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Unconscious patients are nursed in a variety of clinical settings and therefore it is necessary for all nurses to assess, plan and implement the nursing care of this vulnerable patient group. This article discusses the nursing management of patients who are unconscious and examines the priorities of patient care.
This pilot study looks at the clinical application of bispectral index (BIS) monitoring within the palliative care situation. Using this instrument, the level of awareness in 12 patients was tracked from the onset of unconsciousness until death, and the levels were then related to the patients' clinical state and treatment. The results give a surprising insight into the nature of unconsciousness in dying patients and the effects of treatment. The monitor proved to be a simple, effective, and acceptable method of assessing awareness in palliative care patients. A few minor problems were encountered in adapting it to the palliative care situation, but most of these were overcome as we became more familiar with the instrument. The study suggests that BIS could contribute significantly to patient care and lead to a better understanding of the dying process.
The physician-patient relationship is recognized as having an essential role in the process of medical care, providing the context in which caring and healing can occur. Good patient-doctor relationship goes far deeper than the behaviour of physicians, particularly those behaviours recognized in popular culture as acting in a professional manner, being respectful of the patients' circumstances and bedside manner. The therapeutic relationship is a relationship between two persons--on one side is the patient who is psychologically modified in his illness, in regression, with resistance mechanisms, defences, fears and need for gratification, care and also for secondary profit. On the other side is the physician with his authority, knowledge, personality, habits, defences, unconscious of his own pharmacological effect on the patient, as the most potent drug. In the patient-centred medical model, based on contemporary scientific knowledge of disease, the physician has to understand the patient's "world of illness", and to accept the patient as a person with his whole conscious and unconscious reasons for suffering and not only as a"collection of symptoms".
This paper illustrates our clinical and personal experiences concerning the vast and complex theme of 'Polylingualism in psychoanalysis'. The issue of polylingualism and polyglotism reintroduces some general psychoanalytic hypotheses. For instance, is the nature of the unconscious predominantly pre-verbal, or is it structured as a language? What occurs if some languages are known since very early childhood, and belong to a pre-symbolic structural patrimony closely bound to bodily sensations and concrete experiences? How does the learning of new languages, later on, affect or modify thought processes? How do new and old unconscious 'thing' and 'word' representations interact with each other? What are the related problems regarding repression and memory? Our paper illustrates and discusses problems of communication and comprehension within the clinical situation, in cases when the analytic language is not the mother-tongue of the analyst, or of the patient, or of either of them.
A review is given over the aspects of awareness during general anaesthesia. Traditional clinical signs for evaluating depth of anaesthesia can be supplemented by objective methods such as EEG, cerebral function monitor and sensory evoked potentials. However, it has been difficult to establish the practical applications of these methods. Awareness can be graded from the obvious form, with recall of intraoperative events, to an unconscious form where the memory can be activated through special psychological techniques. We discuss the possibility of using unconscious perception of auditory signals for positive instructions to patients under anaesthesia.
The therapeutic relationship frequently comes under a strain during the course of an analysis. At these times, the analysand perceives and reacts to the analyst as if the analyst were a critical or seductive archaic object. When this occurs, the analyst has the choice of interpreting the unconscious source of the analysand's non-therapeutic reactions or of interacting with the analysand in a manner which re-establishes and potentially strengthens the therapeutic relationship. Interpretations during the early phases of an analysis are unlikely to mitigate the strain until the therapeutic relationship has become stronger and until considerable reality testing has promoted a context which allows the analysand to understand and to tolerate her or his unconscious wishes.
Human exposure to +Gz-induced loss of consciousness (G-LOC) remains of some concern relative to the well-being of the individuals experiencing the unconscious episodes. Detailed kinetic analysis of over 500 G-LOC episodes on a human centrifuge allowed an evaluation of the time for subjective recognition by observers of the onset of G-LOC and subsequent recovery to normal baseline conditions. The characteristics of early, coincident, and late recognition of the onset of G-LOC were evaluated. Earlier recognition of G-LOC was observed to occur when the rate of onset of the +Gz-stress was gradual (less than 0.6 G/s). Rapid onset rate (greater than 0.6 G/s) exposures were more likely to result in late recognition of G-LOC. The duration of the resulting period of unconsciousness (absolute incapacitation) was very sensitive to the time for recognition of G-LOC and most rapid return to a normal (+1 Gz) environment. The absolute incapacitation increased significantly from early (10.7 s) to coincident (11.4 s) to late (13.2 s) recognition of G-LOC which differed by a total of only 4.6 s. The results allow development of an initial standard of care envelope for apparently safe exposure of human subjects to centrifuge G-LOC since no adverse effects were observed with any of the exposures. The results also demonstrate the extreme sensitivity of the central nervous system to small changes in exposure to +Gz-stress which can be accurately measured.
In this article, two basic meditation techniques are described--namely, concentration and mindfulness. The relationship between mindfulness and health is discussed in the context of findings linking repression to physical disorders. Parallels between meditation and psychoanalysis as methods for uncovering the unconscious, using both Freudian and Kellian constructs, are described. It is concluded that meditation, like free association, can be used to facilitate the emergence of unconscious (sub-verbal) material and allow for its integration at a higher (more cognitive) level of awareness.
In order to clearing the influence of neurotransmitters in concussive unconsciousness, immediate convulsion and mortality, the following experiments were performed. Awake male mice of dd-strain were restrained and subjected to head injury using a bakelite weight of 30 gm dropped from a height of 20 cm on to the skull. This injury resulted in immediate loss of consciousness in 100%, convulsive seizure in 66% and death in 30% of animals. The severity of consciousness disturbance was evaluated by two parameters; (1) time interval required for the recovery of righting reflex (RR) and (2) time interval for the recovery of spontaneous movement (SM). Agonist or antagonist of various neurotransmitters was given intraperitoneally 0.5 or 2 hours before injury. The following results were obtained although some of them were statistically not significant. Physostigmine shortened both RR (p less than 0.1) and SM (p less than 0.01), whereas scopolamine did not change these intervals. Atropine sulfate shortened both of them. Nevertheless, atropine methylbromide, which dose not pass through blood-brain-barrier, also had same effects. Methamphetamine shortened both RR (p less than 0.1) and SM (p less than 0.05), whereas haloperidol prolonged these intervals. 5-HTP shortened RR (p less than 0.05), but prolonged SM (p less than 0.1). Methysergide shortened both RR (p less than 0.05) and SM (p less than 0.01). Convulsive seizure was suppressed by physostigmine (p less than 0.01) or 5-HTP (p less than 0.20). These results suggested that suppression of dopaminergic and cholinergic systems, and/or activation of serotonergic system contribute to concussive unconsciousness.
An analysis of Freud's forgetting of the name Signorelli provides a framework for an explication of some central concepts in Lacan's theory of the unconscious. The parapraxis is viewed as a symptom which is structured like a metaphor. The creation of a symptom during the process of repression produces a gap in conscious discourse. The analysis of such symptoms provides evidence for Lacan's assertion that the unconscious is structured like a language.
A case history is reported of a patient who had several episodes of unconsciousness (because of ventricular extrasystole) while on antiarrhythmic and antihypertensive therapy consisting of quinidine (200 mg b. i. d.), sotalol (80 mg b. i. d.) and hydrochlorothiazide (50 mg g. d.). The syncopal attacks continued after discontinuation of quinidine but ended when sotalol was replaced by metoprolol and later on by verapamil. Marked prolongation of the previously normal Q-Tc interval (up to 0.71 s) was observed during the therapy with sotalol alone or combined with quinidine. The syncopal attacks were preceded by feeling of cardiac arrhythmia and they were most likely caused by torsade de pointes tachycardia. The prolongation of the Q-Tc interval by sotalol alone or combined with quinidine was obviously related to the tendency to cardiac arrhythmia and consequent episodes of unconsciousness.
The need for complex psychotherapy is reified by using the combination of group psychotherapy with methods of individual and behavioral therapy as an example. The fact that certain forms of maldevelopment cannot be satisfactorily checked by dynamic group psychotherapy alone is considered to be due not only to the conditioning of, and automatism associated with, neurotic malbehavior. It is especially in the case of inordinate dread and fear of disease, which is generally referred to as nosophobia, that the patient's great difficulty in accepting the possibility of a mental origin or causation of his ailment stands in the way of making effective use of such a therapy. The authors are of the opinion that acceptance by the patient of a mental origin or causation is made difficult especially by the fact that in the case of neurotic maldevelopments the kind and degree of neurotic conflictiveness are lore or less unconscious. This fact, which has not so far received much attention, should be taken into consideration in future research into the unconscious.
The work of Matte-Blanco is little understood by psychoanalysts largely because he used mathematical logic as an essential method to elucidate psychoanalytic theory. His findings, however, seem to be important and warrant this simple introductory paper explaining key ideas. Two fundamentally distinct processes, defined as asymmetrical and symmetrical logics are introduced and illustrated. Asymmetrical logic is analogous to secondary process while symmetrical logic has affinity with primary process. Both logic seem to interweave in any thought processes but with asymmetry predominating in scientific thought while symmetrical logic is most evident in psychosis and dreams. It is furthermore argued that the various characteristics of the unconscious, as described by Freud, can be seen as different mental outcomes with symmetrical logic at the base of all of them. A parallel is discovered by Matte-Blanco between the characteristics of symmetrical logic and those of infinite sets as defined mathematically. This leads to an investigation of the concept of infinity and of psychological infinite experiences. These can be readily detected in omnipotence, omniscience, and idealization, but they also seem to occur in extreme emotional states such as being in love, dread and grief. If nuclei of extreme states are contained in any affect, then it is likely that all affects in their cognitive aspects contain experiences of infinity. Symmetrical logic may thus be a common background both to the characteristics of the unconscious and emotionality generally.
Ongoing unconscious processes may be influenced by related conscious processes without self-awareness. (a) When the conscious semantic interpretation of physically identical shapes changes due to their angular rotation, the sequence of saccadic movements arid the localization of eye fixations over the shapes change as well. (b) The amplitude of the P 300 wave of visual evoked potentials is related to the conscious cognitive interpretation of identical stimuli. (c) The instants of figure reversals are influenced by conscious cognitive programs delineated by means of corresponding experimental instructions. It is assumed that unconscious and conscious processes may be considered functional manifestations of the same complex and specific neuronal network at different levels of its hierarchical organization and that mutual interactions between both types of processes do not require the existence of any mediating "interface" system.
Clinical observations as well as words pronounced by brain injured patients in coma awaking phases attest the emergence of an unconscious psychic register, which arises at the time of coma and resuscitation, and takes an active part in their perspective background during the subsequent phases. Reported clinical fragments illustrate the interconnections between this unconscious register and the various physiological breakdowns suffered by patients as well as their attempts to recover this background.
The history of art-historical responses to psychoanalysis has yet to be written. Art historians have imported a wide variety of psychoanalytic concepts, and psychoanalysis continues to be a major interpretive resource for the discipline of art history. But beyond the core of art-historical texts that are directly and explicitly influenced by psychoanalysis is a much larger, and I think more important, class of texts that do not cite psychoanalytic concepts, but would nevertheless not be possible without psychoanalysis and especially the fundamental concept of the unconscious. This paper examines the ways that the idea (or notion) of the unconscious affects current thinking about the control artists have over their works; I argue that, in this more general sense, psychoanalysis has tended to help art historians to take away artists' control and awareness of their own work, replacing it with the model of artists as workers largely unaware of what they do. Against this I argue that artists who are imagined to 'preside over their work with their eyes open' can be more interesting subjects, both historically and psychologically.
The model of human perception and cortical regulation of unconscious interoceptive signals from the internal organs (heart, lungs, liver, intestines) was created by acupuncture of the corresponding channels. The features of the spatial organization of cortical electrical activity were analysed. A positive effect (for example, a decline of initially high heart rate) was accompanied by a fall in the general level of spatial synchronization, a decrease in the linear and non-linear correlations between potentials led from the anterior areas of the right hemisphere and the left posterior areas, and a growth of coherence in the range of 21.5-23 Hz. Absence of the acupuncture effect (or its negative influence) correlated with less expressed (or of another character) changes in the spatial organization of electrical activity. The conclusion is drawn that reorganization of cortical activity is necessary for perception and regulation of unconscious interoceptive information. Functional significance of this reorganization consists in the restriction of processing of exteroceptive information.
Respiratory frequency has been studied by strain gauge and impedance pneumography in a group of unconscious patients suffering from a variety of medical conditions, and has been compared with breathing in control subjects during wakefulness and sleep. Seventeen of 25 comatose patients had breathing patterns amenable to computerized statistical analysis of respiratory rate which demonstrated abnormalities in all patients studied. Unconscious patients breathed more rapidly and regularly than controls. Rapidity of respiration was not consistently associated with any specific central nervous system lesion, and was usually accompanied by coexistent pulmonary disease. Increasing regularity of respiration correlated well with deepening of coma and accurately reflected ultimate outcome even when other clinical signs were unchanging.