cancer treatment was significantly higher than laparoscopic radical prostate cancer treatment [ 21 ], but our study did not show a difference between the two groups, possibly due to the small number of cases included in open radical prostate surgery.

In summary, the incidence of inguinal hernia after radical prostate cancer surgery is relatively high, and the specific cause is still unclear. Our study shows that pelvic lymph node dissection is a risk factor for inguinal hernia.

Limitations

The sample size of this study is small, and it belongs to a single-center study, so the representativeness of the research conclusions may not be strong. This time, we followed up the samples for 2 years, which was not long enough and may have overlooked the real incidence of inguinal hernia. In addition, this study is a retrospective study, and the clinical parameters observed are not very comprehensive, which may ignore the influence of other factors on the IH. Because our data is derived from clinical data, some data cannot be detected. These problems need further study by more scholars.

Data availability

We cannot provide and share our datasets in publicly available repositories because of informed consent for participants as confidential patient data. Data may be obtained from the corresponding author upon reasonable request.

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This work was supported by the following funding: the grant 2019GY23 from Huzhou Science and Technology Bureau Public welfare application research project of China.

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An-Ping Xiang, Yue-Fan Shen, Xu-Feng Shen & Si-Hai Shao

Department of Urology, Huzhou Key Laboratory of Precise Diagnosis and Treatment of Urinary Tumors, Huzhou, 313000, China

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An-Ping Xiang designed the study and drafted and revised the manuscript, Yue-Fan Shen recorded the patients cases, Xu-Feng Shen participated in the follow-up. An-Ping Xiang and Si-Hai Shao analyzes the data and draw graphs.

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Correspondence to Si-Hai Shao .

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The study protocol was approved by the ethics committee of the First People’s Hospital of Huzhou (approval number, 2018137). We have obtained written informed consent from all study participants. All of the procedures were performed in accordance with the Declaration of Helsinki and relevant policies in China.

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Xiang, AP., Shen, YF., Shen, XF. et al. Correlation between the incidence of inguinal hernia and risk factors after radical prostatic cancer surgery: a case control study. BMC Urol 24 , 131 (2024). https://doi.org/10.1186/s12894-024-01493-w

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MINI REVIEW article

Beyond clinical case studies in psychoanalysis: a review of psychoanalytic empirical single case studies published in isi-ranked journals.

• 1 Department of Psychoanalysis and Clinical Consulting, Ghent University, Ghent, Belgium
• 2 Department of Experimental, Clinical and Health Psychology, Ghent University, Ghent, Belgium

Single case studies are at the origin of both theory development and research in the field of psychoanalysis and psychotherapy. While clinical case studies are the hallmark of psychoanalytic theory and practice, their scientific value has been strongly criticized. To address problems with the subjective bias of retrospective therapist reports and uncontrollability of clinical case studies, systematic approaches to investigate psychotherapy process and outcome at the level of the single case have been developed. Such empirical case studies are also able to bridge the famous gap between academic research and clinical practice as they provide clinically relevant insights into how psychotherapy works. This study presents a review of psychoanalytic empirical case studies published in ISI-ranked journals and maps the characteristics of the study, therapist, patient en therapies that are investigated. Empirical case studies increased in quantity and quality (amount of information and systematization) over time. While future studies could pay more attention to providing contextual information on therapist characteristics and informed consent considerations, the available literature provides a basis to conduct meta-studies of single cases and as such contribute to knowledge aggregation.

Introduction

Single case studies are at the origin of both theory development and research in the field of psychotherapy in general and psychoanalysis in particular ( McLeod, 2010 , 2013 ). Increasingly, empirical case studies made their entrance in the field and are recognized as important sources of evidence to address the complexity of psychotherapeutic processes ( Goodheart, 2005 ; American Psychologcial Association [APA], 2006 ; McLeod and Elliott, 2011 ). Systematic meta-studies of single cases moreover allow knowledge aggregation and as such could enhance the scientific merits of case studies ( Iwakabe and Gazzola, 2009 ). We argue that in order to explore the full potential of empirical single cases in the field of psychoanalysis, it is important to map the existing field of such cases and get an overview of their characteristics, strengths and weaknesses. The goal of the current review is to provide this information and delineate points of interest for future case studies and context for meta-studies in the field.

From its origin, the clinical case study was the dominant research method in psychoanalysis. Sigmund Freud, the founding father of psychoanalysis, is still both famous and notorious for his elaborate clinical case studies through which he developed his theoretical framework during the course of his life. Famous because of the richness of his case presentations and because of the resulting theoretical and clinical advancements that up until this day permeate the whole psychotherapeutic and cultural field. Notorious because the scientific merit of this method received increasing criticism and is mostly relegated to the scientific trash can ( Bornstein, 2005 ).

While empirical research continues to be a major source of debate and controversy in psychoanalysis (e.g., Aron, 2012 ; Benecke, 2014 ; Mills, 2015 ), the questioning of its scientific credibility and therapeutic efficacy gave rise to a wealth of (group level) research indicating the efficacy of psychoanalytic psychotherapy (e.g., Leichsenring et al., 2015 ). Nevertheless, the case study has a privileged place in the field of psychoanalysis. Indeed, the clinical case study is still very common, however, increasingly, empirical case studies appear to see the light of day.

Critiques on the subjective bias of therapists’ retrospective reports, the anecdotal quality and uncontrollable nature of clinical case studies ( Spence, 2001 ) influenced the emergence of systematic (quantitative and qualitative) approaches to conduct single case studies that are no longer (solely) dependent on the interpretation of the therapist. Methodological articles on single-case experimental designs (for a review see Smith, 2012 ), case-based time series analysis ( Borckardt et al., 2008 ), case comparison methods ( Iwakabe, 2011 ), and theory-building case studies ( Stiles, 2008 , 2010 ) are but a few examples of the increased recognition of the potential value of empirical case-based research to build knowledge ( Edwards et al., 2004 ; McLeod and Elliott, 2011 ). In the entire field of psychology, such idiographic approaches are increasingly considered to be important tools to bridge the science-practitioner gap and address the lack of alignment between the object of study and the method that is often criticized in mainstream evidence-based practice research (e.g., Westen et al., 2004 ; Desmet, 2013 ).

Despite this recognition of empirical case study methods, an important critique on generalizability problems remains. A way to address this and build knowledge resulting from single case studies is to conduct meta-studies on published single case studies or as Dattilio et al. (2010 , p. 436) state “One observation or one case offers only a small piece of evidence, but repeated observation […] across a series of cases provides a way of constructing a database of evidence on which clinical theory can be built.” Currently the potential for knowledge aggregation across cases surely remains unexplored despite the existence of methodological tools to do so, for example, meta-synthesis methods ( Finfgeld, 2003 ; Willemsen et al., 2015 ) and case comparison methods ( Iwakabe and Gazzola, 2009 ). A preliminary requirement to facilitate meta-studies, however, is a well-organized database that gathers published case studies ( Fishman, 2005 ; Iwakabe and Gazzola, 2009 ). The single case archive (SCA; Desmet et al., 2013 ) provides such a tool for psychoanalytic single cases published in ISI ranked journals. 1 Such a tool allows gathering cases on a specific topic and conducting meta-studies. Nevertheless, an overview of the nature of existing empirical case studies would provide important contextual information when considering a meta-study, yet this is currently lacking in the literature.

This study attempts to address this need and explores the following questions concerning empirical case studies in the field of psychoanalysis: ‘Which studies have been done?’; ‘What is the nature of these case studies?’; and ‘What are their merits and weaknesses?’ We investigate this through a review of empirical case studies published in ISI-ranked journals.

Cases were selected through the original SCA ( Desmet et al., 2013 ), which comprises psychoanalytic and psychodynamic case studies, published in ISI-ranked journals between 1955 and 2011. Cases were selected starting from a search on ISI Web of Knowledge using the search terms (psychoanal ∗ OR psychodynam ∗ ) AND (case OR vignette). This search provided 2760 results, which after screening for title, abstract, and if necessary the full text of the article, resulted in 445 articles presenting psychoanalytic or psychodynamic treatment of an original single case (no comments on already published cases). For this study, all English case studies of this dataset that were classified as either experimental (i.e., N = 1 subject experiments, testing hypotheses in an experimental design) or (naturalistic) systematic case studies (i.e., case studies using data from sources other than the therapist’s report and where data are investigated by one or more researchers other than the therapist) 2 were selected (52 articles discussing 55 cases). Moreover, for this study, the same search procedure was followed for the period of 2012–2017 to update the sample with empirical case studies from these more recent years. Screening the 1093 search results resulted in 31 articles discussing 38 empirical cases. All empirical cases were screened with the Inventory for Basic Information in Single Cases (IBISC; Desmet et al., 2013 ), which inventories basic descriptive information on study characteristics [design, type of data, type of analysis, presence of clinical (process) description, presence of informed consent], therapist (gender, age, education, experience) and patient (gender, age, diagnostic information) characteristics, and therapy characteristics (duration, number of sessions, session frequency, therapy outcome).

In the screened period (1955–2017), 83 articles were identified that comprise 93 cases using empirical case designs. The selected manuscripts included one to three case studies. Figure 1 depicts the number of case studies for each year empirical cases could be identified and indicates an increase of published empirical case studies over time.

FIGURE 1. Number of cases per year.

Study Characteristics

Of the empirical case studies, five cases (5.4%) were experimental designs and 88 were naturalistic systematic case studies (94.6%) following the definition of Iwakabe and Gazzola (2009) . Analysis of the case was mostly based on one type of data (44.1%); 25.8% used two types of data, 14% three types, and 3.2% four or more types of data. The amount of different types of data was not spread equally across time: before 2000 only one study mentioned more than one type of data, between 2000 and 2010 there were regular studies mentioning two types of data; while starting from 2010 studies start to appear that mention three and four or more types of data. The type of data most commonly used were audio recordings (or videotapes) (64.5%), followed by self-report or observer rated scales (36.6%) and interviews (35.5%). In 14% of cases (also) other types of data were used like behavioral measures, notes of the therapist, patient, or relatives, or biological measures.

Different ways of analyzing the data were used, from purely quantitative (21.5%) to purely qualitative (17.2%). Yet, in most studies mixed approaches (56%) were used combining for example clinimetric methods (e.g., ratings of session material using the Shedler Westen Assessment Procedure-200 (SWAP-200; Westen and Shedler, 1999 ) with clinical, qualitative, or quantitative approaches.

A clinical description of the patient and/or therapy process was provided in 73.1% of the cases. In 24.7% of the cases such a description was lacking, while in two cases there was somewhat of a clinical description through a patients’ retrospective report in one case and a qualitative description of specific analyzed sessions in the other case.

Informed consent (IC) was mentioned in 45.2% of the cases, meaning it was not mentioned in more than half of the cases. Before 2000, IC was mentioned in 4 out of 18 cases, between 2000 and 2010 it was mentioned in 13 out of 35 cases, and between 2011 and 2017 it was mentioned in 25 out of 40 cases. In this last period, of the cases not mentioning IC, four cases did mention an ethical approval, which might indicate that there was also an informed consent on the patient’s side.

Therapist Characteristics

In most studies information about the therapist was almost entirely lacking. We inventoried information about gender, age, education and experience, yet in 34.4% of the cases there was no information at all. In 10.8% of the cases information about only one of these variables was provided (mostly the therapist’s gender), while in 18.3, 29, and 7.5% of the cases information was provided about 2, 3, and 4 variables respectively.

Concerning gender, 24.7% were female therapists and 36.6% were male therapists. In one case there was both a male and a female therapist involved in therapy. For the remaining 37.8% of cases gender of the therapist was not mentioned. Age was mentioned in only 17.2% of the cases. Education was mentioned in 44.1% of the cases and included all kinds of degrees/description with psychologist, psychotherapist, social worker, and psychiatrist as the most common terms. Experience was mentioned in 57% of the cases, with 10.8% novice therapists (<5 years of experience), 21.5% experienced therapist (6–15 years of experience), and 10.8% senior therapists (>15 years of experience).

Patient Characteristics

Generally, more information was provided about the patient. There was consistent information about the patients’ gender with 68.8% female and 31.2% male patients. Concerning age, almost always (98.9% of cases) information was present with 6.5% children (2–11 years), 6.5% adolescents (12–17 years), 12.9% young adults (18–24 years), and 73.1% adults (25–65). There were no cases discussing elderly patients.

There was no information about diagnosis in three cases; all other cases provided diagnostic information. The descriptive terms used in the manuscript are included in the SCA database, however, they differ tremendously across cases. This is illustrated by the observation that in 49.5% of the cases there was no diagnostic system mentioned. In other cases, one or more diagnostic systems were used: 34.5% used a version of the DSM, 10.8% used a version of the ICD, 4.3% used the OPD or PDM, and 8.8% used another system (e.g., SWAP-200, AAI). Therefore, when diagnostic information was available, this was categorized into the main DSM-IV-R categories (multiple categories could apply) to be able to get an overview. Prevalence of diagnostic categories is presented in Figure 2 . Clearly mood and anxiety disorders were the most common.

FIGURE 2. Primary diagnosis of cases per DSM-IV-R category.

Therapy Characteristics

In considering the characteristics of therapy we see that mostly at least some information is provided about objective characteristics and outcome.

The duration of investigated therapies consisted of 15.1% therapies shorter than 5 months, 12.9% lasting between 6 and 11 months, 32.3% lasting between 1 and 3 years, 18.3% lasting longer than 3 years, and 21.5% of cases were duration was not mentioned. Related to the duration of therapy, the number of sessions was mentioned in 66.7% of cases with 10.8% of therapies comprising less than 20 sessions, 22.6% between 21 and 50 sessions, 12.9% between 51 and 200 sessions, and 20,4% more than 200 sessions.

Session frequency ranged from less than once a week (2.2%), over once a week (35.5%), two to three times a week (17.2%) to a classical analytic setting of four to seven times a week (18.3%) and was not mentioned in 26.9% of the cases.

To inventory therapeutic outcomes the description of the authors was followed and categorized into successful (53.8%), failure (3.2%), or mixed (33.3%). In 9.7% of the cases no information about outcome was provided. Clearly, the description of authors/researchers starts from different frames of reference (e.g., in a long-term analysis success appears to require change at more levels than in studies on short-term psychodynamic psychotherapy who tend to conceptualize success more often as symptom decrease on a symptom rating scale) and consequently any appreciation of outcome is relative to these frames of reference.

Mapping psychoanalytic empirical case studies published in ISI-ranked journals showed that they, while still remaining scarce, clearly increased in quantity and quality throughout the last decennia. The increase in quality is shown in the results of our review that indicate a larger amount of information provided in more recent studies, a broader use of different sources of data and analysis methods, and more explicit informed consent considerations. However, also when reading the articles to rate the IBISC, it was clear that generally there is more attention for a detailed description of the study, its methods, the patient and his or her therapeutic process. Especially, in the last decennium a remarkable increase could be seen in the amount of published cases and the systematic nature of these cases that increasingly include multiple sources of data and combine different methods of analysis. These include both instruments and methods developed within the field of psychoanalysis [e.g., the Core Conflictual Relationship Theme method ( Luborsky and Crits-Christoph, 1998 ) or Reflective Functioning ratings ( Bucci, 1997 )] and more generic methods that allow the connection to broader psychological research (e.g., the Beck Depression Inventory; Beck et al., 1996 ).

When considering systematic case studies in the broader field of psychoanalytic case studies – which remain to be mainly clinical case studies – it is clear that they provide much more descriptive information than clinical case studies, which mostly pay little attention to giving comprehensive descriptive information, despite the rich clinical description they provide ( Desmet et al., 2013 ). Nevertheless, information about certain topics remains generally absent. Especially a description of the therapist is often omitted, which might however, be important contextual information if one intends to compare or aggregate different cases. As the role of the therapist in explaining outcome is increasingly recognized (e.g., Kraus et al., 2011 ) and because of the inherently interactive nature of the therapeutic encounter (e.g., Strupp, 2008 ), its importance can hardly be overestimated.

The range of diagnoses, short- and long-term therapies, and successful and unsuccessful cases investigated in empirical case studies, however, provide a myriad of possibilities for meta-studies. Moreover, while we noticed a wide array of methods, there also are trends and recurring methods indicating that meta-studies are feasible. For example, methods like Reflective Functioning or the SWAP-200 are used in different studies and should allow for good quality meta-studies. On the other hand, we noticed that studies focusing on purely quantitative methods often omit a clinical description of the patient and the therapy process. In our opinion, this is throwing away the baby with the bathwater. While critiques on the anecdotal nature of clinical case studies may be apt, discarding a clinical or qualitative description altogether is to disown the essence and the strength of the psychoanalytic single case study. Moreover, with respect to clinical relevance and to possible meta-studies, this clinical contextual information is quintessential.

Concerning ethical considerations of research in such delicate circumstances as the psychotherapeutic setting, it appears that even more attention could be paid to informed consent. While informed consent was mentioned much more than was found in the overall archive ( Desmet et al., 2013 ) – where it was mentioned in only 9% of cases – still more than half of the studies did not provide information about informed consent despite their explicit research context.

Surely, our review has certain limitations. Using other search criteria for example, might result in other cases and probably more empirical psychoanalytic cases exist. Also, the inclusion of cases published in books might be a valuable addition. Nevertheless, we think a representative and large sample of systematic case studies could be retrieved through this method. If this is the case, surely future research should aim to investigate age groups that are currently underrepresented in the field as most case studies focus on (young) adults.

We conclude that psychoanalytic empirical case studies, although they were adopted somewhat later than in other orientations, are of increasing and high quality. Moreover, journals currently provide more clear guidelines as to what comprises an eligible case study. High quality cases, for example Gazillo et al. (2014) , Mauck and Moore (2014) and Cornelis et al. (2017) , set the tone for a future where case aggregation based on scientifically sound cases that include triangulated data and analysis methods while not disregarding clinical context becomes increasingly possible. This attention for the clinical context is of crucial importance in the field of psychotherapy ( Spence, 2001 ). Psychotherapy is and always will consist of a unique encounter between patient and therapist, a complex interaction that cannot be easily disentangled ( Strupp, 2008 ). While systematically investigating what happens in this process is crucial for the advancement of the psychotherapeutic endeavor, this should not come at the cost of the clinical richness of these ever-singular encounters that comprise the magic of the psychotherapeutic profession.

Author Contributions

RM: conception of the study, contribution to data collection, data-analysis and interpretation, main author of the manuscript; RI: contribution to conception of the study, contribution to data collection, main reviewer of the manuscript; JK: contribution to data collection, data-analysis and interpretation, reviewer of the manuscript; LN: contribution to data collection, data-analysis, reviewer of the manuscript. All authors read and approved the final version of the manuscript.

This project was partly supported by Flanders Research Foundation (FWO, Belgium; grant number: AUGE/15/15 – G0H3116N).

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgment

We want to thank Mattias Desmet and Jochem Willemsen for the cooperation on the foundation of the SCA.

• ^ The original single case archive ( www.singlecasearchive.com ) comprises 445 articles between 1955 and 2011. Currently, there is an ongoing project to elaborate the SCA with cases from other theoretical orientations that should be finished at the end of 2018.
• ^ For more information on the types of case studies and their definition, see Iwakabe and Gazzola (2009) or the IBISC manual available through http://www.singlecasearchive.com/downloads/IBISC%20manual3.pdf .

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Keywords : empirical single case studies, psychoanalysis, review, single case archive, psychodynamic psychotherapy

Citation: Meganck R, Inslegers R, Krivzov J and Notaerts L (2017) Beyond Clinical Case Studies in Psychoanalysis: A Review of Psychoanalytic Empirical Single Case Studies Published in ISI-Ranked Journals. Front. Psychol. 8:1749. doi: 10.3389/fpsyg.2017.01749

Received: 14 July 2017; Accepted: 21 September 2017; Published: 04 October 2017.

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Copyright © 2017 Meganck, Inslegers, Krivzov and Notaerts. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Reitske Meganck, [email protected]

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