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PubMed1983

The analyst and the patient's object world: notes on an aspect of countertransference.

I have discussed an aspect of the problem of countertransference that has received little comment--the relation of the analyst to objects in his patient's world. Emotional reactions stimulated in the analyst by his perception of such objects can have a profound effect on the course and outcome of his analytic work. Such responses are a product of complex interactions between the impulses, affects, fantasies, and defenses evoked in the therapist by the mental representations he has formed of these objects. Such objects, in fact, can have a variety of meanings for the analyst. Not only are they related to self-and object representations past and present, but they may, in his imagination, be part of a network of interactions involving the patient, his family, and other of his objects as the result of the reawakening in the analyst of fantasies, memories, and expectations derived from his sibling and family relations. Emotional responses aroused in the therapist by the patient may also be displaced onto objects in the patient's world and not be recognized as countertransference phenomena. Finally, I have commented on the way that reconstructions can be influenced by the analyst's perceptions of his patients' objects, and I have made some note of the special situation when an object in the patient's life is also known to the analyst. While awareness of his conscious attitudes and feelings toward such objects can serve a useful function for the analyst, too complacent an attitude regarding the protective value of such self-awareness may make difficult his recognition of the link between the image of the object known to both patient and analyst and the reawakened self- and object images of the analyst's childhood--a link that, in fact, constitutes the deepest source of countertransference difficulties.

Adolescent↗
PubMed2000

Affect and pictographic image: the constitution of meaning in mental life.

The author explores the processes of revealing, creating and working through new meaning in mental life and relates these processes to specific methods of producing representations of emotional experience through their transformation into unconscious symbolism in the form of imagery. Drawing on several dreams and other experiences from a detailed clinical case, the author argues for the value of considering three interpenetrating levels of meaning that operate simultaneously in mental life, namely hidden meaning, absent meaning and potential meaning: 'hidden' meaning resulting from dynamic forms of repression, absent meaning from a pregnant pressure exerted on psychic life by unconscious internal objects whenever any new emotional situation confronts the ego. Absent meaning is not just waiting in the unconscious to become explicit in a unique form. It is in its very nature to remain partially absent and it can never be rendered wholly conscious. All symbolic constructions that are expressed at first by unconscious imagery found especially in dreams are attempts to capture and represent the absent meaning. The concept of potential meaning refers to experiences produced by the interpretation of absent meaning, and consists of a specific case of this latter. Potential-meaning, when interpreted, rearticulates meanings on a specific symbolic field, and opens up new experiential possibilities, thus creating new meanings that expand the possibilities for emotional development. The author's ideas draw on the formulations of Aulagnier, Bion, Ferro, Green and Khan.

Affect↗
PubMed1991

Paranoid phenomena and pathological narcissism.

Paranoid phenomena can be seen to arise from pathological narcissism. As a result of certain kinds of trauma to the ego-ideal and/or losses of important self-object relationships, the self becomes dislodged from internal agencies and representations. Narcissistic cathexis of the self to these internal psychic structures loosens and hope, aspiration, affection and will become markedly diminished. Meaningful goals and choices become impossible to adopt and make. The paranoid patient is internally at "loose ends"; he is lost. Tragically, being gripped by the paranoid condition and its manifest delusional system is the only kind of security that the paranoid patient knows. No wonder it is so hard to give up. The vulnerability to paranoid phenomena may be seen to be a result of past experiences of subversion of "selfhood." In significant ways, the patient vulnerable to paranoid phenomena has not been adequately attended nor adequately "left alone." The self can be seen as arising out of crucial mother-infant exchanges that are paralleled by interactions between developing internal psychic structures. Out of these "reflections," the self is born. The narcisstic cathexis of self to the ego, superego and ego-ideal is the result of self-expression. If full self-ownership has not been possible then self-expression is vulnerable. Given these understandings of the relationship between paranoid phenomena and pathological narcissism, treatment will focus on reducing the threats to selfhood, refinding the self, and reestablishing ties to internal sources of affection, initiative and aspiration.

Ego↗
PubMed2006

[Post-traumatic psychosis: the contribution of an acute post-immediate trauma to a dynamic theorization].

SUMMARY: In his recent publication (2004), in which he favors the psycho-dynamic approach, M. Bertrand underlines the importance of traumatic matter at the heart of new clinical, methodological and epistemological challenges of psychopathology. TRAUMATIC PSYCHOSIS CONCEPT: Our contribution ("post-traumatic psychosis") comes within that prospect in reference to the semiology of traumas generated by extreme situations, such as the tsunami in South Asia (December 2004), the terrorist attacks in Madrid (March 2004) or the hostage taking in North Ossetia (September 2004). Four principle sets of themes lead us to suggest a traumatic psychosis when the person shows symptoms of a neurotic psychic structure: 1. There's no traumatic representation or psychic inscription of the event. Sideration (and its stupor-like confusion symptoms) or panic flight (together with hallucinations or acute delirious fits) often illustrate this first clinical aspect. 2. According to the psychodynamic frame of reference, psychic processes tend to ignore the pleasure/displeasure principle. They are governed by the "invasion" of affects of pain and compulsion to repeat. 3. The models of neurosis and psychic conflict are not efficient in the management of the "quota of affect" and the drive influence. 4. It would be necessary to add, from a psychopathological point of view, the appearance of temporary fits of mental confusion, self-destructive and autolysis behavior. CLINICAL FEATURES: The frame of reference of a DSM IV type "descriptive" psychopathology (ie acute Stress Disorder) seems to de inadequate to convey the implemented post traumatic stakes. If trying to soothe the symptoms is undeniably important, psychic disorganizations that generate a semiology that is essentially present in the symptomatology of the psychoses cannot be ignored. A first clinical approach makes it possible to specify the argumentation of our proposal: "a post-traumatic psychosis". It is supported by five main syndromic classes: 1) the symptoms are often more or less temporary delirious fits (delirious ideas or perceptions of a persecutory, cenesthetic or hypochondriac nature), mental confusion (oneiroid state, anxiety and stupor), phases of depersonalization and derealization, severe death pangs, serious physical disorders, divides close to schizophrenic-type dual personalities; 2) the adhesiveness marks the impossibility for the victims to keep away from a trauma. The objects are bound, persecuting and adhesive; 3) traumatic temporality imposes a factual and current omnipresence of the trauma. It destroys the temporal projections of the patient as well as an anamnesic reconstruction; 4) the "traumatic body" is not that of hysterical neurosis conversions. The somatic semiology marks operational-type functioning (P. Marty); 5) traumatic compliance doesn't work on the level of facilitations that lead to the formation of symptoms. The identity structure appears disorganized by the dismantling of the primary psychic envelopments. PSYCHOPATHOLOGICAL ASPECTS: A second theoretical approach makes it possible to promote this immediate psychotic-type post-traumatic psychopathology. Four considerations of fundamental psychopathology support our contribution: 1) Pictogramic inscription. The severe traumatism does not produce the polarity required for the process of "self-fathering" described by P. Aulagnier in connecting with original processes. Traumatic adhesiveness does not separate the victim from the trauma. It splits the necessary mediation spaces and distance for the emergence of representation processes. 2) Pain affect. The pain affect generated recalls the first experiences of the newborn, primitive agony and anaclitical collapse; the "narcissistic contract" is broken and the patient lives without a secure base or a sufficiently good and supporting psychic container (D.W. Winnicott). 3) Anxiety status. The anxiety is not of neurotic nature but truly annihilating. It is often similar to anxieties caused by disasters, psychoses due melancholy (H. Ey) or more "archaic" anxieties that have been observed in hebephrenic pathologies. 4) Body dismantling. The trauma results in "mute somatizations that cannot be symbolized" (M. Bertrand). They appear in sensory outward signs such as dermatosis, pruritus, diarrhea, hemorrhagic periods or persistent headaches for example. These two clinical and theoretical aspects of the severe forms of trauma confirm the unconscious traumatolytic aim of the victim's psychological destruction. The semiological forms most impervious to therapeutic processes seem to be, in reference to hostage-takings or terrorists acts, those where the patient was conformed with a trauma "that was not carried out" like mock hangings or executions. Suicidal dimension seems to be the ultimate recourse so as not to sink into insanity and to keep a subjective position when faced with barbarian figures.

Affect↗
PubMed1995

Adolescent character formation and psychoanalytic theory.

The foremost implication of the Freudian theories of adolescence has been that the analyst enters into an alliance with the patient's developmental process. During sessions, stock is routinely taken of the adolescent patient's defenses and drive fixations. The interpersonal and object relations theories of adolescents' character formation varied with each other and also with the assumptions of classical Freudian metapsychology. Yet, Sullivan, Fairbairn, and Winnicott all stressed relatedness in character formation. They each urged that the attitudes of the actual person in significant relationships, as well as the internal representations of the self and the object, shaped the character tendencies of the child or adolescent. Sullivan was very outspoken about his belief that there could be no uniformly valid theory of character, because people are unique. However, for Sullivan, the needs for the validation of self-worth, and for freedom from anxiety, were universal stimuli for the increasing organization of character trends. In both interpersonal theory and object relations theories, dissociative processes were of paramount importance as defensive operations. Dissociation by the adolescent resulted in further instances of ego splitting (for Fairbairn), of the bad me (for Sullivan), and of the false self (for Winnicott). Fairbairn, and to some extent Winnicott, used the language of classical Freudian theory in order to shape an object relations theory of adolescent development. In spite of their theoretical differences, Sullivan, Fairbairn, and Winnicott spoke with a singular voice in dismissing the exclusive significance of libidinal fixations in character consolidation. I now wish to review Freud's case of Dora as an addendum to this short critical appraisal. The analysis of Dora readily lends itself to a discussion of the confluence of the psychoanalytical models' clinical theories. Dora's unfortunate experience in treatment offered a compelling example of the precariousness of adolescents' adjustment in the midst of developmental and family turmoil.

Adolescent↗
PubMed2002

Comparison of linear-scaling semiempirical methods and combined quantum mechanical/molecular mechanical methods for enzymic reactions. II. An energy decomposition analysis.

QM/MM methods have been developed as a computationally feasible solution to QM simulation of chemical processes, such as enzyme-catalyzed reactions, within a more approximate MM representation of the condensed-phase environment. However, there has been no independent method for checking the quality of this representation, especially for highly nonisotropic protein environments such as those surrounding enzyme active sites. Hence, the validity of QM/MM methods is largely untested. Here we use the possibility of performing all-QM calculations at the semiempirical PM3 level with a linear-scaling method (MOZYME) to assess the performance of a QM/MM method (PM3/AMBER94 force field). Using two model pathways for the hydride-ion transfer reaction of the enzyme dihydrofolate reductase studied previously (Titmuss et al., Chem Phys Lett 2000, 320, 169-176), we have analyzed the reaction energy contributions (QM, QM/MM, and MM) from the QM/MM results and compared them with analogous-region components calculated via an energy partitioning scheme implemented into MOZYME. This analysis further divided the MOZYME components into Coulomb, resonance and exchange energy terms. For the model in which the MM coordinates are kept fixed during the reaction, we find that the MOZYME and QM/MM total energy profiles agree very well, but that there are significant differences in the energy components. Most significantly there is a large change (approximately 16 kcal/mol) in the MOZYME MM component due to polarization of the MM region surrounding the active site, and which arises mostly from MM atoms close to (<10 A) the active-site QM region, which is not modelled explicitly by our QM/MM method. However, for the model where the MM coordinates are allowed to vary during the reaction, we find large differences in the MOZYME and QM/MM total energy profiles, with a discrepancy of 52 kcal/mol between the relative reaction (product-reactant) energies. This is largely due to a difference in the MM energies of 58 kcal/mol, of which we can attribute approximately 40 kcal/mol to geometry effects in the MM region and the remainder, as before, to MM region polarization. Contrary to the fixed-geometry model, there is no correlation of the MM energy changes with distance from the QM region, nor are they contributed by only a few residues. Overall, the results suggest that merely extending the size of the QM region in the QM/MM calculation is not a universal solution to the MOZYME- and QM/MM-method differences. They also suggest that attaching physical significance to MOZYME Coulomb, resonance and exchange components is problematic. Although we conclude that it would be possible to reparameterize the QM/MM force field to reproduce MOZYME energies, a better way to account for both the effects of the protein environment and known deficiencies in semiempirical methods would be to parameterize the force field based on data from DFT or ab initio QM linear-scaling calculations. Such a force field could be used efficiently in MD simulations to calculate free energies.

Binding Sites↗
PubMed2005

The relationship between object files and conscious perception.

Object files (OFs) are hypothesized mid-level representations which mediate our conscious perception of persisting objects-e.g. telling us 'which went where'. Despite the appeal of the OF framework, not previous research has directly explored whether OFs do indeed correspond to conscious percepts. Here we present at least one case wherein conscious percepts of 'which went where' in dynamic ambiguous displays diverge from the analogous correspondence computed by the OF system. Observers viewed a 'bouncing/streaming' display in which two identical objects moved such that they could have either bounced off or streamed past each other. We measured two dependent variables: (1) an explicit report of perceived bouncing or streaming; and (2) an implicit 'object-specific preview benefit' (OSPB), wherein a 'preview' of information on a specific object speeds the recognition of that information at a later point when it appears again on the same object (compared to when it reappears on a different object), beyond display-wide priming. When the displays were manipulated such that observers had a strong bias to perceive streaming (on over 95% of the trials), there was nevertheless a strong OSPB in the opposite direction-such that the object files appeared to have 'bounced' even though the percept 'streamed'. Given that OSPBs have been taken as a hallmark of the operation of object files, the five experiments reported here suggest that in at least some specialized (and perhaps ecologically invalid) cases, conscious percepts of 'which went where' in dynamic ambiguous displays can diverge from the mapping computed by the object-file system.

Attention↗
PubMed2003

Sonic intelligence as a virtual therapeutic environment.

This paper reports on the results of a research project, on comparing one virtual collaborative environment with a first-person visual immersion (first-perspective interaction) and a second one where the user interacts through a sound-kinetic virtual representation of himself (avatar), as a stress-coping environment in real-life situations. Recent developments in coping research are proposing a shift from a trait-oriented approach of coping to a more situation-specific treatment. We defined as real-life situation a target-oriented situation that demands a complex coping skills inventory of high self-efficacy and internal or external "locus of control" strategies. The participants were 90 normal adults with healthy or impaired coping skills, 25-40 years of age, randomly spread across two groups. There was the same number of participants across groups and gender balance within groups. All two groups went through two phases. In Phase I, Solo, one participant was assessed using a three-stage assessment inspired by the transactional stress theory of Lazarus and the stress inoculation theory of Meichenbaum. In Phase I, each participant was given a coping skills measurement within the time course of various hypothetical stressful encounters performed in two different conditions and a control group. In Condition A, the participant was given a virtual stress assessment scenario relative to a first-person perspective (VRFP). In Condition B, the participant was given a virtual stress assessment scenario relative to a behaviorally realistic motion controlled avatar with sonic feedback (VRSA). In Condition C, the No Treatment Condition (NTC), the participant received just an interview. In Phase II, all three groups were mixed and exercised the same tasks but with two participants in pairs. The results showed that the VRSA group performed notably better in terms of cognitive appraisals, emotions and attributions than the other two groups in Phase I (VRSA, 92%; VRFP, 85%; NTC, 34%). In Phase II, the difference again favored the VRSA group against the other two. These results indicate that a virtual collaborative environment seems to be a consistent coping environment, tapping two classes of stress: (a) aversive or ambiguous situations, and (b) loss or failure situations in relation to the stress inoculation theory. In terms of coping behaviors, a distinction is made between self-directed and environment-directed strategies. A great advantage of the virtual collaborative environment with the behaviorally enhanced sound-kinetic avatar is the consideration of team coping intentions in different stages. Even if the aim is to tap transactional processes in real-life situations, it might be better to conduct research using a sound-kinetic avatar based collaborative environment than a virtual first-person perspective scenario alone. The VE consisted of two dual-processor PC systems, a video splitter, a digital camera and two stereoscopic CRT displays. The system was programmed in C++ and VRScape Immersive Cluster from VRCO, which created an artificial environment that encodes the user's motion from a video camera, targeted at the face of the users and physiological sensors attached to the body.

Adaptation, Psychological↗
PubMed1995

A clerking tool for the patient record system.

1. BACKGROUND. The goal of the PEN&PAD (Elderly Care) project is to develop a patient record system to assist the many different professionals that care for patients in a hospital setting. At the core of the project is the use of structured data which can be reused in a variety of ways--both within the system for further manipulation and display, and externally for auditing and statistical purposes. To accommodate these needs, a compositional method of data entry called Structured Data Entry (SDE) was used in this application. SDE was developed in an earlier project PEN&PAD (GP)(1). Our application utilizes a network representation of the medical semantics that can be queried to obtain what is sensible to "say" about a particular concept. This functionality is contained within a separate application known as the Terminology Server (TeS), which has been developed within the GALEN project (2). The client application (the patient record system) requests information from the TeS which can then be used to produce compositional data entry forms that require the user to choose values for given attributes (e.g., if information pertaining to chest pain were being recorded, the attribute 'location' and a choice of possible values i.e., 'left' 'right' and 'bilateral' might appear on the form). Given the importance of capturing clinical information in a highly structured format, SDE is a valuable tool. However, its long term success depends on a very comprehensive model of the medical terminology corpus. This component is currently being studied by the GALEN team. 2. CURRENT WORK. We are developing a clerking tool to be used to create records for the newly admitted patient. The clinician seeks to identify a patient's problems based on physical examination and information obtained through conversation with the patient. Patients are usually admitted with a presenting complaint and obtaining more information about this complaint is an important part of the clerking process. While the physician may be able to use the clerking data to consider possible diagnoses right away, he/she often needs to review relevant body systems before a diagnosis is made. In traditional paper based clerking systems, notes are highly formalized but still subject to variation between clinicians. A typical clerking records information such as: 1) history of the presenting complaint; 2) previous medical history; 3) review of body systems; 4) medication; 5) social history; and 6) investigations. We have attempted to retain this clerking outline as much as possible, focusing primarily on the presenting complaint and review of body systems sections. To begin the clerking process, the user chooses a presenting complaint (from the list provided) to launch the 'clerking' window. Access buttons for the different clerking sections are positioned above a data entry window. This window contains a form for collecting information on the presenting complaint. The form is divided into sections to allow the user to record the absence or presence of an associated symptoms and other details. Free text comments can be added to the window, and a data display area shows information entered so far. The user can query the body system database by choosing a system from a menu. At this point the presenting complaint window is replaced by one on the body system in question. The user is free to switch back and forth between the presenting complaint and body system screens. On returning to a previously visited window, the user may pick up where he/she left off when exiting the window. Once the clerking is completed, the information is entered as a unit into the patient record with the date and clinicians name attached. Thereafter, the file becomes read-only. We are currently putting a prototype clerking system through field trials with clinicians from of a local hospital. In our demonstration, we hope to elaborate on these trials and their outcomes.

Admitting Department, Hospital↗
PubMedDate not supplied

[Validation study of the Depressive Experience Questionnaire].

Sidney Blatt, considering as being insufficient the categorical-symptomatic approach of depression, has worked out a theory of depression and psychopathology that integrates the contributions of psychoanalysis as well as cognitive and developmental psychology. Within a broad psychoanalytic framework, Blatt's formulation focus on the quality of interpersonal relationship, the nature of object representation and early life experiences. Personality development is viewed as the consequence of the interaction of 2 basic developmental tasks: the establishment of the capacity to form stable, enduring, mutually satisfying interpersonal relationships and the achievement of a differentiated, realistic, essentially positive identity. The relationship between these 2 developmental lines involves a complex dialectical process during which progress in each line is essential for progress in the other and which contributes to the development of both a sense of identity and the capacity for interpersonal relatedness. These developmental lines permit not only to define an during individual's primary personality configuration but also enable to identify cognitive structures that are inherent in various forms of psychopathology, including depression. Disruptions at different developmental stages create vulnerability to different subsequent psychological disturbances. Blatt characterised as anaclitic or dependent the axis concerned with interpersonal relationship and as introjective or self-critical the axis concerned with development of the sense of self and identity. Depressive Experience Questionnaire was developed by Blatt et al. to determine the validity of this model of psychopathology which emphazises continuities between normal and pathological forms of depression. The instrument was developed by Blatt et al. by assembling a pool of items describing experiences frequently reported by depressed individual. Sixty-six items were selected and administered to a large nonclinical sample (500 female and 160 male undergraduates). Principal component analysis within sex performed on the answers to DEQ confirmed his assumption in identifying two principal depressive dimensions. The first factor involved items that are primarily externally directed and refer to a disturbance of interpersonal relationships (anaclitism); the second factor consists of items that are more internally directed and reflect concerns about self-identity (self-criticism). A third factor emerged, assessing the good functioning of subject and confidence in his resources and capacities (efficacy). Scales derived from these factors have high internal consistency and substantial test-retest reliability. The solutions for men and women were highly congruent. Factor structure has been replicated in several nonclinical and clinical samples, supporting considerable evidence to the construct validity of the DEQ Dependency and Self-criticism scales. An adolescent form of DEQ (DEQ-A) has successively been developed. Factor analysis revealed three factors that were highly congruent in female and male students and with the three factors of the original DEQ. The reliability, internal consistency and validity of DEQ-A indicate that the DEQ-A closely parallels the DEQ, especially in the articulation of Dependency and Self-criticism as two factors in depression. These formulations and clinical observations about the importance of differentiating a depression focused on issues of self-criticism from issues of dependency are consistent with the formulations of others theorists which, from very different theoretical perspectives, posit 2 types of depression, one in which either perceived loss or rejection in social relationships is central and the other in which perceived failure in achievement, guilt or lack of control serves as the precipitant of depression. These 2 types of experiences have been characterized as dominant other and dominant goal , as anxiously attached and compulsively self-reliant and as sociotropic and autonomous . Our work presents the results of a validation study of both forms of Blatt's questionnaire (for adults--DEQ--and for adolescents--DEQA) translated in French in a large population of normal subjects, aged 15 to 45 years. DEQ and DEQ-A were compared by inspection of items loading strongly on each factor and by correlation of the three factors of adults and adolescents. The exploratory factor analysis of DEQ and DEQA revealed three orthogonal factors, corresponding with Blatt's original dimensions. Consistency and external validity were adequate for all 3 factors of DEQ and DEQ-A. Anaclitism and self-criticism dimensions of DEQ and DEQ-A correlate positively with measures of depression (DSM-IV, Beck Depression Inventory), consistently with the results obtained by Blatt. Differently from this author, anaclitism appears to be less differentiated in males than in females, suggesting that the concept of dependence could assume different relevance for men and women.

Adult↗
PubMed2000

Gamma knife radiosurgery as a primary treatment for prolactinomas.

OBJECT: The purpose of this study was to estimate the efficacy of gamma knife radiosurgery (GKS) in controlling tumor growth and endocrinopathy associated with prolactinomas. METHODS: Between 1993 and 1997, 164 of 469 patients with pituitary adenomas treated by GKS harbored prolactinomas. The dose to the tumor margin ranged from 9 to 35 Gy (mean 31.2 Gy), and the visual pathways were exposed to a dose of less than 10 Gy. The mean tumor diameter was 13.4 mm. The mean follow-up time for 128 cases was 33.2 months (range 6-72 months). Tumor control was observed in all but two patients who underwent surgery 18 and 36 months, respectively, after GKS. Clinical cure was achieved in 67 cases. Clinical improvement was noted with a decrease in the hyperprolactinemia after GKS. Nonetheless, in 31 (29%) of 108 patients who were followed for more than 2 years no improvement in serum prolactin levels was demonstrated, although this could be normalized by bromocriptine administration after treatment. Nine infertile women became pregnant 2 to 13 months after GKS and all gave birth to normal children. There was no visual deterioration related to GKS. Five women experienced premature menopause. In these patients there was subtotal disappearance of the tumor and an empty sella developed. CONCLUSIONS: Gamma knife radiosurgery as a primary treatment for prolactinomas can be safe and effective both for controlling tumor growth and for normalization of prolactin hypersecretion. A higher margin dose (> or = 30 Gy) seemed to be associated with a better clinical outcome. Gamma knife radiosurgery may make prolactinomas more sensitive to the bromocriptine.

Humans↗