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PubMed1979

Scopophilia and object loss.

The study of a case of voyeuristic perversion and of some previously published cases of simple scopophilia suggests that fear of object loss early in life may be an important factor predisposing one to a propensity for voyeurism. The increased need to maintain visual contact with the object and to incorporate it visually leads to a hypercathexis of the visual function which is at the base of voyeurism. This need later becomes sexualized, while still retaining its pregenital connotations. Although object loss was apparently significant in the case of the patient described in this paper, it is not necessarily a factor in all cases of perverse voyeurism and, when present, may be considered as only one element in its pathogenesis.

Adult↗
PubMed1983

[Principles for evaluating reactivity in the clinical picture of alcoholism and addiction during drug therapy].

Eighteen patients with chronic alcoholism, stages II-III were examined during tisercin treatment and medicamental interval. In patients with stage II alcoholism, perversion of the central neuronal tisercin effect was shown. Phenothiazines efficacy during abstinence period appeared to be linked with the perversion observed. Individual constant control of blood pressure, heart rate, acetylcholinesterase serum level, sleep function etc. during drug treatment is considered to be a perspective trend for an increase of toxicomania treatment efficacy.

Adult↗
PubMed1983

[Effects of recent psychoanalytic theories and therapy concepts on the treatment technics of sex offenders].

Recently developed psychoanalytic theories on the pathogenesis and psychodynamics of sexual perversions are described and their effects on treatment technique discussed. Then a proposal based on these theories its put forth for a comprehensive treatment plan for sex offenders, among person with sexual perversions an especially difficult group to treat. Special emphasis is placed on the problems and possibilities associated with such a psychoanalytically oriented approach, and the author then argues that during the initial phase of treatment two approaches, both psychoanalytically oriented therapy and behavior therapy, should be used parallel to each other.

Behavior Therapy↗
PubMed1980

Medicaid and the Mainstream: Reassessment in the Context of the Taxpayer Revolt.

California's Medicaid program-Medi-Cal-attempted to implement the ideal of mainstream medical care for the poor by giving program beneficiaries a "credit card" for use in the private health care marketplace. This exposed the program to the perverse economic incentives of the fee-for-service, costplus health care system, and contributed to a high rate of increase in program costs. Attempts to control costs have been equally perverse, resulting in low payment rates, the second-guessing of physician professional judgments, the probing of medical and fiscal records, and the use of computerized surveillance systems. Attempts to shift to the use of more efficient delivery systems have had small success. Attempts to attain cost containment through restructuring the Medi-Cal program have been rejected in the name of the mainstream ideal. Costs have continued to escalate, with annual increases as high as 20 percent in some years. Medi-Cal now costs $4 billion per year, the largest single program in California state government. The taxpayer revolt in California is creating a fiscal crisis that will force rethinking of the premises of publicly funded health care for the poor, and a restructuring of strategies for reaching that objective. In the short run, it appears that the issue may not be whether the indigent will have access to mainstream medical care, but whether they will have access to any medical care. In the longer run, the crisis should represent an opportunity for building a system of health care that can serve the financially disadvantaged at a cost tolerable to our society.

California↗
PubMed1994

Aspects of urethrality in women.

It has long been noticed that women experience direct sexual stimulation from urethral practices that men do not. However, this empirical finding remains to be integrated with the general theory of female psychosexual development. An attempt is made to begin such an integration, with a focus on urethral perversions or perverse trends.

Adult↗
PubMed1994

The man with the bus symptom.

This paper attempts to illustrate the clinical and technical vicissitudes of the psychoanalytic treatment of an adult male patient whose psychopathology alternated between a relatively stable phobic-obsessional structure and a perverse structure. The latter appeared in his life paroxysmally and took the form of riding the buses, when he would engage in various furtive sexual practices with small and adolescent girls. Both psychopathological structures were, of course, manifested in the relationship with the analyst. The description of their interplay in the transference-countertransference and of their relationship with the patient's life history makes up the first part of the paper. The gradual establishment of the perverse acting out in the therapeutic link led to a distortion of the setting which threatened the continuity of the analytic process, giving rise to a pragmatic paradox. This establishment of acting out in violation of the setting, coupled with recourse to the technique of reformulation of the setting, constitutes the main focus of this paper. The significant changes which ensued in the analytic process after this reformulation are then examined.

Acting Out↗
PubMed1993

The absent father: his role in sexual deviations and in transference.

In this paper, sexual perversion is discussed and connected with the absence of the father and with the failure of a primary relationship with a mother who is incapable of leading the child to the threshold of Oedipus. Sexual perversion may be considered as the expression of a narcissistic personality organisation which makes massive use of splitting and projective identification as a defence against separation anxiety. This prevents homosexual perverts from dis-identifying from their mothers and from attaining a distinct gender identity. The clinical case of a homosexual male patient is presented, where the absence of the father underlay his resentment, conveyed in the transference by means of lamentations and boredom, with which the patient sadistically tormented the analyst, thus giving vent to his deep resentment over an absent and unreliable father and over a mother from whom he could only be separated at the cost of persecutory anxiety and feelings of jealousy.

Adult↗
PubMed1995

A psychoanalytical theory of 'drug addiction': unconscious fantasies of homosexuality, compulsions and masturbation within the context of traumatogenic processes.

Drug addiction is considered in terms of an addiction syndrome, and a theory for its motivation is proposed, based on the treatment of several drug addicts in psychoanalysis and psychotherapy. It is suggested that the main cause of the addiction syndrome is the unconscious need to entertain and to enact various kinds of homosexual and perverse fantasies, and at the same time to avoid taking responsibility for this. It is hypothesised that specific drugs facilitate specific fantasies and using drugs is considered to be a displacement from, and a concomitant of, the compulsion to masturbate while entertaining homosexual and perverse fantasies. The addiction syndrome is also hypothesised to be associated with life trajectories that have occurred within the context of traumatogenic processes, the phases of which include social, cultural and political factors, encapsulation, traumatophilia, and masturbation as a form of self-soothing. This hypothesis about the traumatic origins of the addiction syndrome is illustrated with data from the psychoanalyses of addicts.

Adult↗
PubMed1995

The anal world of a six-year-old boy.

Clinical material from the psychoanalysis of a 6-year-old boy is presented which manifests the creation of an anal psychic world--a psychic world which is blatantly anal in content and characterised by the formal qualities of de-differentiation and interchangeability, which are linked to anal experience and the level of cognitive maturation typical during the anal phase. This case demonstrates the existence at an earlier developmental level of perverse qualities which have previously been identified in adults. In particular, similarities are noted with the fantasies of adult perverts and the Marquis de Sade. Psychodynamic antecedents which have previously been extrapolated from investigation of these adults are confirmed in statu nascendi in this child. Like adult perverts, this boy appears to have created his anal world to defend against acknowledgement of sexual and generational differences. His anal world play is conceptualised as an example of a perverse play style.

Child↗
PubMed1977

[Status of vampirism and autovampirism].

Any interpretation of the perversion called vampirism ought to take into consideration the myths in which the relations between living and dead people (vampires, incubi, succubi, etc...) are represented, myths through which the persons alive project onto the dead ones to ambivalent, sexual and agressive, wishes they had toward the dead when they were still alive. Clinically the word vampirism should be used to name all sexual or agressive acts, whether blood-sucking happens or not, committed on a dead or dying person. In one third of the cases the act has both a sexual and an agressive components (mutilation of the dead body); in the other two thirds the act seems to have only a sexual component (sexual pleasure in the presence of or in contact with the dead body). The origin and the meaning of this exceptional perversion are discussed. Auto-vampirism, even more exceptional than vampirism, differs from the latter by the fact that blood succion is the essential symptom and by the fact that it is not on the side of sadism but on the side of masochism. In the light of two case-histories, one of which never published before, and on the basis of the Freudian theory of masochism, an interpretation of the data is propounded.

Adult↗
PubMed1997

Managed care and the survival of neurology referral centers. A commitment to centers of excellence.

Since the collapse of federal health system reform legislation in 1994, there has been a growing concern with the quality of care provided within managed care systems. Just as physicians practicing under a traditional fee-for-service payment base have financial incentives to do as much as possible for each patient (doing well by doing good), physicians working for managed care plans are sometimes given perverse incentives to do as little as possible. A major quality-related concern among patients and payers (often referred to jointly and ambiguously as consumers of care) is the much larger role assigned to primary care physicians in managed care plans than is usually the case with traditional indemnity insurance.

Aged↗
PubMed2005

Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance.

CONTEXT: Clinical practice guidelines (CPGs) have been developed to improve the quality of health care for many chronic conditions. Pay-for-performance initiatives assess physician adherence to interventions that may reflect CPG recommendations. OBJECTIVE: To evaluate the applicability of CPGs to the care of older individuals with several comorbid diseases. DATA SOURCES: The National Health Interview Survey and a nationally representative sample of Medicare beneficiaries (to identify the most prevalent chronic diseases in this population); the National Guideline Clearinghouse (for locating evidence-based CPGs for each chronic disease). STUDY SELECTION: Of the 15 most common chronic diseases, we selected hypertension, chronic heart failure, stable angina, atrial fibrillation, hypercholesterolemia, diabetes mellitus, osteoarthritis, chronic obstructive pulmonary disease, and osteoporosis, which are usually managed in primary care, choosing CPGs promulgated by national and international medical organizations for each. DATA EXTRACTION: Two investigators independently assessed whether each CPG addressed older patients with multiple comorbid diseases, goals of treatment, interactions between recommendations, burden to patients and caregivers, patient preferences, life expectancy, and quality of life. Differences were resolved by consensus. For a hypothetical 79-year-old woman with chronic obstructive pulmonary disease, type 2 diabetes, osteoporosis, hypertension, and osteoarthritis, we aggregated the recommendations from the relevant CPGs. DATA SYNTHESIS: Most CPGs did not modify or discuss the applicability of their recommendations for older patients with multiple comorbidities. Most also did not comment on burden, short- and long-term goals, and the quality of the underlying scientific evidence, nor give guidance for incorporating patient preferences into treatment plans. If the relevant CPGs were followed, the hypothetical patient would be prescribed 12 medications (costing her 406 dollars per month) and a complicated nonpharmacological regimen. Adverse interactions between drugs and diseases could result. CONCLUSIONS: This review suggests that adhering to current CPGs in caring for an older person with several comorbidities may have undesirable effects. Basing standards for quality of care and pay for performance on existing CPGs could lead to inappropriate judgment of the care provided to older individuals with complex comorbidities and could create perverse incentives that emphasize the wrong aspects of care for this population and diminish the quality of their care. Developing measures of the quality of the care needed by older patients with complex comorbidities is critical to improving their care.

Aged↗
PubMed1998

Health economics research and antitrust enforcement.

Antitrust analysis is typically very fact intensive, and enforcement outcomes always depend on the circumstances in particular markets. Nonetheless, there are issues of broad antitrust significance, and it is in these areas that health economics can make important contributions to enforcement policy. Indeed, health economics has already provided valuable guidance to antitrust enforcers in some areas. For example, when antitrust was first applied to hospital mergers in the early 1980s, it was sometimes argued that competition among hospitals was inherently perverse, inflating rather than restraining costs and prices. But studies of the 'California experience' with selective contracting and more careful assessment of the 'medical arms race' hypothesis provided persuasive support for applying standard antitrust presumptions to health care markets. Important new issues continue to arise. Some come from new challenges of standard presumptions in antitrust analysis, while others are attributable to changes in the rapidly evolving health care markets. These issues present new opportunities for health economists to provide guidance to antitrust enforcers and the courts. Guidance is most valuable when researchers recognize the key issues and understand the methodology with which antitrust analysts tackle competitive problems. The accompanying articles in this special issue are important contributions in these regards. In this article, we point to two recently litigated cases to highlight still other issues in which additional theoretical and empirical work by health care economists could be helpful in informing antitrust decision makers.

Antitrust Laws↗
PubMedDate not supplied

Managing risk selection incentives in health sector reforms.

The object of the paper is to review theoretical and empirical contributions to the optimal management of risk selection incentives ('cream skimming') in health sector reforms. The trade-off between efficiency and risk selection is fostered in health sector reforms by the introduction of competitive mechanisms such as price competition or prospective payment systems. The effects of two main forms of competition in health sector reforms are observed when health insurance is mandatory: competition in the market for health insurance, and in the market for health services. Market and government failures contribute to the assessment of the different forms of risk selection employed by insurers and providers, as the effects of selection incentives on efficiency and their proposed remedies to reduce the impact of these perverse incentives. Two European (Netherlands and Spain) and two Latin American (Chile and Colombia) case studies of health sector reforms are examined in order to observe selection incentives, their effects on efficiency and costs in the health system, and regulation policies implemented in each country to mitigate incentives to 'cream skim' good risks.

Economic Competition↗
PubMed1998

Economics and ethics in mental health care: traditions and trade-offs.

BACKGROUND: Both economic and ethical perspectives are exerting increasing influence at all levels of mental health policy and practice; yet there is little consensus on how these two different perspectives are to be reconciled or explicitly incorporated into decision-making. AIM: This review article is directed towards a fuller understanding of the complex trade-offs and compromises that are or may be made by clinicians, managers and policy-makers alike in the context of mental health care planning and delivery. METHOD: We briefly outline a number of key principles of health care economics and ethics, and then focus on the particular incentives and trade-offs that are raised by these principles at three levels of the mental health system: government and society; purchasers and providers; and users and carers. RESULTS: At the level of government and society, we find (economically influenced) attempts to reform mental health care offset by concerns revolving around access to care: whether society is prepared to forgo economic benefits in exchange for improved equity depends to a considerable extent on the prevailing ethical paradigm. The implementation of these reforms at the level of purchasers and providers has helped to focus attention on evaluation and prioritization, but has also introduced "perverse incentives" such as cost-shifting and cream-skimming, which can impede access to or continuity of appropriate care for mentally ill people. Finally, we detect opportunities for moral hazard and other forms of strategic behaviour that are thrown up by the nature of the carer:user relationship in mental health care. CONCLUSION: We conclude by highlighting the need to move towards a more open, accountable and evidence-based mental health care system. Acknowledgement of and progress towards these three requirements will not deliver ideal levels of efficiency or equity, but will foster a greater understanding of the relevance of ethical considerations to mental health policies and strategies that are often influenced strongly or solely by economic arguments, whilst also demonstrating that equity must come at a price.

Journal Article↗
PubMed1995

Safety of intravenous valproate.

This multicenter, open-label trial was designed to study the safety of intravenous (IV) sodium valproate in patients with epilepsy. All 318 patients (previously treated with antiepileptic drugs) were hospitalized for seizure control or anticipated seizures. The protocol allowed physicians to set the number of infusions and treatment duration. Adverse events, laboratory studies performed, and seizure activity were documented on case report forms. The patients' mean age was 34.4 years (range, 2-87 years). The most common reason for admission was lack of seizure control (235 patients, 185 of whom were admitted for video-electroencephalographic monitoring). The median dosage of valproate was 375 mg infused over 1 hour. The median number of doses was four, given over 2 days. In 54 patients (17%), transient adverse events were reported. The most frequent were headache, reaction at the injection site, and nausea (2.2% each); somnolence (1.9%); vomiting (1.6%); and dizziness and taste perversion (1.3% each). No persistent or severe hematologic or serum chemistry abnormalities were found. Vital signs were not significantly affected by the IV infusion of valproate. At the dosages and rates of administration studied, intravenous valproate appears to be safe and well tolerated.

Adolescent↗
PubMed2003

Public funding for residential and nursing home care: projection of the potential impact of proposals to change the residential allowance in services for older people.

BACKGROUND: This paper investigates the potential effects of a policy change in the funding of UK residential care. The White Paper Modernising Social Services (Cm 4169, 1998) outlined plans to change the distribution of the Residential Allowance (RA), payable in support of residents in independent residential or nursing home care, from a component of income support paid direct to establishments to a grant to local authorities. This change was intended to remove the perverse incentive in accessing independent residential care more favourably than local authority care. A further objective was to encourage local authorities to use the grant to support home-based alternatives to residential care. The policy rests on a model in which price signals dictate the choice of care for an older person. By, in effect, raising the price of independent residential and nursing home care, the policy provides an incentive for authorities to seek alternatives to institutional care. METHODS: Managers from 16 UK social services departments attended a focus group discussion, completed questionnaires and provided information to assist in calculating the potential diversionary effect of the policy. RESULTS: Managerial estimates indicated a small diversionary effect of the policy; A potential effect of 0.26 and 0.19 per 1000 older people diverted from residential and nursing care respectively. CONCLUSIONS: The study indicated that wider organisational factors other than price are likely to play a greater role in deciding whether an older person is admitted to care. Changes in public funding alone do not reflect the complexities involved in decision-making concerning the residential placement of older people.

Aged↗
PubMed2005

European health policy challenges.

Few countries are immune to the international health care 'virus' of reform, with many countries regularly re-cycling changes that shift costs and benefits in ways that are arbitrary, inefficient and offer short term political palliation. Much of this activity has little evidence base and reveals lack of clarity in defining public policy goals, establishing trade-offs and aligning incentive structures with these objectives. Well established failures in health care delivery systems such as variations in medical practice and continuing absence of systematic outcome measurement, have persisted for decades as nations grapple inefficiently with recurring problems of expenditure inflation and waiting times. The lack of emphasis on evidence to inform the efficient management of chronic disease and the reduction of health inequalities is a product of perverse incentives and managerial inertia that maintains the incomes of powerful interest groups.

Europe↗