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[The search for meaning--the subject and freedom, a psychoanalytic contribution].

Behaviour or symptoms of neurotic nature are characterized as actions provided we succeed in uncovering their "secret motives" by construction or reconstruction. I. e. we may say insofar we succeed in describing the "whither", the "what for" (S. Freud), to which necessarily belongs "from where" (s. Freud, 1916/17, p. 284, 277) we find sense in nonsense. We also say, that sense already was in existence insofar defense mechanisms were operating preventing its overt expression. But we say sense and rationality have been constituted insofar something, which has never been translated into conscienceness, was raised to the level of language. Both processes take place during the psycho-analytic situation. The following preconditions are apparently necessary for their realization: a) the experience of the acknowledgement of a basic drive-wish by the therapist. This event has the character of evidential nature and as to this is in itself preverbal. Nevertheless we need a verbal phrasing of the corresponding interaction and the accompanying emotion in order that both may be included into the executive power of the ego, i.e. the subject. The strict obedience to the rules of a setting which bind both, patient and therapist at the same time. Because of this a firm basis exists which cannot be doubted. It forms the common background object (J. Grotstein) by which and through which both partners of the dialogue may be "at-one" with one another and to which they may also return insofar further developmental events of their interactional process produce alienations and is pushing them to turn to different external objects. Insofar processes as just alluded to take place, the subject is predicated in a play of argumentated reasoning. And if secret motives and hidden reasons concerning the presented modality of the subject's actions are understood, the subject itself realizes, that it has its origin not in its products but in a negation, in a "zero" position which in itself is a equivalent of freedom. In order that interpretative work in the service of the aims just mentioned may become possible, there are some other preconditions to be fulfilled by the therapist: a) the attitude of "evenly hovering attention" (S. Freud) because it is this attitude which makes the therapist receptive for emotional cathexis, originating in the patient's unconscious.(ABSTRACT TRUNCATED AT 400 WORDS)

Freedom↗

The last resort: regulation by law.

Within the health professions the diminished constraint of conscience and custom upon aggrandizement, acquisitiveness, and exploitation has given rise to the increased role of the government in regulating health care delivery. This situation will continue to exist in direct proportion to the public's convictions that the private sector is incapable of satisfying public expectations. Conversely, when the health care profession, as a whole, recommits itself to a sense of stewardship and accountability to patients and the community, the present system of regulation will pass.

Delivery of Health Care↗

[Transcultural social psychiatric treatment. Case report of a suicide attempt].

This article reports on the treatment of a young Moroccan woman in a psychiatric department located near the patient's domicile. This woman suffered under the mental stress imposed by an unwanted pregnancy leading to a severe mental and social conflict with the traditional cultural values and standards upheld by her family and troubling her conscience. The aetiology is discussed on the basis of the hypothesis that the conflict of loyalties of immigrants between traditional cultural standards and those of their present country of residence can develop into a cultural intrafamilial conflict in the minds of the younger, second generation. The article concludes with suggestions to achieve therapeutic orientation aids in the treatment of patients who have their roots in countries with an entirely different pattern of culture. Two suggestions are underlined: on the one hand, to enlist the help of a person from the same country of origin as the patient, who will be able to aid the therapist with relevant information; and, on the other hand, to include the family of the patient in the overall treatment concept.

Acculturation↗

Healthy personality: toward a unified theory.

It is argued that healthy personality is potentially as identifiable a pattern as is any diagnostic category and is not equivalent simply to "normality." In moving toward a theory of psychological health one needs to examine structure and dynamics with respect to the functions of instigation, regulation, meaning, and style. Psychoanalytic theory is taken as a point-of-departure. Viewed as a theory of neurosis, psychoanalysis does not provide an adequate treatment of ego-constructive functions, components of the superego (aside from conscience in a negative sense), or human motivation. Humanistic theory helps by focussing on health, although it falls short with regard to motivation. The essential properties of healthy humanness emerge as integration among the structures of personality and progression in the dynamics of personality functioning. Four major pathways in development are outlined to highlight how health differs from other patterns.

Biological Evolution↗

The anonymous letter writer--a psychological profile?

Anonymous letters fall into many categories--threats, obscene messages, racial slurs, extortion demands, guilty conscience statements, stool pigeon letters, robbery or burglary notes, and so forth. These are examined by the document examiner for any information that may lead to the identity of the writer. Such examinations involve unusual aspects of paper or envelopes, watermarks, detection of indented impressions, and so on, and also a comparison with previous anonymous submissions. Several cases will be discussed where, additionally, psychological profiles of the writer were produced by a psychiatrist and a psychologist, based upon the content of the letters.

Crime↗

Plaintiffs' view of malpractice litigation.

All of us want to improve the quality of practice in our professions and develop methods for ridding ourselves of the incompetent practitioner. Unfortunately, PSROs and state licence review committees have proved completely inadequate. Committed dentists, doctors, and lawyers are as frustrated as the general public when they attempt to establish reasonable standards by which to police their respective professions. Although no one likes to be sued, I would suggest that the private lawsuit has developed into the most helpful tool for accomplishing mutual interprofessional aims and upgrading all of the professions. Certainly the competent individual who makes an honest mistake that causes harm should be financially responsible to the injured party. More importantly, especially since most lawsuits involve in minority of practitioners who hurt the public and the profession, both in stature and financially through increased insurance rates, the malpractice lawsuit provides a fact-gathering process upon which both education and discipline can be predicted. Individual dentists, when they see examples of consistently poor work, are still understandably reluctant to file charges. They have enough to occupy their time in keeping up with their own practices and continuing education. They are understandably reluctant to become self-appointed policemen or keepers of the community conscience. Where, however, the information can be brought to the attention of a dental society, with the facts already marshaled through the litigation process, such groups have in recent years been much more ready to act. Since their action comes as a response to demands and pressures external to the profession, it is more easily accepted by other dentists, and therefore more likely to be effective.

Defensive Medicine↗

[Haemophilus influenzae meningitis. Review of 21 cases].

Twenty-one cases of "Haemophilus influenzae" meningitis occurred over a seven year period. An ampicillin-resistant strain was isolated in three (14,2%), but the percentage of ampicillin-resistant strains rose to 33% over the last two years, in meningitis and to 38% in all patients whose blood or CSF grew "Haemophilus influenzae". One case (4,7%) had severe neurologic damage, and 3 (14%) had minor damage. The estimated duration of symptoms prior to proper treatment correlated with duration of fever conscience depression, and hospital stay. Both of the patients with symptoms prior to treatment lasting over 72 hours had sequellae. Chloramphenicol should be included in the therapy of every patient suspected of having severe "Haemophilus influenzae" infection in our region.

Ampicillin↗

[Proposal for a project in psychotherapeutic strategy in behavior disorders].

Considerations are reviewed that do not permit any separation "from the unconscious", conceived as a reality which, together with the conscience, operates as a behavioural regulation factor through a set system that regulates behaviour by giving meaning to incoming information and giving a sense to experience. Mention is made of concepts of anxiety, removal and catharsis, and to recent research on the functions of the cerebral hemispheres. A psychotherapeutic strategy is proposed, finally, consisting of an analysis of a subject's history in a state of relaxation with guided associations, over the time span, along chains of mental content; and in the restructuring of sets through appropriate techniques.

Behavior Therapy↗

[Transference and countertransference in Gestalt therapy].

The aim is to demonstrate the presence of transference within Gestalt Psychotherapy, opinion not shared by many gestaltists. For this purpose she includes Freud's findings and comments on transference. She also takes into consideration Jung's and Melanie Klein's concepts on transference. The author concludes that transference is in Psychoanalysis a decisive concept in diagnosing and defining a prognosis. She refers to the fact that in Gestalt Psychotherapy the patient projects on the therapist disturbed aspects of his personallity as well as healthy ones, which determines the characteristics of the relationship. In Gestalt Therapy transference is made easy by the self-responsibility the patient has to assume in the process. Within this frame-work some of the techniques which facilitate the use of transference are mentioned: gestual observation, conscience awareness, an alliance with the healthful aspects of the patient, work in the "here-and-now", clarifying projections, switch from environmental support to inner support.

Countertransference↗

Oedipal grief: mourning or melancholia?

A discussion of "Oedipal Grief" by Robert May, Ph.D. A clinical syndrome seen in late adolescent men, oedipal grief refers to a depressive state sustained by a vengeful conscience and a pattern of self-punitive acting out. The psychopathology of this syndrome is clarified and differentiated sharply from the normal developmental process of grieving the loss of an idealized oedipal father. As a form of developmental melancholia, the repressed ambivalence and weakening of the ego in this syndrome is highlighted. May's reconceptualization of the structural-instinctual model of the superego and ego ideal is then critically reviewed; his tendency to reduce oedipal to preoedipal developmental phenomena is noted. A more developmentally differentiated theoretical model is suggested in terms of the incomplete internalization of the functions of self-control and self-esteem in the type of adolescent personality organization which underlies, and is perpetuated by, the psychopathology in the oedipal grief syndrome. The main task of brief psychotherapy is thus to promote the ego's capacity to tolerate increased inner conflict so that a developmental shift toward greater internalization can take place. The skillful treatment conducted by May is reinterpreted in these terms; and the therapeutic facilitation of adolescent grieving is placed in the context of structural-developmental change.

Child Development↗

Sex offences.

The investigation of offences involving sexual assaults and the examination of the victims of such crimes, are matters of concern to the community, to medical people and to law enforcement agencies. Throughout the world, much thought has been given to these matters during the last few years. The subject has stimulated anger and frustration as well as sympathy. The public conscience has been stirred and professional groups--doctors, lawyers, legislators and law enforcement agencies--goaded on many occasions by feminist groups, have deliberated the various aspects of this problem. A deal of practical advice has been given on this subject and throughout the world there has been a number of different approaches to the manner in which the medical examination of these victims is handled.

Australia↗

[Value of continuous electrocardiographic monitoring of patients with syncope. Results of a prospective study].

AIM: Syncope, a temporary loss of conscience, is a frequent cause for consulting the family doctor or more often being brought to the hospital emergency ward. In order to evaluate the importance of the continuous recording of ECG in the formulation of the diagnosis, the relevant data were extrapolated from more general data in the prospective study. MATERIAL: A total of 194 patients were enrolled whose diagnosis was divided into three distinct stages. Continuous echographic registration using Holter's method and/or bedside monitoring was included in the 2nd stage and was performed in 134 patients. RESULTS: 102 out of 134 patients (76.11%) showed rhythm alterations: varying degrees of atrio-ventricular block were recorded in 6 patients; supraventricular arrhythmia in 73 cases which were divided according to a modified to a modified version of Lawn's classification. Continuous ECG recording alone proved decisive in formulating a diagnosis in 6 patients (one of which together with echocardiogram): in 2 patients due to the presence of complex ventricular extrasystoles; in 4 due to torsion of the tip, sinusal arrest, cardiac arrest, supraventricular tachycardia with aberrant intraventricular conduction, respectively. CONCLUSIONS: Especially when standard surface ECG is carried out rapidly following an acute attack, continuous ECG recording is of scant diagnostic value due to the etiological definition of syncope. But due to its moderate cost and non-invasive character it is worth performing in syncopes of suspected cardiogenic etiology with a more severe prognosis.

Aged↗

[Possibilities and limitations of immunosuppressive therapy for glomerulonephritis].

Possibility and necessity of the immunosuppressive treatment is considerably determined by the underlying pathologo-anatomical substrate. The uncertainty concerning the chances of the success of such a therapy for the individual patient at least still at present allows a latitude of estimation. From this results the demand for a particularly intensive conscience of the responsibility taken on by us in finding the decision.

Acute Disease↗

Caring for corpses or killing patients?

Care of patients in a persistent vegetative state raises serious ethical questions. Often misdiagnosed, this "new disease," which is the result of advancing medical technology, raises such serious issues as the definition of death, nurses' personal ethical and religious convictions, and the ethical integrity of the nursing profession. Conscience clauses that allow nurses to refuse to cause death in non-dying patients vary widely, but few, if any, address the situation of incompetent but non-dying patients.

Brain Death↗

[Partnership and role of the psychiatrist beside the mentally handicapped persons and their families].

Partnership and role of the psychiatrist beside the mentally handicapped persons and their families. The author analyses his 35 years long collaboration with parents and their associations, and the follow up of mentally handicapped persons themselves. The author questions:--the generalisation of debatable theories without enough explicativity, which makes difficult the "therapeutic alliance" with the parents--the deficiency of educative projects--the doubtful reactions from the responsibles of parents associations in the scientifical spheres, and their refusal to make up their mind with some incomplete results of education. However, the collaboration with most of the parents is usually efficient and pleasant. It seems difficult to manage the psychopedagogy with the toddlers and the polyhandicapped persons without them. Finally, the author insists on the necessity of a patient psychological preparing of the handicapped person, in order he becomes conscience of his difference. Argument for a reflexion about each one role and responsibility, for a real partner-ship, with harmony and complementarity.

Family↗

Residents' attitudes to training in ethics in Canadian obstetrics and gynecology programs.

OBJECTIVE: To determine residents' attitudes toward their current training in ethics, including their preferred learning format, time commitment, and the influences of training and personal background on their views and decision-making process. METHOD: All 203 residents from English-speaking Canadian obstetrics and gynecology programs were mailed an 18-question, numerical-response questionnaire in prestamped return envelopes. One hundred thirty-one residents (64.5%) responded (81 to the first mailing and 50 to the second). RESULTS: The number of hours in the residency program devoted to ethical issues correlated positively with the residents' perception of the residency program in shaping their ethical views (P = .015, r = 0.22). Of the respondents, 44.7% preferred case presentations as their learning format and 30.7% ranked seminars as their first choice. Informal discussions and rounds were less popular, and lectures were considered least appropriate by 69.3%. When asked what most influenced the residents' ethical decision-making process, 34.2% indicated family views, 17.1% undergraduate teaching, 15.4% religious background, 12.8% views of consulting staff, 11.1% residency training, and 9.4% peer attitudes. Sixty-eight percent of residents felt that their training in ethics during their residency program should be increased; this may reflect response bias. A position of conscience conflict during residency training was reported by 28.9% of residents. CONCLUSION: Findings from this survey support the benefit of more discussion of ethical issues during residency programs, particularly with the use of case presentations.

Attitude↗

[Pituitary apoplexy].

Pituitary apoplexy results from necrosis or haemorrhage of a pituitary adenoma. This rare complication occurs in 2 to 10% of operated adenomas. The acute form results from massive intrapituitary bleeding leading to violent headache, meningeal signs, impaired conscience and ophthalmology signs, basically bilateral blindness. Associated signs are frequent including paralysis of the oculomotor nerves, epilepsy seizure, hemiplegia. Diabetes insipidis is exceptional. In less acute forms, the sudden nature of the headache and ophthalmology signs can suggest diagnosis. Standard X-ray reveals destruction of the sella turcica. Computed tomography shows either a haematoma or a cystic cavity in the pituitary gland which must be perfectly described together with the integrity of the bone structures due to the risk of lysis. Magnetic resonance imaging is an essential technique which can be used to describe the volume and suprasellar extension of the tumour, its texture, possible compression of adjacent structures and determine the age of the haemorrhage. This imaging technique can also isolate rare optochiasmatic apoplexia requiring intracranial evacuation. Emergency surgery is mandatory for most all authors. Rhinal-septal decompression is usually used, but the intracranial route may be preferred for very large suprasellar tumours. Medical treatment alone may be successful for small prolactin adenomas. Outcome depends on the time lapse to decompression. Optic nerve recovery is usually possible if the delay is less than 7 days. Cranial nerve recovery is less dependent on the time interval. In all cases hormone substitution is required.

Adenoma↗

[Acute poisoning caused by hydrogen sulphide: clinical features of 3 cases].

We describe three cases of acute intoxication by hydrogen sulphide which were produced after remaining between 50 and 60 minutes inside a cellulose tank. The three patients had loss of conscience. One of the patients developed a persistent vegetative state; another patient recovered although with neurological post-anoxic sequelas and the third case completely recovered one week after his hospitalization. The patients underwent symptomatic treatment and the environmental concentrations of hydrogen sulphide were measured at the site of the accident. Finally, the application of preventive measures is stressed.

Adult↗