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Fixing women: devaluation, idealization, and the female fetish.

A particular ideal of femininity which has long been popular in our culture is the image of the esthetically perfect but behaviorally compliant woman. By comparing two clinical cases, I have attempted to show that this stylized image is sometimes part of a specific defensive structure, enacted in extreme forms as part of a perverse ritual. The idealized image is a secondary formation with roots in early transitional representations. As an adult defense, it isolates devalued attributes, particularly anal attributes, from an esthetic ideal and enables the narcissistically disturbed individual to effect an illusion of separation while maintaining compulsive control over a needed object. The enactment of this defensive pattern frequently requires the cooperation of a partner. Women comply not only for masochistic reasons or because of intimidation, but because the fetishistic ritual itself is often an important part of their defensive armory. Women who rely on the idealization provided by a partner as the major source of their self-esteem are sometimes willing to accept pathological features of a partnership rather than give up this narcissistic support. At the more creative end of the continuum between pathological and adaptive transitional representations, the idealized image of woman may lend a playful romantic tone to relationships between men and women. In its most compulsive manifestations, however, it tends to perpetuate superficiality and impedes understanding between the sexes. Patients in whom the ideal is elaborated in its most distorted forms offer a useful opportunity to explore the roots of these phenomena.

Adult↗

Clinical dimensions of masochism.

In this paper, I propose a general classification of masochistic psychopathology and describe relations between this clinical domain and other types of psychopathology. My main objective is to provide an outline relevant for diagnostic, prognostic, and treatment considerations of masochistic pathology. This includes descriptions of and relations among a wide variety of masochistic phenomena from the depressive-masochistic personality to extreme forms of self-destructiveness. Ego organization, object relations, superego development, narcissistic organization, and polymorphous perverse infantile sexuality are considered as codeterminants of the levels and clinical features of masochistic pathology. Finally, the relations between masochistic pathology and negative therapeutic reactions are reexamined.

Depressive Disorder↗

Aggression and love in the relationship of the couple.

In this paper I examine the interplay of love and aggression in a couple's emotional relationship. I explore the activation of dominant repressed or dissociated object relations with the parental figures, and the unconscious collusion of both partners to enact these past relationships in the present. I then examine the couple's relationship as determined by differences in male and female development, as well as the counterpart of these differences--unconscious moves toward "twinship" and complementarity. Unresolved oedipal conflicts are explored as a major cause of invasion of the couple's sexual boundaries, and a vehicle for the expression of dissociated aggression from many sources. Perversity--the "recruitment of love at the service of aggression"--as a threat to the basic fabric of a couple's love life is one alternative to the normal channels for elaboration of aggression in their relationship. Protective functions of the couple's interaction with their social network are examined in the context of their elaborating and integrating aggression with love.

Aggression↗

Psychological-mindedness as a defense.

Many patients seen today use sophisticated capacities for psychological reflection and premature synthesis to ward off knowledge of more primitive conflict and islands of unintegration. They show a precocious talent for free association, a talent they perversely misuse. Similarly, they enjoy access to a rich fantasy life, even as they subtly impoverish it. Effective therapeutic work requires that they suffer "traumatization"--experiences of dedifferentiation that undermine their considerable capacity to know what they feel and think. Structural and process variables interact with content variables in complex and ambiguous ways. As a consequence, estimates of the authenticity and "fit" of personal and interpersonal experiences and behaviors of both partners in the therapeutic encounter become necessarily involved. Such factors may increase the possibility of misunderstandings, but also of more authentic and firmly grounded understandings. Similar issues are eventually revealed in these patients' early lives, where psychological and other formulaic understandings were prematurely applied to offset overwhelmedness and other unarticulable experiences; the patient's talents for ambiguity, irony, self-soothing, or responsiveness to others were, in effect, exploited at the expense of full psychological growth. Versions of this clinical presentation may be increasingly common in a new generation of analyzable patients. Clinical work with them is facilitated by a synthesis of contemporary developmental, structural, and object relations theory.

Adult↗

The analyst's interpretation as fetish.

This paper explores the transference dynamics and underlying fantasies of analysands whose characters have been shaped by conflict solutions common to perversion. Giving the impression of a serious engagement for therapeutic ends, these individuals live out in the treatment a sexualized enactment in which the analyst's interventions are transformed into a fetish. This enactment is designed to support a defensive effort to avoid external perceptions that trigger certain fantasies of danger, including that of castration. It is designed also to cancel out interventions of the analyst that become equated with these frightening fantasies. Since the analyst's efforts to explore and interpret this enactment are also turned into a fetish, such a transference poses grave difficulties for the analysis. A technical approach is suggested in which the analyst focuses on the contradiction itself, the operation of the disavowal, the fantasy of danger that motivates the persistent use of disavowal, and the underlying, often vengeful and envious wishes that contribute both to the undermining of the analysis and to the content of the fantasies of danger that provoke so much anxiety.

Adult↗

Double-blind comparative trial of ciprofloxacin versus clarithromycin in the treatment of acute bacterial sinusitis. Sinusitis Infection Study Group.

This multicenter, randomized, double-blind trial compared the efficacy and safety of ciprofloxacin (CIP; 500 mg twice daily for 10 days, placebo for 4 days) to those of clarithromycin (CLARI; 500 mg twice daily for 14 days) in 560 adults with clinically documented and radiologically confirmed acute sinusitis. Of 457 efficacy-valid adults (236 CIP, 221 CLARI), clinical resolution plus improvement at the end of therapy was 84% for CIP-treated patients compared to 91% of CLARI recipients (CI95 = -0.131, -0.013). At the 1-month follow-up, more than twice as many CLARI-treated patients, 18 (10%), experienced a relapse, compared to 7 (4%) CIP-treated patients. The combined clinical response analyses (end of therapy and 1 -month follow-up) demonstrated that CIP and CLARI were statistically equivalent (CI95 = -0.106, 0.044). Diarrhea, nausea, headache, and dizziness were the most frequently reported drug-related adverse events in both treatment groups; diarrhea and taste perversion were reported more frequently among CLARI recipients. In summary, the combined end of therapy and follow-up clinical evaluation analyses revealed that CIP and CLARI were equally effective in the management of acute sinusitis, although twice as many relapses were reported among CLARI recipients.

Acute Disease↗

Psychological profiling of sexual murders: an empirical model.

Psychological profiling represents the investigative technique of analyzing crime behaviors for the identification of probable offender characteristics. Profiling has progressively been incorporated into police procedures despite a surprising lack of empirical research to support its validity. Indeed, in the study of sexual murder for the purpose of profiling, very few quantitative, academically reviewed studies exist. This article reports on the results of a 4-year study into Australian sexual murders for the development of psychological profiling. The study involved 85 cases of sexual murder sampled from all Australian police jurisdictions. The statistical procedure of multidimensional scaling was employed. This analysis produced a five-cluster model of sexual murder behavior. First, a central cluster of behaviors was identified that represents common behaviors to all patterns of sexual murder. Next, four distinct outlying patterns--predator, fury, perversion, and rape--were identified that each demonstrated distinct offense styles. Further analysis of these patterns also identified distinct offender characteristics that allow for the use of empirically robust offender profiles in future sexual murder investigations.

Australia↗

Assessing peer review in the quest for improved medical services and the implications for education in quality assessment: Part IV.

Three court decisions reviewing medical peer review conducted in hospitals were discussed at length in part III of this article. In their opinions the courts gave at least tacit approval to the procedures followed in the hospitals, and they accepted that an evidentiary basis for adverse action against the physicians was present. But not all medical peer review in hospitals resulting in adverse actions is found satisfactory when challenged in court, and the most prominent litigation in the decade of the 1980s concerning medical peer review, Patrick v. Burget (1), is testimony to the potential for its perversion. Part II adverted to the potential for bias or lack of objectivity in assessing physician performance. Part I mentioned the problem of bias in the context of peer review of articles for publication and of research grant proposals. The objectives of Part IV are: (1) to examine the concern about bias in medical peer review and to indicate how it may be lessened, if not eliminated; (2) to address further the difficulty created by the relative lack of valid criteria to employ in medical peer review; (3) to review the extent of protection from liability afforded to participants in medical peer review; and (4) to describe the changes that should be anticipated in review of medical services in the future. Before addressing these subjects it is essential to remind the reader that medical peer review is not conducted primarily for disciplinary purposes; rather, its purpose is to evaluate the quality of care.(ABSTRACT TRUNCATED AT 250 WORDS)

Bias↗

Objectives, information and incentives in the NHS internal market.

In order to achieve and monitor success in the NHS internal market, it is important that information related to health care objectives is developed and used. The paper argues that these objectives are not always easy to specify but that four groups can be identified: efficiency, equity, quality and accountability/responsiveness. Although information management specialists have emphasised the construction and use of appropriate frameworks for planning information flows, whether appropriate information is used depends on the existence of incentives for its supply. Using concepts from game theory, the paper offers a non-technical examination of the incentives that the contracting environment imposes on the development of new information. The article concludes by suggesting that, for a variety of reasons, the incentives to produce information which would help monitor medical outcomes and related objectives, as distinct from inputs or activities, are often weak and sometimes perverse.

Cost-Benefit Analysis↗

Programme budgeting revisited: special reference to people with learning disabilities.

The recent reorganization of community care in the UK removed many of the perverse incentives identified in the previous system. However, the organization of care for many people is still divided across several agencies in the public and independent sectors. As purchasing and providing agencies in both the National Health Service and local authority personal social services attempt to coordinate policy objectives and the means to achieve them, the total resources available and their allocation across different care groups and among people in the same care groups from a consistent focus of attention. The principles and practice of programme budgeting provide important lessons for planning and monitoring expenditure. This paper rehearses such principles in the specialized area of policies for people with learning disabilities and draws on the experience of mapping expenditure on relevant services in a survey over 10 local authorities in England.

Budgets↗

Pharmacokinetic and tolerance evaluation of actisomide, a new antiarrhythmic agent, in healthy volunteers.

The pharmacokinetics and tolerance of actisomide (SC-36602) were determined following intravenous doses of 2.1, 4.2, and 8.4 mg/kg infused over five hours. Plasma concentrations observed in the low-dose group (2.1 mg/kg) were below the assay's limit of detection and were not included in the pharmacokinetic analysis. The following pharmacokinetic parameters were obtained in the medium-dose (4.2 mg/kg) and high-dose (8.4 mg/kg) groups, respectively: peak plasma concentration 4.25 +/- 0.26 and 7.81 +/- 0.31 micrograms/mL; area under the plasma concentration versus time curve 19.79 +/- 2.96 and 39.81 +/- 7.05 h.micrograms/mL; elimination rate constant of the beta phase 0.105 +/- 0.77 and 0.093 +/- 0.009 h(-1), and half-life 8.85 +/- 4.61 and 7.51 +/- 0.69 h. Left ventricular ejection fraction decreased by 10, 11, and 16 percent in the low-, medium-, and high-dose groups, respectively. Heart rate was not altered during the low-dose infusion. At the medium- and high-dose levels, resting peak heart rate increased by 18 and 27 percent, respectively. Systolic and diastolic blood pressures were not significantly changed in any of the dose groups. Changes in electrocardiographic intervals for the three dose groups were not significant except at the highest dose where an average 20 percent increase in the QRS interval was seen. Mild subjective adverse effects (dizziness, taste perversion, and circumoral paresthesia) which did not necessitate discontinuing the infusion occurred in the highest dosage group. Further studies are warranted to more fully characterize the pharmacokinetic profile and therapeutic potential of actisomide.

Adult↗

Informing prescribing allocations at district level in England.

OBJECTIVES: To derive a predictive model based on the morbidity, demographic and socio-economic characteristics of district populations to explain variations in prescribing costs in England. METHOD: Inter-relations between morbidity, demographic, socio-economic, general practice supply characteristics and net ingredient cost per age, sex and temporary resident originated prescribing unit (ASTRO-PU) were explored statistically for 90 districts in England using 1994 cost data. The possibility of mutual inter-relationship between 'supply' and 'demand' was examined; then the associations between a range of factors and prescribing costs were estimated using ordinary least squares regression and the predictive power of the possible models was systematically examined. RESULTS: Whilst there was a relatively weak relationship between the supply factors that were measured, there did not appear to be any reciprocal relationship. Three parsimonious models estimated using ordinary least squares multiple regression techniques based on combinations of permanent sickness, low birth weight and the proportion of general practitioners registered for postgraduate certificate of education were identified. The models explained up to 61% of variation between districts in prescribing costs. CONCLUSIONS: 'Need' and 'supply' characteristics are independently associated with variations in prescribing costs at district level. The negative association between the proportion of general practitioners eligible for postgraduate education allowance and prescribing costs may reflect 'better' prescribing but could not be introduced into a resource allocation formula without introducing perverse incentives. The combination of permanent sickness and low birth weight complement each other by providing a proxy measure of morbidity mostly applicable to adult males (permanent sickness) and mothers (low birth weight being a measure of maternal health). These variables should be considered further for use in the process of allocating resources for prescribing to districts.

Cost Allocation↗

Sociopolitical determinants of an AIDS prevention program: multiple actors and vertical relationships of control and influence.

In every country, health and prevention "come down" from the authorities responsible for this mission by way of planners, local authorities, and peer educators until it reaches the target population. International and national systems function on the premise of a top-down transmission, with little room for integrating local information that might provide a better understanding of the implementation process. This analysis is based on an empirical evaluative research of HIV/AIDS prevention projects with sex workers in a remote area of northern Brazil. It illustrates how nursing sociopolitical analysis can reveal how political interests can have perverse effects by contaminating the group's internal relations and with established partnerships, thereby weakening the impact of prevention programs. These effects can seriously affect community relations and social practices, far beyond the technical division of work and political hierarchies in the sociosanitary network.

Brazil↗

Occupational and environmental medicine in the United States: A proposal to abolish workers' compensation and reestablish the public health model.

The workers' compensation model of occupational and environmental medicine should be converted to a public health model. Occupational and environmental medicine, as a part of the public health infrastructure,could play a much more substantive part in bringing about a national program to deal with occupational and environmental health. The workers' compensation insurance system could be discontinued at any time,but it will be vital to do so when national health insurance is adopted in the United States. Abolishing workers' compensation would remove the perverse incentives that currently undermine the practice of occupational medicine. Medical care for workers should be provided by health care professionals who are not subject to influence by employers or insurers. Eligibility for benefits should not be determined by health and safety professionals. Wage-replacement benefits for workers should be determined by guidelines established by government and industry that prevent manipulation of health and safety professionals by employers and insurers. A nationwide comprehensive system to track work-related injury and illness, superior to the current reliance on records provided by employers and collated by government agencies, should be adopted. When unusually high rates of injuries, illnesses,and fatalities occur, government inspectors ought to respond and regulate the industry accordingly. Occupational health and safety professional strained in public health can and should participate in these activities, but not when they are in the employ of industry or insurers.

Accidents, Occupational↗

Comparison of the efficacy and tolerability of topically administered azelastine, sodium cromoglycate and placebo in the treatment of seasonal allergic conjunctivitis and rhino-conjunctivitis.

OBJECTIVE AND SETTING: Azelastine (AZE) in a novel, eye drop, formulation, was compared with topically applied sodium cromoglycate (SCG) and placebo (PLA) in the treatment of seasonal allergic conjunctivitis or rhino-conjunctivitis in a multicentre, parallel group study. RESEARCH DESIGN: 144 subjects ranging in age from 16 to 65 years participated. All had at least a 2-year history of seasonal allergic conjunctivitis and were symptomatic at the time of inclusion. Medications were administered topically either twice daily (AZE/PLA) or four times daily (SCG) over a 2-week treatment period. Method and outcome measures: Azelastine and placebo were compared double-blind; the comparison versus SCG was carried out in an open manner. Itching, redness, flow of tears, eyelid swelling, foreign-body sensation, photophobia, soreness and discharge were scored on a 4-point severity scale. RESULTS: Results for the decrease of main conjunctivitis symptoms (itching, tearing and conjunctival redness) showed a marked effect for both active treatments on day 3 with a sustained improvement on days 7 and 14. A clear response to treatment (an improvement of sum scores for day 3 of >/=3 points compared to baseline) occurred in 85.4% of azelastine-treated patients, 83.0% of sodium cromoglycate patients and 56.3% of placebo patients. Response rates for both active treatments were statistically superior to those for placebo (azelastine p = 0.005; sodium cromoglycate p = 0.007). Global assessment of efficacy was at least 'satisfactory' for 90.0% of azelastine patients, 81.3% of sodium cromoglycate patients and 66.3% of placebo-treated patients. The most frequent adverse effects were transient application site reactions which tended to disappear with increasing duration of treatment, and, less frequently, taste perversion. CONCLUSION: The results of this study indicate that the therapeutic use of azelastine eye drops in patients with seasonal allergic conjunctivitis or rhino-conjunctivitis can be recommended.

Administration, Topical↗

Short-course therapy of acute bacterial exacerbation of chronic bronchitis: a double-blind, randomized, multicenter comparison of extended-release versus immediate-release clarithromycin.

OBJECTIVE: The objective of this study was to compare the efficacy and safety of two clarithromycin formulations given for 5 days to patients with acute bacterial exacerbation of chronic bronchitis (ABECB). PATIENTS AND METHODS: This was a double-blind, randomized, multicenter study of ambulatory patients between 40 and 75 years of age with a medical history of chronic bronchitis, chronic obstructive pulmonary disease and a presumptive diagnosis of ABECB who met Anthonisen Type 1 criteria (increased dyspnea, increased sputum volume and increased sputum purulence). Eligible patients received a 5-day course of clarithromycin extended-release (ER) 500 mg once daily or clarithromycin immediate-release (IR) 250 mg twice daily. Clinical cure, bacteriological cure and pathogen eradication rates were determined at the end of therapy and at a follow-up visit. RESULTS: Clinical cure rates were similar at the test-of-cure visit for evaluable patients in the clarithromycin ER group (97%, 298/307) and clarithromycin IR group (98%, 300/307) (95% CI (-3.2, 1.9)). The bacteriological cure rate was 89% and the pathogen eradication rate was 90% in both treatment groups. Resolution or improvement in cough, sputum production, sputum volume and sputum appearance was observed in > 90% of evaluable patients in each treatment group. The incidence of study drug-related adverse events was 6.6% (23/351) in the clarithromycin ER group and 5.4% (19/352) in the clarithromycin IR group. The most frequently occurring study drug-related adverse events were abdominal pain, diarrhea and taste perversion. CONCLUSION: Clarithromycin ER 500 mg once daily for 5 days is equivalent to clarithromycin IR 250 mg twice daily for 5 days in treating adults with ABECB. Both regimens were effective in resolving clinical signs and symptoms of ABECB and eradicating the target pathogens, and were well tolerated.

Acute Disease↗

Comparison of the efficacy and safety of travoprost with a fixed-combination of dorzolamide and timolol in patients with open-angle glaucoma or ocular hypertension.

PURPOSE: The purpose of this study was to compare travoprost (TRAV; travoprost 0.004%) and the fixed-combination of dorzolamide/timolol (DTFC; dorzolamide 2.0%/timolol maleate 0.5%) ophthalmic solutions for reducing intraocular pressure (IOP) in patients with primary open-angle glaucoma (OAG) or ocular hypertension (OHT). METHODS: This was a randomized single masked, study with parallel controls. The TRAV group (n = 29) dosed once daily at 9:00 PM while the DTFC group (n = 27) dosed twice daily at 9:00 AM and 9:00 PM. IOP was measured at baseline, and following 3 weeks and 6 weeks of treatment at 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. RESULTS: Mean average IOP reductions from baseline during the course of the day were 7.5 (32.7%) and 7.1 (30.7%) mmHg for TRAV and 4.8 (23.1%) and 4.5 (21.7%) mmHg for DTFC at 3 weeks and 6 weeks, respectively. The greater IOP reduction for patients receiving TRAV was statistically significant at both the 3 and 6 week visits when averaged across all four time points (p < 0.01). The two products were well-tolerated over the course of the 6 week study. Some factors such as taste perversion were reported more often in the DTFC group. CONCLUSIONS: Travoprost monotherapy provided better efficacy in terms of IOP reduction and percentage of IOP reduction compared to dorzolamide 2.0%/timolol maleate 0.5% fixed combination.

Cloprostenol↗

Reconsidering the public health failings of the criminal justice system: a reflection on the case of Scott Ortiz.

Throughout most of the world, the primary response to the health and social impacts of illicit drug use has been to intensify the enforcement of drug laws. The consequences of this policy approach include an unprecedented growth in prison populations and increasing concerns regarding drug-related harms within prisons and without, including increased risk of HIV and hepatitis C (HCV) infection. This has led to calls from public health and prisoner advocacy groups to prison authorities to improve health services available in the community and those available to prisoners. While considerable progress has been made with respect to the growing implementation of HIV and HCV prevention measures within some nations' prisons, the case of Scott Ortiz illuminates a new set of challenges for prisoners and their advocates as judges often have a faulty understanding of public health arguments and data. In this case we see one such instance where a judge acts in ways not rooted in sound public health evidence or practice to produce a perverse outcome that violates both sound medical and judicial objectives.

Editorial↗