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We describe our clinical experience with a subset of chronically depressed patients characterized as introverted, with an early onset of feeling different from, and often feeling more sensitive than, others. We outline six central issues that concern a psychodynamic approach to chronically depressed people. This article describes and illustrates how a modified supportive-expressive psychotherapy influenced by the relational perspective can help in the treatment of these patients. In particular, we facilitate an interaction in which the patient speaks from rather than merely about his or her depressed self. A couple of clinical moments are presented to illustrate how a lack of recognition by the therapist of the self the depressed patient is at the moment leads to a kind of lifeless despair, and conversely, how the therapist's recognition facilitates the patient talking from his depressed state rather than merely about it.

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SUMMARYWe report a strikingly unusual case of traumatic intraperitoneal perforation of an augmented bladder from clean intermittent self-catheterisation (CISC), which presented a unique diagnostic challenge. This case describes a 48-year-old T1 level paraplegic, who had undergone clamshell ileocystoplasty for detrusor overactivity, presenting with abdominal distension, vomiting and diarrhoea. Initial investigations were suggestive of disseminated peritoneal malignancy with ascitic fluid collections, but the ascitic fluid was found to be intraperitoneal urine from a perforation of the urinary bladder. This was associated with an inflammatory response in the surrounding structures causing an appearance of colonic thickening and omental disease. Although the diagnostic process was complex due to this patient's medical history, the treatment plan initiated was non-operative, with insertion of an indwelling urinary catheter and radiologically guided drainage of pelvic and abdominal collections. Overdistension perforations of augmented urinary bladders have been reported, but few have described perforation from CISC. BACKGROUND