Clinical Phenomena Research Articles

Clinical Evidence, Triangulation of Perspectives and Contextualization. Part 1: The Beginning of Carla’s Treatment

We propose to critically evaluate and strengthen the level of clinical evidence in psychoanalysis, using a strategy of triangulating clinical phenomena from different perspectives and increasing contextual knowledge. Insufficient discussion of alternative hypotheses and limited contextual information are two Achilles heels of psychoanalytic case presentations. We examine the concept and quality standards of clinical evidence in psychoanalysis and related disciplines, with particular attention to the contribution of the three-level model (3-LM). We analyze the case of a patient treated with transference-focused psychotherapy (TFP), making explicit the theoretical-clinical agreements and disagreements of the authors. We discuss the strengths and limitations of triangulation and contextualization, concluding that they make clinical work and psychoanalytic writing more reliable, transparent, auditable, and replicable.

The Continuing Challenges of Studying Parallel Behaviours in Humans and Animal Models.

The use of animal models continues to be essential for carrying out research into clinical phenomena, including addiction. However, the complexity of the clinical condition inevitably means that even the best animal models are inadequate, and this may go some way to account for the apparent failures of discoveries from animal models, including the identification of potential novel therapies, to translate to the clinic. We argue here that it is overambitious and misguided in the first place to attempt to model complex, multifacetted human disorders such as addiction in animals, and especially in rodents, and that all too frequently "validity" of such models is limited to superficial similarities, referred to as "face validity", that reflect quite different underlying phenomena and biological processes from the clinical situation. Instead, a more profitable approach is to identify (a) well-defined intermediate human behavioural phenotypes that reflect defined, limited aspects of, or contributors to, the human clinical disorder, and (b) to develop animal models that are homologous with those discrete human behavioural phenotypes in terms of psychological processes, and underlying neurobiological mechanisms. Examples of past and continuing weaknesses and suggestions for more limited approaches that may allow better homology between the test animal and human condition are made.

Epileptic Network Surgery: From Network Basis to Clinical Practice

Epilepsy is a common chronic neurologic disorder, with about 30%‐40% of patients suffering from recurrent seizures despite receiving enough antiseizure medication. Growing evidence of extensive structural and functional research has revealed that epilepsy is a network disorder, and the network investigation is crucial in the presurgical evaluation. This narrative review is aimed at providing an overview of the conceptual development of epileptic surgery, the epileptic network formation, and the network‐oriented strategy in clinical practice. We searched the PubMed database before October 2022 with no language or regional restrictions for studies of network exploration in epilepsy patients. The study eligibility criteria were original connectivity or network research studies using neuroimaging or neurophysiological approaches, focusing on seizure localization, neuropsychological evaluation, neuromodulation, or surgical prognosis. The initial search revealed 2046 studies. The selection process presented 746 papers that meet the inclusion criteria. The results indicated that epilepsy was characterized by the alternation of brain networks, which account for the clinical, electrographic, and neurocognitive phenomena related to human seizures and changes across different disease stages. Hubs have garnered significant attention due to their extensive connections, which make them prone to facilitating the spread of seizures to various brain regions. Unlike the seizure onset zone, the removal of the majority of these ictogenic nodes demonstrated a significant correlation with positive outcomes. Therefore, performing a network analysis during the epilepsy presurgical evaluation seems essential and will influence surgical decisions. It is hoped that studying the network of epilepsy will enhance our ability to determine the most appropriate surgical strategy for patients with epilepsy, thus contributing to success in terms of effective seizure control with maximal sparing or even improvement of brain functioning.

Biophysical Modelling for Insight into Oxygen Diffusion, Distribution, and Measurement.

Building on an extensive history of physiological and systems-oriented modelling, my group and others have recently used molecular simulation studies to understand oxygen (O2) transport and localisation. Molecular simulations enable biophysical insight into processes difficult to study with experiments alone and are sometimes described as a "computational microscope." Our work has emphasised lipid membrane contributions to oxygen diffusion and uptake, suggesting that lipid-based pathways along membranes and lipid deposits are likely to accelerate diffusive transport through cells and tissues. Moreover, the lipid and fluid fractions of the tissue are expected to be primary determinants of the local oxygen partial pressure (pO2) as well as the oxygen permeability. Measurements using molecular probes can be influenced by the local molecular environment, due to differential solubility of both the probe and the oxygen molecules in various components of the cell's complex solvent system. The biomolecular simulation work complements experimental studies, which enable evaluation of the models' accuracy and their applicability to real biological systems. Further work is needed to assess fully the possible influence of nanoscale crowders and obstacles (especially protein molecules) on tissue-level diffusive transport of oxygen. Likewise, water-rich carbohydrate layers, such as the glycocalyx, should be evaluated as potential barriers to oxygen transport. Insights gained through biophysical modelling studies could be broadly relevant to clinical phenomena affected by tissue oxygenation, such as tumour radiotherapy, ischaemia, neuropathy, and wound healing.

Clinical Tumor Dormancy.

This chapter summarizes clinical evidence on tumor dormancy, with a special focus on our research supporting the role of dormancy both in local and distant recurrence of breast cancer following mastectomy. Starting from these premises, we propose a model of neoplastic development that allows us to elucidate several relevant clinical phenomena, including the mammographic paradox, the significance of ipsilateral breast tumor recurrence after conservative surgery, and the effect of surgeries performed after the removal of the primary. We will discuss the biological implications of the dormancy-based model, which are at odds with Somatic Mutation Theory. We will then review new models, alternatives to the Somatic Mutation Theory, for cancer development, with special emphasis on the Dynamic System Theory and the originality of its conceptual approach. Finally, we will put particular emphasis on the view of cancer development as a tissue-level process. We believe that this will help harmonize the molecular biology research with the new conceptual approach and bridge the knowledge gap on dormancy between bench and bedside.

Electroretinography and suicidal behaviors: a systematic review

BackgroundElectroretinogram (ERG) is one of the tools used to investigate the electrophysiological underpinnings of mental health illnesses and major clinical phenomena (e.g., suicide) to improve their diagnosis and care. While multiple studies have reported specific ERG changes among individuals with suicidal behaviors, we know of no review that has been done to characterize their findings to inform future research.MethodsThis review included available literature concerning ERG and suicidal behaviors. The paper’s first section briefly overviews the theoretical basis of ERG and neurotransmitters involved in suicidal behaviors. The second section describes the findings of a review of studies reporting ERG findings among individuals with suicidal behaviors.ResultsMost reviewed studies reported normal amplitude and implicit time of the a-waves, but the latency in individuals with suicidal behaviors was lower than normal. Additionally, the b-waves amplitude was reduced, but the implicit time and latency were increased. The b-a amplitude ratio and oscillatory potential were decreased.ConclusionDespite identifying certain ERG correlates with suicidal behaviors in the existing studies, there is a need for adequately powered and methodologically robust studies to advance clinical translation.

I can't handle my desires: Development and validation of a self-report measure of desire intolerance and associations with distress intolerance.

Desire intolerance is conceptualized as a motivational counterpoint to the transdiagnostic risk factor of distress intolerance and is defined as the inability or unwillingness to "sit with" the motivation to approach a rewarding object or task. The current work describes the development and validation of a novel measure of desire intolerance. After initial item development and exploratory factor analysis (Study 1) and confirmatory factor analysis (Study 2), the 10-item unidimensional Desire Intolerance Questionnaire (DIQ) was created. Desire intolerance was conceptually related to low self-control (Studies 1-4) and both approach and avoidance motivation (Studies 2, 4, 5) and was distinct from delay of gratification (Study 3). Greater desire intolerance was also associated with higher distress intolerance (Studies 4 and 5). In Study 4, we used qualitative coding to explore what people were thinking about when they considered their "desires." Findings revealed that higher desire intolerance was associated with thinking about desired long-term outcomes more than proximal short-term hedonic pleasures. Finally, Study 4 focused on unique and independent associations between desire and distress intolerance with psychopathology, and we found that both distress intolerance were associated with heightened psychological distress and borderline personality symptoms. Only distress intolerance was uniquely associated with uncontrolled eating and self-criticism, whereas only desire intolerance was uniquely associated with aggressive behavior and dichotomous thinking. The current research supports the DIQ as a psychometrically sound indicator of difficulties withstanding desires and allows for a better understanding of intolerance as a transdiagnostic clinical phenomena. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

To fully leverage fine-grained clinical phenomena, we have to think beyond DSM-based concepts and the presumption of diagnostic kinds.

In light of the limitations of dominant psychiatric classification systems such as the Diagnostic and Statistical Manual of Mental Disorders (DSM), this special section positions fine-grained clinical phenomena as key to the future of psychopathology research. This shift is necessary given the constraints DSM-based diagnoses place on (a) the specificity of theories and models of psychopathology and (b) efforts to develop alternative paradigms. Fine-grained clinical phenomena offer comparative advantages, but transitioning to their study involves significant challenges. Chief among these challenges is the need to move beyond DSM as a source of concepts. Implicit assumptions that DSM-based disorders provide valid, circumscribed, and explanatory definitions of clinical phenomena perpetuate existing reification of diagnostic categories rather than reimagining psychopathology nosology beyond DSM, thus needlessly restricting and even undermining research efforts. Moving forward requires careful attention to consensual operationalization. Otherwise, we will continue to struggle to develop valid compositional explanations of clinical phenomena and to organize them into explanatory conceptual taxonomies. Scientific progress here depends on coordinated pluralism that incorporates different lenses into psychopathology and different approaches to data collection and analysis, with a firm grounding in construct validity and a corresponding commitment to continually reimagine rather than reify our concepts and objects of study. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Towards a dynamical understanding of microstate analysis of M/EEG data

One of the interesting aspects of EEG data is the presence of temporally stable and spatially coherent patterns of activity, known as microstates, which have been linked to various cognitive and clinical phenomena. However, there is still no general agreement on the interpretation of microstate analysis. Various clustering algorithms have been used for microstate computation, and multiple studies suggest that the microstate time series may provide insight into the neural activity of the brain in the resting state. This study addresses two gaps in the literature. Firstly, by applying several state-of-the-art microstate algorithms to a large dataset of EEG recordings, we aim to characterise and describe various microstate algorithms. We demonstrate and discuss why the three “classically” used algorithms ((T)AAHC and modified K-Means) yield virtually the same results, while HMM algorithm generates the most dissimilar results. Secondly, we aim to test the hypothesis that dynamical microstate properties might be, to a large extent, determined by the linear characteristics of the underlying EEG signal, in particular, by the cross-covariance and autocorrelation structure of the EEG data. To this end, we generated a Fourier transform surrogate of the EEG signal to compare microstate properties. Here, we found that these are largely similar, thus hinting that microstate properties depend to a very high degree on the linear covariance and autocorrelation structure of the underlying EEG data. Finally, we treated the EEG data as a vector autoregression process, estimated its parameters, and generated surrogate stationary and linear data from fitted VAR. We observed that such a linear model generates microstates highly comparable to those estimated from real EEG data, supporting the conclusion that a linear EEG model can help with the methodological and clinical interpretation of both static and dynamic human brain microstate properties.

Immunomodulatory and regenerative potentials of breast milk, prematurity and children’s heart

Recent expansion of fundamental knowledge on the physiology of lactation, and breast milk exosomes, stem cell biology, mother-child interactions from prenatal period to postnatal development requires a progressive, dynamic view from the scientific community and practicing physicians when analyzing known, generally accepted clinical phenomena and patterns (development of the immune system of infants and young children, natural and artificial feeding, features of postnatal development and growth of organs and tissues in children born prematurely). The components of the mother-breast-milk-infant triad are closely related to each other and influence developmental trajectory of the infant. According to modern concepts, breast milk of a nursing woman is a “living, metabolic / endocrine signaling system”, which may be considered an “immune organ” significant for postnatal growth and body programming of a premature baby. A valuable phenomenon of early postnatal development is actively discussed in the special literature, i,e., “microchimerism” caused by breastfeeding which, according to modern concepts, may play a key role in development of immune system and the whole body. Absence of protective (immunomodulatory and regenerative) effects of breast milk from a nursing woman on the spontaneous, uncorrectable impact of adverse factors of prematurity is likely predispose for remodeling and dysfunction of heart in prematurely born children, and, at longer range, in adults. The young children born prematurely show a unique cardiac phenotype characterized by reduced biventricular volume, relatively lower systolic and diastolic function, disproportionate muscle mass gain, clinically manifesting by increased risk of cardiovascular disease, hypertension, and decreased exercise tolerance. Hence, the premature birth may be considered a chronic disease state. Therefore, the natural feeding which provides a natural evolutionarily protective mechanism for the child’s heart should be attributed to the fundamental factors that play a vital role in prevention of cardiovascular diseases in prematurely born children and at later life periods.

Curriculum Innovations: A Podcast-Based Neurologic Emergency Flipped Classroom Curriculum for Neurology Residents.

Education on the management of neurologic emergencies is vital for neurology residents, and effective educational methods are needed. This study aims to implement and evaluate the impact of a podcast-based flipped classroom curriculum in neurologic emergencies. "Flipped classroom" instructional methods have been used in GME and informed by experiential learning theory. The objectives of this curriculum were to (1) compare the clinical phenomena discussed in the neurologic emergencies podcast(s) with your own clinical experience; (2) discuss the pitfalls in the management of the neurologic emergencies discussed in the podcast(s); and (3) develop a management plan for the neurologic emergencies discussed in the podcast(s). At 10 neurology residency programs, we implemented a 3-session flipped classroom curriculum covering topics in acute stroke, movement disorder emergencies, and status epilepticus. Each session consisted of a Neurology® podcast followed by content discussion with a clinical expert. Assessment of the curriculum included presession and postsession surveys focused on learners' confidence and attitudes toward podcast-based education. Our data sample consisted of survey responses from residents, with response volumes ranging from 29-111 across all surveys. Podcasts are already highly used by neurology residents in their self-directed education. Confidence increased among learners in the management of movement disorder emergencies (18% confident before vs 79% confident after, p < 0.001) and status epilepticus (72% confident before vs 91% confident after, p = 0.014) among those who completed the curriculum. A change in confidence in acute stroke management was not found (p = 0.15). Podcasts were consistently preferred over lectures and reading-based instructional methods while less preferred compared with simulation-based learning and case-based discussion with faculty. The podcast-based curriculum studied here showed high levels of enjoyment and perceived utility. We present a 3-part curriculum to help build learners' familiarity and confidence in 3 neurologic emergency categories. The educational impact is established in Level 1 of the Kirkpatrick paradigm. Future studies can explore a higher-level impact of this curriculum. Evolution in neurology education is shifting increasingly toward immediately accessible information via digital media. This curriculum can be useful to neurology educators who need to be increasingly agile and facile with multiple educational techniques to meet learners' needs.

Шкала открытости будущему: русскоязычная адаптация и валидизация

&lt;p style="text-align: justify;"&gt;&lt;strong&gt;Introduction.&lt;/strong&gt; The Openness to the Future Scale (OFS) was developed in 2018 to measure a new phenomenon in the field of positive psychology [5]. Contemporary professionals use it in research on both positive psychological resources and clinical psychological phenomena. &lt;strong&gt;Objective.&lt;/strong&gt; The aim of this study was to adapt the Russian&amp;ndash;language version of the Openness to the Future Scale on a population&amp;ndash;based sample. &lt;strong&gt;Method.&lt;/strong&gt; There were three groups of respondents: 374 volunteers from the general population, 72 homeless people temporarily living in the &amp;laquo;Warm Reception&amp;raquo; shelter, and 68 young adult graduates of orphanages and teenagers living in orphanages and dormitories at educational institutions. All participants filled out the Russian version of the Openness to the Future Scale, and participants in the second and third groups additionally filled out measures to assess psychological resources. &lt;strong&gt;Results.&lt;/strong&gt; Confirmatory factor analysis showed a single&amp;ndash;factor model identical to the factor structure of the original version of the Openness to the Future Scale, which confirmed the factor validity of the adapted instrument. The Cronbach's &amp;alpha;&amp;ndash;value was 0,83, which is evidence in favor of the internal reliability of the Russian version of the Openness to the Future Scale. Openness to the future scores were higher for male and younger respondents compared to female and older respondents. Openness to the future was positively correlated with life attitudes in the homeless and with resilience and proactive coping in young adult graduates and adolescents from orphanages. &lt;strong&gt;Conclusion.&lt;/strong&gt; The basic psychometric properties of the adapted instrument allow recommending it as a research tool. This pilot study determines the need for further psychometric examinations of the Russian&amp;ndash;language version of the Openness to the Future Scale, including by expanding the study sample, involving experts and respondents from different age and clinical groups, and comparing self&amp;ndash;report data with objective psychometric assessments.&lt;/p&gt;

Are there verbal hallucinations in autism? Review from a historical and transparadigmatic perspective

The differential diagnosis between autism and schizophrenia in childhood has been the subject of numerous controversies. Because verbal hallucinations could be one of the main clinical phenomena when establishing a differential diagnosis, the objective was to investigate the presence or absence of verbal hallucinations in autism. For this, a selective and unsystematic review of the current scientific evidence was carried out. Added to this, the phenomenon of hallucination, and mainly verbal hallucination, was conceptualized from a historical perspective; the relevance given to hallucinations in the delimitation of the mentioned nosographic constructs was broached; and verbal hallucinations in autism were analyzed comparing different paradigms, including contributions from psychoanalysis. We observe that from the side of scientific evidence it is not possible to state strong conclusions regarding the presence or absence of verbal hallucinations in autism. In turn, the historical review of the concept of verbal hallucination from classical psychiatry together with contributions from psychoanalysis, invite us to think that one of the differential characteristics between autism and psychosis is the absence of verbal hallucinations in the first diagnosis, and that if there were hallucinations in autism, these would present different qualities from those of psychosis. We consider it highly relevant to be able to establish this differentiation in the hallucinatory phenomenon in autism, not only in order to establish a differential diagnosis between the two conditions, but also because of the implications that this could have in pharmacotherapy.

Working Through Transformations in Play

ABSTRACT For Bion, one of the aims of analysis is to increase the transformation of negative emotions so that they do not exceed the personal capacity to contain them. Ferro described a transformation in playing as the possibility of giving the patient an emotion contained in action or a concrete situation, intuiting the underlying dream. A possible hypothesis to deepen the “transformations in playing” theory is that they can be a valuable tool to explore the relational area that escapes the word. Through transformation into play, the unthought can find a way to establish an invariant, a profound relational continuity that can move toward elaboration. The frequent clinical entanglement between transformations in play and reverie suggests that these are clinical phenomena that can take place in an area of analytical work at the frontiers of dreaming (Ogden, 2001). In this process, reverie seems to reveal itself both as a possible endpoint of a potential transformation in dreaming and a starting point of a possible transformation in playing. Transformation in play defines an intersubjective area where one can experience how the transformative capacity of the two subjects can establish continuity even between unmentalized sensory and emotional experiences, enabling the development of the embryonic dreams contained within them. Unlike transformations in dreaming, those in play preserveas wrote by Ogden; in ”Conversations at the frontier of dreaming” the features of playing, namely, bodily sensations and movements and the preservation of paradox.

Impact of genetic variants within serotonin turnover enzymes on human cerebral monoamine oxidase A in vivo

Variants within the monoamine oxidase A (MAO-A, MAOA) and tryptophan hydroxylase 2 (TPH2) genes, the main enzymes in cerebral serotonin (5-HT) turnover, affect risk for depression. Depressed cohorts show increased cerebral MAO-A in positron emission tomography (PET) studies. TPH2 polymorphisms might also influence brain MAO-A because availability of substrates (i.e. monoamine concentrations) were shown to affect MAO-A levels. We assessed the effect of MAOA (rs1137070, rs2064070, rs6323) and TPH2 (rs1386494, rs4570625) variants associated with risk for depression and related clinical phenomena on global MAO-A distribution volume (VT) using [11C]harmine PET in 51 participants (21 individuals with seasonal affective disorder (SAD) and 30 healthy individuals (HI)). Statistical analyses comprised general linear models with global MAO-A VT as dependent variable, genotype as independent variable and age, sex, group (individuals with SAD, HI) and season as covariates. rs1386494 genotype significantly affected global MAO-A VT after correction for age, group and sex (p < 0.05, corr.), with CC homozygotes showing 26% higher MAO-A levels. The role of rs1386494 on TPH2 function or expression is poorly understood. Our results suggest rs1386494 might have an effect on either, assuming that TPH2 and MAO-A levels are linked by their common product/substrate, 5-HT. Alternatively, rs1386494 might influence MAO-A levels via another mechanism, such as co-inheritance of other genetic variants. Our results provide insight into how genetic variants within serotonin turnover translate to the cerebral serotonin system. Clinicaltrials.gov Identifier: NCT02582398. EUDAMED Number: CIV-AT-13-01-009583.

The Role of Multidisciplinary Approaches in the Treatment of Patients with Heart Failure and Coagulopathy of COVID-19.

Coronavirus disease 2019 (COVID-19) is a severe respiratory syndrome caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Heart failure (HF) is associated with a worse prognosis for patients with this viral infection, highlighting the importance of early detection and effective treatment strategies. HF can also be a consequence of COVID-19-related myocardial damage. To optimise the treatment of these patients, one needs to understand the interactions between this disease and viruses. Until now, the validity of the screening for cardiovascular complications after COVID-19 has not been confirmed. There were also no patients in whom such diagnostics seemed appropriate. Until appropriate recommendations are made, diagnosis procedures must be individualised based on the course of the acute phase and clinical symptoms reported or submitted after COVID-19. Clinical phenomena are the criteria for determining the recommended test panel. We present a structured approach to COVID-19 patients with heart involvement.

A Review of Neural Data and Modelling to Explain How a Semicircular Canal Dehiscence (SCD) Causes Enhanced VEMPs, Skull Vibration Induced Nystagmus (SVIN), and the Tullio Phenomenon

Angular acceleration stimulation of a semicircular canal causes an increased firing rate in primary canal afferent neurons that result in nystagmus in healthy adult animals. However, increased firing rate in canal afferent neurons can also be caused by sound or vibration in patients after a semicircular canal dehiscence, and so these unusual stimuli will also cause nystagmus. The recent data and model by Iversen and Rabbitt show that sound or vibration may increase firing rate either by neural activation locked to the individual cycles of the stimulus or by slow changes in firing rate due to fluid pumping (“acoustic streaming”), which causes cupula deflection. Both mechanisms will act to increase the primary afferent firing rate and so trigger nystagmus. The primary afferent data in guinea pigs indicate that in some situations, these two mechanisms may oppose each other. This review has shown how these three clinical phenomena—skull vibration-induced nystagmus, enhanced vestibular evoked myogenic potentials, and the Tullio phenomenon—have a common tie: they are caused by the new response of semicircular canal afferent neurons to sound and vibration after a semicircular canal dehiscence.

Phénoménologie, expertise, méthode : comment les pratiquer avec douceur

ObjectivesThis article aims to show how the forensic psychiatric examination reconstructs, by progressing gently from the facts and the intimate history of a life, a clinical practice which is specific to it. MethodWe set aside the theories that prevail in the medical and judicial domains in order to make the clinical phenomena appear as they occur in the subject's natural experience of the world. We practice this form of reduction beginning with the encounter with the patient, and relate it in this article by choosing a literary style (37 numbered paragraphs made up of a number of equal words), that is faithful to its subjective progression, made of gentleness, formalizations, and cuts showing the objective points of attachment to the solidity of the clinical. ResultsThe clinical facts occur in the patient's lived world and in the common world, each one thought of as a reality of daily life and a reality of work, and which are co-constructed by institutions and culture. Our results are presented as clinical variations on the theme of the forensic psychiatric examination, highlighting the importance of the subject's inner history as well as the importance of his or her culture. DiscussionThis work shows how, by passing from the oral to the written form and then returning to the oral form at the time of the hearing, the expert witness does not so much describe the facts as he produces them, by placing them in direct relation with subjective experience: that of the perpetrator, that of the victim, and that of the expert himself. As a collection of stories, no fact, clinical or judicial, has any meaning in isolation. It only becomes worthwhile through the relationship that it makes present from various angles and points of view, characteristic of the plural realities that make up the co-construction of the expertise. The phenomenological method, by progressing gently, allows the facts to appear as they can make sense to each of the protagonists. A common horizon of values can then emerge from the discussion and the successive passages from oral to written form, which sheds light on the possibilities of discernment, choice, and responsibility that structure the missions entrusted to the expert witness. ConclusionPhenomenology brings to forensic psychiatry a rigorous method of progression on the philosophical level as well as on the clinical level. It can thus contributes to the progression of the judicial truth without draping the reality of the clinical facts with any cerebral mythology or any preconceived theory applied from the outside to the facts, to the subject's own experience, and to what links them.

The Functional Anatomy and Innervation of the Platysma is Segmental: Implications for Lower Lip Dysfunction, Recurrent Platysmal Bands, and Surgical Rejuvenation.

Despite the central role of the platysma in face and neck rejuvenation, much confusion exists regarding its surgical anatomy. This study was undertaken to clarify the regional anatomy of the platysma and its innervation pattern and to explain clinical phenomena, such as the origin of platysmal bands and their recurrence, and the etiology of lower lip dysfunction after neck lift procedures. Fifty-five cadaver heads were studied (16 embalmed, 39 fresh, mean age 75 years). Following preliminary dissections and macro-sectioning, a series of standardized layered dissections were performed, complemented by histology and sheet plastination. In addition to its origin and insertion, the platysma is attached to the skin and deep fascia across its entire superficial and deep surfaces. This composite system explains the age-related formation of static platysmal bands, recurrent platysmal bands after complete platysma transection, and recurrent anterior neck laxity after no-release lifting. The facial part of the platysma is primarily innervated by the marginal mandibular branch of the facial nerve, whereas the submandibular platysma is innervated by the "first" cervical branches, which terminate at the mandibular origin of the depressor labii inferioris. This pattern has implications for postoperative dysfunction of the lower lip, including pseudoparalysis, and potential targeted surgical denervation. This anatomical study, comprised of layered dissections, large histology, and sheet plastination, fully describes the anatomy of the platysma including its bony, fascial, and dermal attachments, as well as its segmental innervation including its nerve danger zones. It provides a sound anatomical basis for the further development of surgical techniques to rejuvenate the neck with prevention of recurrent platysmal banding.

Clinical social work practice in organizational settings: a psychodynamic systems approach

ABSTRACT Clinical social work practice in organisational settings is complex and challenging. Effective practice is contingent on knowledge and skills that are particular for systems-based work involving multiple interprofessional mental health practitioners and clients interacting in a relational matrix. Yet, not all social work theories and constructs that were developed for application in individual, group, and family modalities are directly transferable to the practice environment of a treatment system. This paper offers a conceptual framework that synthesises contemporary psychodynamic theory with systems theory – referred to as a psychodynamic systems approach – to inform and advance knowledge of systems-based social work practice. This approach considers the interplay of dynamic processes among the four levels of the socially co-constructed system which constitute the system as a whole. It examines how five key clinical phenomena – transference, countertransference, splitting, projective identification and enactment – are actualised in systems. Definitions of these phenomena formulated from a dyadic perspective and a contemporary psychodynamic systems approach are offered, and their similarities and differences are discussed. A composite case example is provided to illustrate how several of these phenomena manifest in clinical practice.