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PubMed1982

Narcissistic personality as a symbiotic character disorder.

I have attempted to integrate our theoretical understanding of a particular group of borderline and narcissistic personalities and to relate their development to mother-infant failure to form a normal symbiotic bond, and pathological efforts to compensate. I have attempted to preserve and to integrate some of the valuable contributions of Kernberg and Kohut while, hopefully, avoiding the pitfalls of each theoretical system. The result is a theory of dissociated possession configurations and their actualization in relationships. This is neither a theory of nature (innate rage) nor of nurture (maternal failure) but of the pathological form of adaptation in which objects are used as possessions in order to compensate for absent structures. Whereas the primary introject of the borderline personalities is unmitigatedly self-destructive, the narcissistic personalities have formed a more complex introject including a conditional symbiotic representation, the maintenance of which involves active dissociation of object related needs. The conditional symbiotic relationship, in turn, is a stabilizing and constructive force in his relationships.

Depressive Disorder↗
PubMed1980

The organization of the self-representation and its influence on pathology.

Units within the self-representation provide the quality for ego activity. The ego selects and cathects the appropriate unit of the self-representation. Oedipal identifications internalize the ego capacity to maintain the self-representation and its stability. Conflict can promote instability within the self-representation requiring special defenses to deal with the narcissistic stress. Such narcissistic conflict can arise at all levels of maturity.

Acting Out↗
PubMed1997

Interactive image guidance in skull base surgery using an opto-electronic device.

The applicability of an image guidance frameless system based on an opto-electronic sensor device in skull base surgery was explored in this study. Five embalmed heads with external fiducial markers placed in noncoplanar points were scanned (CT scan) and different skull base approaches were reproduced in these specimens. The opto-electronic system is comprised of an infrared camera, a local rigid body, and a 24-light-emitting diode probe attached to different surgical instruments. DOS-based calibration and transformation software and Unix-based surgical planning software were also used. The anatomic landmarks identified during the dissection were matched with the corresponding points derived from computed tomographic (CT) scans. This information allowed the surgeon to develop a three-dimensional representation of the surgical field and to anticipate the next anatomic structure encountered during the dissection. This infrared device operated in real time, is not affected by external factors with regard to its accuracy, and does not interfere with standard neurosurgical techniques. This frameless system is helpful in minimizing the risk of morbidity and provides an accurate guide during the approach, as well as unobstructed access to the surgical field.

Journal Article↗
PubMed1999

Principles of medical decision making.

The consequences of medical decisions are inherently uncertain at the decisive moment. Using clinical examples related to the diagnosis and management of low back pain, the authors review some principles that can help physicians deal with this uncertainty. This article addresses the following: the use of probability as a useful representation of uncertainty, the use of Bayes' theorem to update probability estimates when new information is obtained, the measurement of a diagnostic test's accuracy, the use of the threshold model for choosing a diagnostic test, the principles of expected-value decision making, the use of utility assessment as a way of attaching value to outcomes, and the use of quality-adjusted life years as a measure of value. These principles can aid physicians in approaching complex and uncertain decisions with their patients. As the use of computers becomes more integrated into the process of care, the opportunity exists to move formal decision models from the policy level to the patient care level.

Cost-Benefit Analysis↗
PubMed1986

Identification and its vicissitudes as observed in psychosis.

I have described the mechanisms that operate in psychotic identification. One mechanism is psychotic introjection, characterized by a refusion of 'all good' self and object representations. This re-fusion threatens the destruction of the self as a consequence of the defensive blurring of these self and object representations. The second operative mechanism is projective identification, which I have defined in comparison with and in contrast to projection. Projective identification threatens the destruction of the relation with the object. The case I have described in detail illustrates these psychotic identifications, the development of psychotic transferences wherein the patient cannot differentiate herself and her thinking from the therapist and his thinking, and the struggle around a sense of personal identity at a point of resolution of the psychotic transference. This case also illustrates that an integrated self includes two types of self-representations: those centred on self differentiation and those which reflect the observing functions of the parental images internalized into the self.

Adult↗
PubMed2003

The development of an attachment-based treatment program for borderline personality disorder.

The treatment of borderline personality disorder (BPD) remains controversial. The authors have developed an evidence-based treatment program rooted in attachment theory that integrates research on constitutional factors with environmental influences. BPD is conceived of as a disorder in the self-structure brought about through environmentally induced distortion of psychological functioning, which decouples key mental processes necessary for interpersonal and social function. The primary mental function involved is mentalization, which is enfeebled by an absence of contingent and marked mirroring during development. Treatment strategies target mentalization in order to foster the development of stable internal representations, to aid the formation of a coherent sense of self, and to enable to borderline patient to form more secure relationships in which motivations of self and other are better understood. Destabilization of the self leads to emotional volatility, so treatment also needs to focus on identification and appropriate expression of affect. This article describes some of the techniques used to enhance mentalization within the context of group and individual psychotherapy. Targeting of current symptomatology and behavior is insufficient. Therapists need to retain their own ability to mentalize, maintain mental closeness, focus on current mental states, and avoid excessive use of conflict interpretation and metaphor while paying careful attention to the use of transference and countertransference.

Affect↗
PubMed1994

The association between early life mental representations and suicidal behavior.

The escalation of self-destructive acts among all age groups has motivated researchers to identify the factors that may contribute to suicidal behavior. Suicide has been attributed to numerous etiologic factors, including the presence of psychopathology (e.g., affective disorders), neuroendocrine dysregulation and genetic tendencies. Nevertheless, investigations have not identified the precise mechanism(s) by which self-destructive proclivities are generated. This paper proposes a developmental psychopathology model based on early life mental representations that would enable clinicians to chart an individual's susceptibility to suicide and to better anticipate when suicidal behavior could become activated.

Adolescent↗
PubMed1998

Working with spiritual and religious themes in group therapy.

This article explores the analytic therapy group as a spiritual community that can deepen the implications of group transference. From this perspective, group-as-a-whole dynamics include a spiritual dimension in addition to the recapitulation of the family of origin. Clinical vignettes are introduced from a midphase group to illustrate a means of working with spiritual and religious themes psychodynamically through managing them like dreams. Amplification and interpretation of the symbolic themes guide members through the transference to the family of origin. There, members gain access to childhood memories and to the childhood transitional space of religious experience where they created their God representations as a means of solving their self and object dilemmas. The working-through process facilitates the integration or transformation of new self and God images.

Adult↗
PubMed2005

Long-term stability of parental representations in depressed outpatients utilizing the Parental Bonding Instrument.

This study addressed two questions: (a) What are the 30-month, 60-month, and 90-month test-retest reliabilities of the Parental Bonding Instrument (PBI); and (b) are recollections of parental bonding stable across changes in the level of depressed mood? Participants included 97 outpatients with primary early-onset dysthymic disorder and 45 outpatients with episodic major depressive disorder. Follow-ups were conducted at 30, 60, and 90 months after entry into the study. The PBI was scored using both the original two-factor model and a three-factor solution. As indexed by intraclass correlations, stability for the original two-factor model ranged from .64 to .88, with a median of .77. The intraclass correlations for the three-factor model ranged from .54 to .87, with a median of .73. The intraclass correlations were generally higher between adjacent assessments, but the decrease over increasingly longer intervals was quite small. Overall, the results indicated that the PBI is highly stable for intervals as long as 90 months. In addition, reports of parental bonding were relatively stable despite significant changes in the level of depressed mood. Thus, the present study provides evidence for the long-term stability of parental representations, as measured by the PBI, in depressed outpatients.

Adolescent↗
PubMed2001

The Fc gamma receptor genotype as a severity factor for chronic periodontitis in Japanese patients.

BACKGROUND: Functional polymorphisms of immunoglobulin G (IgG) Fc receptors (Fc gamma R) have been shown to be associated with generalized aggressive periodontitis (GAgP) or recurrence of chronic periodontitis (CP) in Japanese patients. The purpose of this study was to evaluate whether Fc gamma R polymorphisms are also associated with severity of CP. METHODS: Fifty Japanese non-smoking patients with severe CP and 39 Japanese non-smoking patients with moderate CP were identified according to established clinical criteria, including measurements of probing depth (PD), clinical attachment level (CAL), and alveolar bone loss (BL). Fc gamma R genotypes for 3 bi-allelic polymorphisms (Fc gamma RIIa-R/H131, Fc gamma RIIIa-158V/F, Fc gamma RIIIb-NA1/NA2) were determined in these CP patients and 64 race-matched, non-smoking healthy controls by means of allele-specific polymerase chain reactions. RESULTS: There was a significant over-representation of Fc gamma RIIIa-158V allele in severe CP patients compared to moderate CP patients (odds ratio 2.03, 95% confidence interval [CI] 1.03-4.01, chi 2 = 4.86, P = 0.028). In addition, we found a strong association between CP severity and Fc gamma R composite genotype comprising Fc gamma RIIIa-158V plus Fc gamma RIIIb-NA2 (severe CP versus moderate CP: odds ratio 4.69, 95% CI 1.52-15.10, chi 2 = 9.35, P = 0.002; severe CP versus healthy controls: odds ratio 4.10, 95% CI 1.62-10.59, chi 2 = 11.13, P = 0.0009). Moreover, CP patients positive for the composite genotype exhibited more severe signs of periodontitis than composite genotype-negative individuals (positive versus negative; mean PD: 3.8 mm versus 3.2 mm, P = 0.005; mean CAL: 4.5 mm versus 3.7 mm, P = 0.005; mean % BL: 37.6% versus 29.9%, P = 0.008). CONCLUSION: Our results document the Fc gamma RIIIa-158V allele and possibly Fc gamma RIIIb-NA2 to be associated with severity of CP in Japanese patients.

Adult↗
PubMed1988

Morphology of sections through the fetal heart.

Two human embryos, of 28 and 29 mm crown-rump length, were studied. One had been serially sectioned in the transverse plane, the other in the sagittal plane. With the help of a graphic reconstruction method two new sets of sectioning planes were constructed. One set started from the transverse plane, which was gradually angulated towards the frontal plane. The other set started from the sagittal plane, which, too, was angulated towards the frontal plane. These procedures were carried out at various levels in both cases. We produced a continuous series of sectioning planes of the young fetal heart, which together give a clear representation of spatial morphology. We believe that these images can be of help in the interpretation of fetal echocardiograms. The morphology of these young fetuses differs considerably from older stages in that the atrioventricular septum is not yet present. Full development of the tricuspid valve and the mitral valve can only later lead to the different septal attachments of the two valves.

Echocardiography↗
PubMed2006

The critical effect of object loss in the development of episodic manic illness.

This article is a detailed psychoanalytically oriented case study of a patient whose mania followed the loss of a parent. Repetitive childhood trauma such as recurrent separations from parents because of political repression, fears of being abandoned, extremely contradictory parental expectations, multiple mothering, and restricted peer interaction forced the excessive use of primitive defense mechanisms, especially denial leading to grandiosity, resulting in po-rous ego boundaries and later serious conflict related to magical thinking and world destruction fantasies. These issues were compounded during latency by emigration to this country from eastern Europe and having to adapt to an entirely new culture. Successful mourning was precluded due to the blurring of self and object representations and the overwhelming need to minimize the finality of death by means of manic regression, the clinical stages of which are described precisely.

Adult↗
PubMed2002

Children's internal representations, empathy, and fantasy play: a validity study of the SCORS-Q.

The authors investigated relationships among internal representations, empathy, and affective and cognitive processes in fantasy play to test the validity of the Social Cognition and Object Relations Scale Q-Sort (SCORS-Q; D. Westen, 1995) with children. Eighty-six 8-10-year-olds were administered 8 Thematic Apperception Test cards, a standardized play task, and a self-report empathy measure. Teachers rated children's empathy and helpfulness. As predicted, internal representations were related to empathy, helpfulness, and quality of fantasy play. Developmental differences on the SCORS-Q were consistent with object relations theory and with results from the original SCORS. The findings support the value of internal representations as a means of understanding children's interpersonal functioning and contribute to the validity of the SCORS-Q for use with children.

Child↗
PubMed1992

Empirical and clinical assessments of children's object relations and object representations.

A series of investigations that assess children's object representations using the Rorschach Mutuality of Autonomy (MOA) Scale are reviewed. The scale is viewed as a summary measure of a child's repertoire of previous interpersonal interactions. It has been effective in delineating qualitative aspects of a number of child psychopathological syndromes, in documenting short-term object representational shifts in children undergoing surgery, and in foretelling key paradigms in child psychotherapy. This effectiveness provides empirical support for the hypothesized salience of object representations as an integral facet of personality and affirms Escalona's (1968) contention that capturing a child's phenomenological experience enhances our capacity to predict later outcome.

Child↗
PubMed2001

Potential fascial dome made by the upper leaf of the phreno-esophageal membrane.

We describe the configuration and size of the artificial fascial dome created in 57 cadavers. This dome protrudes into the thoracic cavity from the esophageal hiatus. This dome was a potential space realized by finger dissection (i.e., a specific but common surgical procedure during surgery of the upper part of the stomach). The vagus nerves penetrated the top of the dome and ran down along the esophagus. The height of the ventral wall of the dome ranged from 10-60 mm, while the dorsal wall was 10-40 mm longer than the ventral one since the dorsal wall attached to the lower, dorsal limb of the esophageal hiatus. Accordingly, the dorsal wall separated the "thoracic" aorta from the "abdominal" esophagus. We considered that the upper leaf of the phreno-esophageal membrane forms the fascial dome, although the lower leaf of the membrane was not identified in this study. According to the results, we proposed a schematic representation of the phreno-esophageal membrane.

Aged↗
PubMed1997

Sequence and structure alignment of Paramyxoviridae attachment proteins and discovery of enzymatic activity for a morbillivirus hemagglutinin.

On the basis of the conservation of neuraminidase (N) active-site residues in influenza virus N and paramyxovirus hemagglutinin-neuraminidase (HN), it has been suggested that the three-dimensional (3D) structures of the globular heads of the two proteins are broadly similar. In this study, details of this structural similarity are worked out. Detailed multiple sequence alignment of paramyxovirus HN proteins and influenza virus N proteins was based on the schematic representation of the previously proposed structural similarity. This multiple sequence alignment of paramyxovirus HN proteins was used as an intermediate to align the morbillivirus hemagglutinin (H) proteins with neuraminidase. Hypothetical 3D structures were built for paramyxovirus HN and morbillivirus H, based on homology modelling. The locations of insertions and deletions, glycosylation sites, active-site residues, and disulfide bridges agree with the proposed 3D structure of HN and H of the Paramyxoviridae. Moreover, details of the modelled H protein predict previously undescribed enzymatic activity. This prediction was confirmed for rinderpest virus and peste des petits ruminants virus. The enzymatic activity was highly substrate specific, because sialic acid was released only from crude mucins isolated from bovine submaxillary glands. The enzymatic activity may indicate a general infection mechanism for respiratory viruses, and the active site may prove to be a new target for antiviral compounds.

Amino Acid Sequence↗
PubMed1982

A new perspective on Bruch's membrane and the retinal pigment epithelium.

Trypsin digestion of retinal pigment epithelium is a technique that bares Bruch's membrane, to allow topographical examination by scanning electron microscopy. Twenty-five human eyes were examined. The zonula occludens of the pigment epithelium was clearly seen as a surface feature, but attachment plaques at the sides and base were not visible. The adhesion between the pigment epithelium and the basal lamina was stronger than between the basal lamina and the rest of Bruch's membrane. Surface features of the basal lamina, inner collagenous zone, elastic layer, and outer collagenous zone were seen in a way that previously required an artist's representation constructed from microscopic sections.

Basement Membrane↗
PubMed2006

[Unusual nucleotide sequence of a DNA fragment isolated from nuclear envelopes of mouse hepatocytes].

Fragments of chromosomal DNA isolated from nuclear envelopes of mouse hepatocytes were previously cloned and partially characterized in our laboratory. One of the cloned fragments (EnvM4) had unusual characteristics: abundant representability in the clone library (about 50%) and homology with DNA of archebacteria. An analysis of nucleotide sequence of this fragment conducted in more detail allowed the detection of an evolutionary conserved region present in the genomes of various organisms (from bacteria to human). Other characteristics of fragment EnvM4 suggest a possible functional role of chromosomal DNA regions determining the attachment of chromosomes to the nuclear envelope.

Animals↗