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PubMed2003

Survival and recovery of consciousness in anoxic-ischemic coma after cardiopulmonary resuscitation.

OBJECTIVE: In patients who remain unconscious after cardiopulmonary resuscitation (CPR) poor outcome may be predicted with several tests. To use these tests, knowledge of a priori chances of poor outcome after varying periods of unconsciousness is needed. This study is aimed at providing such data. DESIGN AND PATIENTS: Data regarding survival and recovery of consciousness were extracted from registry-based and prospective cohort studies of patients with anoxic-ischemic coma. A survival analysis was done using Kaplan-Meier estimates and 28-day outcomes were calculated for all patients unconscious after 24 h and 72 h, and 5 days, 7 days and 14 days after CPR. Patient characteristics and outcomes in our cohort were compared with those of published patient series. RESULTS: After 28 days, 27% of 172 patients from the two cohort studies were alive and conscious, 9% were still unconscious, and 64% had died. The proportion of patients who regained consciousness decreased from 34% of those unconscious within the first 6 h post-CPR to 13% of those still unconscious after 2 weeks. The proportion surviving in an unconscious state increased from 6% of patients who were unconscious initially to 33% of those still unconscious after 2 weeks. The chance of survival remained unchanged up to 7 days after CPR, irrespective of the duration of unconsciousness. Patient characteristics and outcomes in our cohort were comparable to data available from the literature. CONCLUSIONS: The a priori chances of (poor) outcome vary with the duration of unconsciousness after CPR. This study provides data for different time-intervals after CPR.

Adult↗
PubMed1994

Phantasy and its transformations: a contemporary Freudian view.

Over the past fifty years changes have occurred in the theoretical positions of the Contemporary Freudian and Klein groups in the British Society, but fundamental differences remain. This paper considers the meaning of the term 'the unconscious', with particular reference to the censorship lying between consciousness and the Preconscious system--or, in the authors' model, consciousness and the present unconscious. The distinction between the present unconscious and the past unconscious is described. Emphasis is placed on the difference between phantasies in the present unconscious, which exist in the 'here-and-now' and those in the past unconscious, which are for the most part reconstructions based--among other things--on the analyst's theories of mental functioning and of child development. Thus, transference phantasies are phantasies in the present unconscious. The authors go on to emphasise the implications of the distinction between the present and past unconsciouses for analytic work, stressing the need for focus on phantasies and associated conflicts in the present unconscious before turning their attention to reconstruction of the past. Finally, they point to the concept of dialogue with one's introjects (internal objects) as represented in unconscious phantasy, to the stabilising function of (present) unconscious phantasy and to the need to interpret conflict and resistance.

Adult↗
PubMed1999

The performance of electroencephalogram bispectral index and auditory evoked potential index to predict loss of consciousness during propofol infusion.

UNLABELLED: The bispectral index (BIS) of the electroencephalogram and middle latency auditory evoked potentials are likely candidates to measure the level of unconsciousness and, thus, may improve the early recovery profile. We prospectively investigated the predictive performance of both measures to distinguish between the conscious and unconscious state. Twelve patients undergoing lower limb orthopedic surgery during regional anesthesia additionally received propofol by target-controlled infusion for sedation. The electroencephalogram BIS and the auditory evoked potential index (AEPi), a mathematical derivative of the morphology of the auditory evoked potential waveform, were recorded simultaneously in all patients during repeated transitions from consciousness to unconsciousness. Logistic regression procedures, receiver operating characteristic analysis, and sensitivity and specificity were used to compare predictive ability of both indices. In the logistic regression models, both the BIS and AEPi were significant predictors of unconsciousness (P < 0.0001). The area under the receiver operating characteristic curve for discrete descending index threshold values was apparently, but not significantly (P > 0.05), larger for the AEPi (0.968) than for the BIS (0.922), indicating a trend of better discriminatory performance. We conclude that both the BIS and AEPi are reliable means for monitoring the level of unconsciousness during propofol infusion. However, AEPi proved to offer more discriminatory power in the individual patient. IMPLICATIONS: Both the bispectral index of the electroencephalogram and the auditory evoked potentials index are good predictors of the level of sedation and unconsciousness during propofol infusion. However, the auditory evoked potentials index offers better discriminatory power in describing the transition from the conscious to the unconscious state in the individual patient.

Aged↗
PubMed1997

Reverie and metaphor. Some thoughts on how I work as a psychoanalyst.

In this paper, the author presents parts of an ongoing internal dialogue concerning how he works as an analyst. He describes the way in which he attempts to sense what is most alive and most real in each analytic encounter, as well as his use of his own reveries in his effort to locate himself in what is going on at an unconscious level in the analytic relationship. The author views each analytic situation as reflecting, to a large degree, a specific type of unconscious intersubjective construction. Since unconscious experience is by definition outside of conscious awareness, the analyst must make use of indirect (associational) methods such as the scrutiny of his own reverie experience in his efforts to 'catch the drift' (Freud, 1923, p. 239) of the unconscious intersubjective constructions being generated. Reveries (and all other derivatives of the unconscious) are viewed not as glimpses into the unconscious, but as metaphorical expressions of what the unconscious experience is like. In the author's experience, when an analysis is 'a going concern', the analytic dialogue often takes the form of a verbal 'squiggle game' (Winnicott, 1971a, p. 3) in which the analytic pair elaborates and modifies the metaphors that the other has unself-consciously introduced. The analytic use of reverie and of the role of metaphor in the analytic experience is clinically illustrated.

Ego↗
PubMed1990

Readiness potentials preceding spontaneous motor acts: voluntary vs. involuntary control.

Libet et al. (1983) developed a method to compare the onset time of a readiness potential (RP) with the onset time of the corresponding intention to perform a spontaneous voluntary motor act. In relation to the onset of the RP, the time of conscious intention to move followed 350 msec later. From these results Libet (1985) concluded that the cerebral initiation of a spontaneous voluntary act begins unconsciously. We investigated the alternative interpretation that with the instruction to pay attention to feelings of 'wanting to move,' automatic and normally unconscious motor acts might have been brought to a level of conscious awareness. Therefore we conducted 3 kinds of experiment. In the first, RPs were measured from subjects performing unconscious movements. The second experiment was a replication of Libet's study while the third was a resting condition in which subjects looked for intentions to move introspectively. The results showed that RPs beginning approximately 500 msec before movement onset can be obtained with unconsciously as well as consciously performed spontaneous motor acts. The different scalp distributions of the two types of RP indicate that unconscious movements can be attributed to the activation of a contralateral process (lateral premotor system (LPS), primary motor cortex), whereas voluntary spontaneous motor acts seemed to be predominated by the medial premotor system (MPS). It is proposed that in the Libet situation focused attention on internal events led to the conscious detection of a normally unconscious process. This resulted in the activation of the MPS, especially the supplementary motor area (SMA), which released the starting signal for the execution of the motor act. We believe that the activation of the SMA and the urge to move occurred at the same time.

Adult↗
PubMed2004

Posttraumatic Stress Disorder in patients with traumatic brain injury.

BACKGROUND: Severe traumatic stressors such as war, rape, or life-threatening accidents can result in a debilitating psychopathological development conceptualised as Posttraumatic Stress Disorder (PTSD). Pathological memory formation during an alarm response may set the precondition for PTSD to occur. If true, a lack of memory formation by extended unconsciousness in the course of the traumatic experience should preclude PTSD. METHODS: 46 patients from a neurological rehabilitation clinic were examined by means of questionnaires and structured clinical interviews. All patients had suffered a TBI due to an accident, but varied with respect to falling unconscious during the traumatic event. RESULTS: 27% of the sub-sample who were not unconscious for an extended period but only 3% (1 of 31 patients) who were unconscious for more than 12 hours as a result of the accident were diagnosed as having current PTSD (P <.02). Furthermore, intrusive memories proved to be far more frequent in patients who had not been unconscious. This was also the case for other re-experiencing symptoms and for psychological distress and physiological reactivity to reminders of the traumatic event. CONCLUSION: TBI and PTSD are not mutually exclusive. However, victims of accidents are unlikely to develop a PTSD if the impact to the head had resulted in an extended period of unconsciousness.

Accidents↗
PubMed1999

Central nervous system manifestations of childhood shigellosis: prevalence, risk factors, and outcome.

BACKGROUND AND OBJECTIVE: Alterations in consciousness, including seizures, delirium, and coma, are known to occur during Shigella infection. Previous reports have suggested that febrile convulsions and altered consciousness are more common during shigellosis than with other childhood infections. Those reports, however, have been from locations where S dysenteriae type 1 was not common, thus making it difficult to assess the specific contribution that S dysenteriae type 1 infection, and Shiga toxin, might make to the pathogenesis of altered consciousness in children with shigellosis. In this study we seek to determine the prevalence, risk factors, and outcome of altered consciousness in children with shigellosis in Bangladesh, a country where infection with all four species of Shigella is common. We particularly focus on the importance of metabolic abnormalities, which we have previously shown to be a common feature of shigellosis in this population. METHODS: This study was conducted at the Diarrhea Treatment Centre of the International Centre for Diarrhoeal Disease Research, Bangladesh in Dhaka, Bangladesh, which provides care free of charge to persons with diarrhea. During 1 year, a study physician identified all inpatients infected with Shigella by checking the logs of the Clinical Microbiology Laboratory daily. Study physicians obtained demographic and historical information by reviewing the patient charts and by interviewing patients, or their parents or guardians, to confirm or complete the history of illness obtained on admission. Patients were categorized as being conscious or unconscious based on a clinical scale; having a seizure documented in the hospital; or having a seizure by history during the current illness that was not witnessed by medical personnel. Patient outcome was classified as discharged improved, discharged against medical advice, transferred to another health facility, or died in the Treatment Centre. Laboratory examinations were ordered at the discretion of the attending physician; all such information was recorded on the study form. Clinical management was by the attending physician. Factors independently predictive of a documented seizure, or of unconsciousness, were determined using a multiple logistic regression analysis. For this analysis variables associated with unconsciousness or a documented seizure in the analysis of variance or chi2 analyses were entered into the regression equation and eliminated in a backward stepwise fashion if the probability associated with the likelihood ratio statistic exceeded .10. RESULTS: During this 1-year study, 83 402 persons with diarrhea came to the Treatment Centre for care, and 6290 patients were admitted to the inpatient unit. Shigella was isolated from a stool or rectal swab sample of 863 (13.7%) of the inpatients. Seventy-one (8%) of the inpatients with shigellosis were >/=15 years old; 61 (86%) were conscious; 10 (14%) were unconscious; none had either a documented seizure or a seizure by history during this illness. Seven hundred ninety-two patients were <15 years old (92%); 654 (83%) were conscious; 73 (9%) were unconscious; 41 (5%) had a documented seizure (compared with >/=15-year age group); 24 (3%) had a seizure by history during this illness. Of the 41 patients with documented seizures, 19 (46.3%) had a seizure at the time of admission, and 22 (53.7%) had a seizure after admission. Twenty-five (61.0%) of the 41 patients with documented seizures were reported to have a seizure during this illness before coming to the Treatment Centre. Clinical features that are known to cause altered consciousness-fever, severe dehydration, hypoglycemia, hyponatremia, or meningitis-were present in 38 (92.7%) of the 41 patients in whom a seizure was witnessed and in 67 (91.8%) of the 73 patients who were unconscious. Nineteen (46. 3%) of the patients who had a seizure documented had two of these five features, 4 (9.8%) had three, and 1 (2. (ABSTRACT TRUNCATED)

Adolescent↗
PubMed1999

Comparison of bispectral EEG analysis and auditory evoked potentials for monitoring depth of anaesthesia during propofol anaesthesia.

We have compared the auditory evoked potential index (AEPIndex) and bispectral index (BIS) for monitoring depth of anaesthesia in spontaneously breathing surgical patients. Twenty patients (aged 17-49 yr) undergoing day surgery were anaesthetized with computer-controlled infusions of propofol. The mean (SD and range) of each measurement was determined during consciousness and unconsciousness and at specific times during the perioperative period. Mean values for AEPIndex during consciousness and unconsciousness were 74.5 (SD 14.7) 36.7 (7.1), respectively. BIS had mean values of 89.5 (SD 4.6) during consciousness and 48.8 (16.4) during unconsciousness. AEPIndex and BIS were greater during consciousness compared with during unconsciousness. The average awake values of AEPIndex were significantly higher than all average values during unconsciousness but this was not the case for BIS. BIS increased gradually during emergence from anaesthesia and may therefore be able to predict recovery of consciousness at the end of anaesthesia. AEPIndex was more able to detect the transition from unconsciousness to consciousness.

Adolescent↗
PubMed1984

Analyst involvement in the psychoanalytical impasse.

This paper develops the idea that a state of impasse is the objective towards which the patient tends and that this is in response to an unconscious fantasy whose essential aim is to paralyse the object's autonomy and the bond. The fact that in some cases this objective is brought about with the unconscious participation of the analyst is pointed out. This unconscious participation is distinguished from the conscious emotions that permit the diagnosis of the impasse. The manifest content of the verbal material reveals typical features of these states. One of them is the lack, or marked diminution, of representations expressed through visual images. When the representations become evident in the verbal material, it is a sign that the impasse is over and that the process has temporarily resumed its course. The process has unconscious representations which, on becoming evident, reveal the state of deadlock or development through which it is passing. The representations of the impasse situation are typical. Some of these, such as objects endowed with circular movement, static bodies lacking mobility, are pointed out. Verbal material is differentiated in two categories depending on its capacity to transmit or to conceal contents belonging to the unconscious. Material devoid of meaning is inherent to resistance. When the analyst is unconsciously involved in the patient's impasse, he tends to favour a kind of dialogue which is lacking in meaning and symbolic value. The symbol-forming function is not affected.(ABSTRACT TRUNCATED AT 250 WORDS)

Humans↗
PubMed1976

On the nature of brain stem disorders in severe head injured patients.

In head injured patients changes were found in the CSF levels of metabolites of the dopaminergic and the serotonergic neurotransmission (HVA and 5-HIAA). After the fifth day following trauma a significant decrease of the HVA levels in the lumbar CSF after probenecid treatment was found. The intensity of this decrease was found to be related to the severity of the trauma (period of unconsciousness), but not to the state of consciousness. Also the probenecid-induced 5-HIAA levels in conscious patients were decreased after the fifth post-traumatic day. In unconscious patients, the period of unconsciousness, particularly in the period of 5-20 days after trauma. Between 21 and 60 days after trauma the 5-HIAA concentrations in unconscious patients decreased remarkably, but they were still significantly higher than in the conscious patients. It can be concluded that during unconsciousness serotonergic neurons have a high rate of turnover, but that both neurotransmitter systems are damaged by the direct or indirect consequences of the injury.

Adolescent↗
PubMed1985

Awareness of cognitive defences and stress management.

There is considerable disagreement regarding whether defences operate unconsciously, represent deliberate styles of coping with problems, or fall somewhere between. The present study considered the role of awareness in mediating the relation between defence and stress by establishing whether the conscious or unconscious nature of a given defence was associated with a distinct level of stress. The results for projection and rationalization confirmed the classical Freudian version of defence as an unconscious mechanism that reduces the stress of painful thoughts. Unconscious projectors and rationalizers reported singularly low levels of stress over the previous year. Repression without awareness was associated with a distinctly high level of stress, whereas denial with awareness was related to lower stress. While these results provide some support for the view that defences must be unconscious to work effectively, they also suggest the diversity among defences in the role played by awareness in coping with stress.

Adult↗
PubMed2000

Public understanding of medical terminology: non-English speakers may not receive optimal care.

INTRODUCTION: Many systems of telephone triage are being developed (including NHS Direct, general practitioner out of hours centres, ambulance services). These rely on the ability to determine key facts from the caller. Level of consciousness is an important indicator after head injury but also an indicator of severe illness. AIMS: To determine the general public's understanding of the term unconscious. METHODS: A total of 700 people were asked one of seven questions relating to their understanding of the term unconscious. All participants were adults who could speak sufficient English to give a history to a nurse. RESULTS: Correct understanding of the term unconscious varied from 46.5% to 87.0% for varying parameters. Those with English as their first language had a better understanding (p<0.01) and there was a significant variation with ethnicity (p<0.05). CONCLUSIONS: Understanding of the term unconscious is poor and worse in those for whom English is not a first language. Decision making should not rely on the interpretation of questions using technical terms such as unconscious, which may have a different meaning between professional and lay people.

Adult↗
PubMed1984

The symbolic relationship of breast cancer patients to their cancer, cure, physician, and themselves.

This study examined the type of unconscious relationship patients had to their cancer and the extent to which the cancer exhibited its presence through the unconscious of the patients. Before having breast biopsies, 146 tumor patients, between the ages of 17 and 90, were given the Kahn test of symbol arrangement and the lifeline tests. Results of the study using a multivariate analysis of variance that covaried age supported the hypothesis that the presence of a malignant tumor was exhibited prior to biopsy through the unconscious of the patients. Second, compared to the benign tumor patients, the malignant tumor group unconsciously expressed their cure as being more remote. The results suggest that patients whose cancer was expressed through their unconscious before diagnosis may expect to die, despite medical advances which show that early breast cancer detection leads to greater chance of cure. Implications for psychotherapeutic interventions working with patients' belief systems are discussed.

Adolescent↗
PubMed2004

The conceptualisation of the psychical in psychoanalysis.

This article aims to clarify the psychoanalytic conceptualisation of the psychical, which includes a discussion of the relationship between consciousness and the unconscious. The unconscious is conceived of as being on the border between the so-called 'ego's conscious intending' and a rudimentary body-ego experiencing. Phenomenological ideas on the essence of consciousness are used in order to help delineate the crucial differences between consciousness and the unconscious. Only consciousness is characterised by an awareness of itself, that is; self-consciousness. Furthermore, consciousness is characterised by an intentional, synthesising capacity, whereas the functioning of the unconscious, in its most radical form, is the opposite of the intentionality of consciousness. It is argued that the unconscious pre-supposes certain pre-sexual processes, in the form of a body-ego's formation of continuity, coherence and wholeness. The body-ego belongs to the sphere of consciousness/self-consciousness, even if self-consciousness is only given implicitly in the body-ego and not as a fully fledged ego cogito. Attention is drawn to neglected issues in psychoanalytic theorising, namely self-consciousness and the constitution of existence. The importance of this neglected area for the psychoanalytic process is illustrated with clinical examples.

Adult↗
PubMedDate not supplied

The framework of training analyses.

This paper investigates, through specific but disguised vignettes, the influence of deviations from the ideal set of ground rules and boundaries of the analytic situation and relationship (the frame) on the training analysis experience. The material reveals a significant split between the conscious attitudes toward, and understanding of, these framework infringements and their unconscious implications in the thinking of both the analyst and the analysand. Clinical interludes in which deviations are at issue, when studied in terms of the patient's derivative (encoded) expressions, reveal a shift toward valid, unconscious perceptions of the analyst (nontransference) and a variety of pathological instinctual drive satisfactions, superego sanctions, and defenses that are unconsciously offered to the patient by the analyst. The basic therapeutic contract is seen as favoring pathological merger between patient and analyst, and as gratifying pathological narcissistic needs in both participants. As actualities fraught with unconscious meanings, the deviations (when unrectified) generate unconscious negative introjects of the analyst in the analysand. These prove detrimental to the analysand's growth, the resolution of his neurosis, and his development as an analyst. It is recommended that there be two classes of analysts: those who write and teach, and those who analyze candidates while remaining on the periphery of professional activities.

Communication↗
PubMed1984

Understanding Matte-Blanco.

Matte-Blanco claims to explain a wide range of characteristics of the Unconscious from a simple base. His theory of the logic of the Unconscious is based on two principles: first, that the Unconscious treats every class as a subclass of a more general class. Second, that the Unconscious treats relations as reversible. It is claimed that it is possible to explain such a wide range of characteristics of the Unconscious because these two principles contradict one another. From the theory of formal systems we know that any theory with contradictory principles explains everything and so explains very little.

Freudian Theory↗
PubMed1993

The mind of the analyst: from listening to interpretation.

The analyst demands two somewhat contradictory attitudes of himself: on the one hand, he listens and interprets on the basis of his theoretical knowledge, experiences and scheme of reference and, on the other, he must open himself to the new, the unforeseen and the surprising. His work, from listening to interpretation, is situated within a context that includes the history of the treatment as well as the history of the analysand, which is in the process of reconstruction. This context determines the moment of the interpretation (which may vary), i.e. the point ot urgency of a given session. This point denotes the moment when something emerges from the unconscious of the analysand and the analyst believes that it must be interpreted. It is something that occurs within the intersubjective field, which embraces both participants and has its own, partly unconscious, dynamics. This configuration or unconscious fantasy of the field constitutes the common source from which both the discourse of one partner and the other's interpretation spring. The moments of blockage in the dynamics of the field, the obstacles in the analytic process, invite every analyst to take a 'second look' at the field, focusing on the unconscious intersubjective relationship which determines it. Focused either on the analysand or on the field, the interpretation can perform its two dialectically complementary functions: it may irrupt into the disguises of the patient's unconscious, or it may allow him to synthesise and reconstruct his history and identity.

Countertransference↗
PubMed1996

The conceptualisation and communication of clinical facts in psychoanalysis: a discussion.

The author states that the 75th Anniversary Edition of the IJPA (December, 1994) offers a superb collection of diverse views on the daunting question of the ways in which we conceptualise and communicate psychoanalytic clinical facts. The focus of this discussion is certain methodological and epistemological concerns deriving from some of the ideas and clinical examples presented in these writings. It is noted that while our central task is to uncover and recover what had been outside awareness, the concept of 'The Unconscious' has inclined us towards inferring knowledge about another as though it were fact. There is a tendency, descriptively and clinically, to view the analyst as potentially capable, however he or she may arrive at this, of apprehending meaning that is yet unconscious to the patient. Turns of language take place that impute unconscious intentionality to the patient (e.g. 'the patient is unconsciously attacking the analyst') while relieving the analyst of responsibility in the evocation of the patient's perception (e.g. 'the analyst is unconsciously forced to play a role'). Thus, unexamined assumptions are introduced, while perception itself is relegated to a secondary, rather than primary experiential phenomenon, nuances of which remain outside analytic enquiry. As verbal and non-verbal data are often omitted from active exploration, the power of intellectual persuasion risks overtaking the requisite demand for evidence. Clinical examples drawn from each of the three geographical regions are reviewed in detail in order to explicate these conceptual dilemmas.

Communication↗