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PubMed1998

Psychopathology and primitive mental states.

The author discusses the psychoanalytic concept of primitive mental states, arguing that normal primitive mental states contain omnipotent fantasies that in an adult would be classified as delusions and hallucinations, but also contain sufficient reality sense to allow the infant to learn through experience that its omnipotent unconscious fantasies are not real, but only ordinary unconscious fantasies. Psychopathology of the type requiring psychoanalytic treatment is connected to persistent unconscious omnipotent fantasies (delusions). It is not the result of a regression to a normal primitive mental state, since in a normal primitive mental state, such delusions and their resultant inhibitions, symptoms and anxieties are gradually and spontaneously overcome through learning from experience. The unconscious delusions related to psychopathology persist because they are insulated from the effects of the learning from experience that would ordinarily convert them into unconscious fantasies by the use of transformations in hallucinosis, reversal of perspective and realistic projective identification by the psychotic part of the personality. Together, these mechanisms distort experience in such a way that reality appears to confirm, not challenge, the delusions, making learning impossible. The theory that psychopathology is due to a regression or fixation to a normal primitive mental state acts as a defence against the awareness that the mental states associated with current psychopathology are not like normal primitive ones, and that they differ from normal primitive mental states by containing forces that are sufficiently destructive of learning from experience to have prevented the patient's mental state from evolving in a normal fashion.

Adult↗
PubMed2005

Neuropharmacology of cognition and memory: a unifying theory of neuromodulator imbalance in psychiatry and amnesia.

The case of HM, a man with intractable epilepsy who became amnesic following bilateral medial temporal lobe surgery nearly half a century ago has instigated ongoing research and theoretical speculation on the nature of memory and the role of the hippocampus. Neuropsychological testing showed that although HM had extensive anterograde memory loss he could still acquire motor and cognitive skills implicitly, but could not remember the context of this learning. This has lead to declarative and procedural descriptions of the memory process. Cholinergic and monoaminergic neurotransmitter systems have also been implicated in the memory process and anticholinergic drugs traditionally have been associated with impairment of declarative memory. The cholinergic hypothesis of Alzheimer's disease is a classic example of an application of these neuropharmacological findings. In schizophrenia, preattentive deficits have been amply demonstrated by unconscious priming studies. Memory processes are also impaired in these patients. Dopamine, glutamate and even cholinergic dysfunction has been implicated in the clinical picture of schizophrenia. The present paper will attempt to bring together both the anatomical and pharmacological data from these disparate fields of research under a cohesive theory of cognition and memory. A hypothesis is presented for an inverse relationship between monoaminergic and cholinergic systems in the modulation of implicit (unconscious) and explicit (conscious) cognitive processes. It is postulated that muscarinic cholinergic receptors and monoaminergic systems facilitate unconscious and conscious processes, respectively, and they disfacilitate conscious and unconscious processes, respectively (the purported inverse relationship). In fact, the muscarinic and monoaminergic modulations of a neural network are proposed to be finely balanced such that, if, the activity of one receptor system is modified then this by necessity has effects on the other system. It takes into account receptor subtypes and their effects mediated through excitatory and inhibitory G-protein complexes. For example, m1/D2 and D1/m4 paired receptor subtypes, colocalized on separate neurons would have opposing functional effects. A theory is then presented that the critical underlying pathophysiology of schizophrenia involves a hypofunctional muscarinic cholinergic system, which induces abnormal facilitation of monoaminergic subsystems such as dopamine (e.g., a decrease in m1R function would potentiate D2R function). This extends the idea of an inverted U function for optimal monoaminergic concentrations. Not only would this impair unconscious preattentive processes, but according to the hypothesis, explicit cognition as well including memory deficits and would underlie the mechanism of psychosis. Contrary to current thinking a different view is also presented for the role of the hippocampus in the memory process. It is postulated that long-term explicit memory traces in the neocortex are laid down by phasic coactivation of forebrain projecting monoaminergic systems above some basal firing rate, such as the rostral serotonergic raphe, which projects diffusely to the cortex and according to a modified Hebbian principle. This is the proposed principal function of the hippocampal theta rhythm. The phasic activation of the cholinergic basal forebrain is mediated by projections from a separate cortical structure, possibly the lateral prefrontal cortex. Phasic muscarinic receptor activation is proposed to strengthen implicit memory traces (at a synaptic level) in the neocortex. Thus, the latter are spared by medial temporal surgery explaining the dissociation of explicit from implicit memory.

Amnesia↗
PubMed2001

Short-term effects of severe hypoglycaemia in children and adolescents with type 1 diabetes. A cost-of-illness study.

UNLABELLED: The aim of this study was to describe costs and other short-term effects of severe hypoglycaemia in children and adolescents with type 1 diabetes. The study comprised a geographic population of 129 patients <19 y of age with families prospectively registering detailed data after self-reported severe hypoglycaemia. In the period Jan.-Dec. 1998, 16 events were reported with unconsciousness and 95 events without unconsciousness but needing the assistance of another person. Of all events, 20-30% had effects requiring the assistance of people other than parents, school absence, parents' absence from work, extra transport and/or telephone calls. Patient (family) activities were cancelled after 10% (5%) of events. Increased worry for parents was reported after 8% and poor sleep after 7% of events. Hospital visits took place at 5% and hospitalizations at 3% of all events. Patients with severe hypoglycaemia indicated lower global quality of life (p=0.0114). The average socio-economic burden for events of severe hypoglycaemia was estimated at EURO 17,400 yearly per 100 type 1 diabetes patients. Average cost was estimated at EURO 239 per event of severe hypoglycaemia with unconsciousness or EURO 478 yearly per patient with unconsciousness, and EURO 63 per event of severe hypoglycaemia without unconsciousness but needing assistance from another person or EURO 307 yearly per patient in this category. These are conservative estimates and do not include unpaid time and other intangibles, possible road traffic accidents, disabling or premature deaths. CONCLUSIONS: The results suggest the potential for socio-economic savings and increased quality of life for patients and families from severe hypoglycaemia prevention programs.

Adolescent↗
PubMed2002

A new reading of the origins of object-relations theory.

The author presents a reading of Freud's "Mourning and melancholia" in which he examines not only the ideas Freud was introducing, but, as important, the way he was thinking/writing in this watershed paper. The author demonstrates how Freud made use of his exploration of the unconscious work of mourning and of melancholia to propose and explore some of the major tenets of a revised model of the mind (which later would be termed "object-relations theory"). The principal tenets of the revised model presented in this 1917 paper include: (1) the idea that the unconscious is organised to a significant degree around stable internal object relations between paired split-off parts of the ego; (2) the notion that psychic pain may be defended against by means of the replacement of an external object relationship by an unconscious, fantasied internal object relationship; (3) the idea that pathological bonds of love mixed with hate are among the strongest ties that bind internal objects to one another in a state of mutual captivity; (4) the notion that the psychopathology of internal object relations often involves the use of omnipotent thinking to a degree that cuts off the dialogue between the unconscious internal object world and the world of actual experience with real external objects; and (5) the idea that ambivalence in relations between unconscious internal objects involves not only the conflict of love and hate, but also the conflict between the wish to continue to be alive in one's object relationships and the wish to be at one with one's dead internal objects.

Freudian Theory↗
PubMed1991

Scientific creativity: a review.

Aside from possession of the relevant knowledge, skills, and intelligence, what seems to characterize the creative scientist is his imagination, originality, and ingenuity in combining existing knowledge into a new and unified scheme. This creativity frequently emerges from an aesthetic, poetic sense of freedom derived from work, an uninhibited playful activity of exploring a medium for its own sake. We speculate thus: With a preference for irregularities and disorder, the creative scientist temporarily takes leave of his senses, permitting expression of unconfigurated forces of his irrational unconscious. This amounts to a kind of internal "wagering," in which the scientist pits himself against uncertain circumstances, a situation in which his individual effort can be the deciding factor. When working on a difficult problem, there frequently occurs a "creative worrying" in which the problem is consciously and unconsciously carried around while doing other tasks. This period is attended by frustrations, tensions, and false inspirations. Dream and reality are wedded in a largely unconscious process of undefined emotional turmoil. When a uniquely gratifying association is realized, the unconscious deposits its collection of insights into the fringe consciousness, whereupon the full consciousness seizes on it and releases it as a flash of insight. Because the creative scientist possesses a strong and exacting self-concept, he can organize, integrate, and even exploit the conflict within himself. By compensating in fantasy for what is missing in reality, creativeness can be an expressive outlet ameliorating the universal, annoying split between a man's inner unconscious world and his outer conscious world. Although there is a divergence of opinion as to whether creativity can be taught, there is agreement that it can be fostered. However, parents, teachers, and institutions must display considerably more flexibility and tolerance towards individually minded persons who behave in seemingly nonconformist ways.

Creativity↗
PubMed2003

The crashed voice--a potential for change: a psychotherapeutic view.

Jungian analysis is based on the work and extensive writings of C.G. Jung. Jung worked for a while with Freud who expected him to carry on the work of psychoanalysis. However, the two men were very different and Jung broke away from the Freudian model to develop his own unique view of the unconscious and to explore what he believed to be its innate capacity for healing. He said: "My life is the story of the self realization of the unconscious. Everything in the unconscious seeks outward manifestation, and the personality too desires to evolve out of its unconscious conditions and to experience itself as a whole." (Memories, Dreams, Reflections C.G. Jung. 1963) The goal of the therapeutic work for Jung was individuation--the never ending process of becoming fully oneself. This process represents the individual's capacity to choose creatively between both internal and external necessity without denying either. Jungian analysts work in some similar ways to other analysts and see dreams as central to this process. They also sometimes work with archetypal symbols and other forms of creative expression such as painting or dance. All the methods used are there to enable patients to explore their unconscious, understand and accept who they are, and access powers for healing the self. People in creative and expressive fields are often drawn to the work because of its belief in the uniqueness of the individual and its understanding of the healing power of a creative relationship to oneself.

Dissociative Disorders↗
PubMed1993

[Expert assessment of craniocerebral trauma].

The officially appointed external expert needs a precise documentation of the initial clinical findings and the findings at follow-up of the patient with craniocerebral trauma. The next step in preparation of the expert report consists in a pathophysiological and a neurological examination, including CT scan and EEG repeated at intervals; a stable condition can be expected after 1-2 years. In the case of reversible closed head syndrome (brain concussion) the expert should certify a disability for about 6 months; a degree of 20% for over 3 months should not be certified unless there are massive vegetative signs and symptoms. Persisting damage should only be recognized if a substantial brain lesion is present. In cases of cerebral compression or open skull fracture with manifest damage to the substance of the brain the duration of unconsciousness must be taken into account. For children and young people up to 10 days' unconsciousness is not taken to imply later disability; after 10-20 days' unconsciousness such young people are considered fit for work or school to a qualified extent; a persistent defect must be expected to follow unconsciousness lasting over 20 days. Adults who are unconscious for up to 5 days can be expected to make a complete recovery, while a longer duration of coma and more advanced age are associated with a worse outcome. The degree of functional impairment is thus important in the expert's decision on the level of disability. A flow chart is presented for guidance in the preparation of expert reports.(ABSTRACT TRUNCATED AT 250 WORDS)

Brain Concussion↗
PubMed2005

An examination of the right-hemisphere hypothesis of the lateralization of emotion.

The Right-Hemisphere Hypothesis posits that emotional stimuli are perceived more efficiently by the right hemisphere than by the left hemisphere. The current research examines this hypothesis by examining hemispheric asymmetries for the conscious and unconscious perception of emotional stimuli. Negative, positive, and neutral words were presented for 17 ms to one visual field or the other. Conscious perception was measured by using a subjective report-of-awareness measure reported by participants on each trial. Unconscious perception was measured using an "exclusion task," a form of word-stem-completion task. Consistent with previous research, there was a right-hemisphere advantage for the conscious perception of negative information. As in previous studies, this advantage for conscious perception occurred at the expense of unconscious perception. Specifically, there was a right-hemisphere inferiority for the unconscious perception of negative information. Contrary to the predictions of the Right-Hemisphere Hypothesis, there were no hemispheric asymmetries for the perception of positive emotional information, thus suggesting that the Right-Hemisphere Hypothesis may not be applicable to all behavioral studies.

Adolescent↗
PubMed2005

How to trigger elaborate processing? A comment on Kunde, Kiesel, and Hoffmann (2003).

Recently, [Kunde, W., Kiesel, A., & Hoffmann, J. (2003). Conscious control over the content of unconscious cognition. Cognition, 88, 223-242] used a masked priming paradigm to argue that neither the 'elaborate processing' or the 'evolving automaticity' view can account for the processing of unconscious numerical stimuli. In our Experiment 1 we replicated [Kunde, W., Kiesel, A., & Hoffmann, J. (2003). Conscious control over the content of unconscious cognition. Cognition, 88, 223-242] Experiment 4 and show that with a less demanding mask than that used by Kunde et al., 'elaborate processing' can explain priming results given that there are side conditions to trigger elaborate processing of unconscious stimuli. The second experiment further explores this influence of the masks by increasing the relevance of the symbols by which the mask is composed. The results show that an increase in relevance of the mask is accompanied by a decrease in the priming effect, though there was no significant change in conscious awareness of the prime.

Adult↗
PubMed2006

Temporal dynamics of masked word reading.

The repercussions of unconscious priming on the neural correlates subsequent cognition have been explored previously. However, the neural dynamics during the unconscious processing remains largely uncharted. To assess both the complexity and temporal dynamics of unconscious cognition the present study contrasts the evoked response from classes of masked stimuli with three different levels of complexity; words, consonant strings, and blanks. The evoked response to masked word stimuli differed from both consonant strings and blanks, which did not differ from each other. This response was qualitatively different to any evoked potential observed when stimuli were consciously visible and peaked at 140ms, earlier than is usually associated with differences between words and strings and 100ms earlier than word-consonant string differences in the visible condition. The evoked response demonstrates a qualitatively distinct signature of unconscious cognition and directly demonstrates the extraction of abstract information under subliminal conditions.

Adult↗
PubMed2003

Aspiration pneumonia following severe self-poisoning.

PURPOSE: To investigate the risk factors of aspiration pneumonia following severe self-poisoning. MATERIALS AND METHODS: Patients treated due to severe self-poisoning in the ICU of Oulu University Hospital, Oulu, Finland during 1.11.1989-31.10.2000 were analyzed retrospectively. RESULTS: 28.4% of 257 patients fulfilled the criteria of aspiration pneumonia. An unconscious patient who was not intubated until arrival at the emergency room (ER) had an odds ratio (OR) of 3.34 (CI 1.3-8.7) for aspiration pneumonia. If the patient was intubated at the first contact with health care providers, OR was 1.8 (CI 0.6-5.7). The use of gastric lavage or activated charcoal in the case of a non-intubated unconscious patient led to ORs of 2.7 (CI 0.8-9.3) and 3.7 (CI 1.01-12.5), respectively. The mean length of ICU stay was 0.9 (CI 0.8-0.9) days among patients without aspiration pneumonia and 1.9 (CI 1.3-2.6) days among those with aspiration pneumonia. The mean length of hospital stay was 2.8 (CI 2.5-3.1) days among the patients without aspiration pneumonia and 6.5 (CI 5.3-7.6) days among those with aspiration pneumonia. CONCLUSION: To avoid aspiration pneumonia intubation of an unconscious patient on scene before arrival at the ER is recommended. The use of gastric lavage and activated charcoal increase the risk of aspiration pneumonia if the patient is unconscious and not intubated. Aspiration pneumonia significantly prolongs the length of ICU and hospital stay.

Adult↗
PubMed2003

Oculocardiac reflex caused by contact lenses.

PURPOSE: To report two cases of patients who fell unconscious because of the oculocardiac reflex when attempting to wear contact lenses. CASE REPORTS: Case 1: A 15-year-old healthy boy came to our clinic to be fitted with contact lenses. As soon as a hard contact lens was inserted forcibly, he became unconscious. Case 2: A 22-year-old man fell unconscious the instant that the eye was compressed with a hard contact lens. Neither patient had used glasses or contact lenses before. Their blood pressure was decreased while unconscious. They recovered consciousness after about 10 min, and nausea and vomiting settled subsequently. Contact lens insertion was tried again carefully after 1 week avoiding compression of the eyes and there were no problems. They are currently using contact lenses without any problems. CONCLUSION: Insertion of contact lenses may rarely provoke the oculocardiac reflex.

Adolescent↗
PubMed2003

The impact of different directed forgetting instructions on implicit and explicit memory: new evidence from a modified process dissociation procedure.

In contrast to previous research on directed forgetting, the present studies adopted a recent modification of the process dissociation procedure (Jacoby, 1991; Richardson-Klavehn & Gardiner, 1995) to accommodate the cross-contamination of memory test performance by implicit and explicit memorial factors. In Experiment 1, 120 subjects were compared in global directed forgetting, item-by-item directed forgetting, and control conditions on estimates of voluntary conscious memory, involuntary conscious memory, and involuntary unconscious memory performance. In Experiment 2, 80 subjects were compared in specific directed forgetting and control conditions on estimates of voluntary conscious memory, involuntary conscious memory, and involuntary unconscious memory performance. Subjects showed significant decrements in voluntary and involuntary conscious memory performance following instructions for directed forgetting in all conditions. None of the directed forgetting conditions showed a decrement in involuntary unconscious memory performance. Results suggest that, regardless of instruction type, directed forgetting prevents the conscious expression of memorial information (both voluntary and involuntary) while leaving unconscious memory intact.

Adult↗
PubMed2003

Effects of hydrogen sulfide on neurobehavioral function.

BACKGROUND: Nineteen hydrogen sulfide (H2S)-exposed patients were compared with 202 unexposed subjects. This 1997-to-2001 case-referent series was compared with 16 previous (1991-1996) case-referent patients. METHODS: New patients were bystanders of H2S exposure and none had been unconscious. In contrast, 13 members of the prior group were exposed at work and 7 had been unconscious. The three groups were compared on the basis of 8 physiologic and 12 psychological measurements. Observed measurements were compared with predicted ones after adjusting for age, sex, educational attainment (years), and other significant factors (observed/predicted x 100). RESULTS: The new group performed poorly compared with unexposed controls and were similar to the first group on balance, reaction time, color discrimination, visual performance, hearing, Culture Fair, digit symbol, vocabulary, verbal recall, peg placement, trail making A and B, and information. CONCLUSION: H2S impairments associated with H2S were similar in 19 workers (44% had been unconscious) and in 16 bystanders who had not been unconscious.

Adult↗
PubMed2002

Analytical psychology and its relation to psychoanalysis. A personal view.

Jungian analysis is a process based on analytical psychology; it shows local variations giving emphasis to different aspects of Jung's work within the various societies which make up the IAAP. I describe the orientation of the Society of Analytical Psychology (SAP). I have emphasized the different origins of psychoanalysis and analytical psychology and described how, because we encounter the same clinical phenomena, our differences centre on technique and interpretation in the context of our theoretical differences (see Astor 1998, p. 697 & 2001). In the main the link to psychoanalysis has come from the connection forged by Fordham, who recognized that Jung and Klein shared a similar perception of the significance of unconscious phantasy. For Klein unconscious phantasy was the primary unconscious content, and this is different, as Spillius has recently pointed out, from Freud for whom, 'the prime mover, so to speak, is the unconscious wish.

Ego↗
PubMed1991

Arterial blood gases in patients with acute head injury at the accident site and upon hospital admission.

Prior to the start of supportive therapy at the site of the accident, arterial blood samples from 47 patients with acute head injury were taken for blood gas analysis. At the same time, the degree of unconsciousness was assessed using the Glasgow-Coma-Scale. After transport to the hospital, arterial blood gases and the level of unconsciousness were again determined. A very close correlation was found between the initial depth of unconsciousness and the degree of hypercapnia (R = -0.90). Patients with head injury and other multiple injuries did not differ in this report (R = -0.95) from those with isolated head injury. The correlation between PaO2 and the degree of unconsciousness was less well defined, and the results showed a greater degree of scatter (R = 0.54). The acidosis observed resulted mainly from the rise in PaCO2. The absence of any correlation between the base excess and the Glasgow-Coma-Scale levels (R = -0.27) makes a common metabolic derangement unlikely. As a result of intubation and controlled ventilation, the hypercapnia of the comatose patients had been corrected, and a correlation could no longer be found between the Glasgow-Coma-Scale level and the PaCO2. In order to avoid hypoventilation, which carries with it the danger of a rise in intracranial pressure, all patients with severe head injury should be intubated and ventilated as soon as possible after the accident.

Blood Gas Analysis↗
PubMed1999

Initial loss of consciousness and risk of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: Delayed cerebral ischemia (DCI) is a major cause of death and disability in patients with aneurysmal subarachnoid hemorrhage. We studied the prognostic value for DCI of 2 factors: the duration of unconsciousness after the hemorrhage and the presence of risk factors for atherosclerosis. METHODS: In 125 consecutive patients admitted within 4 days after hemorrhage, we assessed the presence and duration of unconsciousness after the hemorrhage, the neurological condition on admission, the amount of subarachnoid blood, the size of the ventricles, and a history of smoking, hypertension, stroke, or myocardial infarction. The relationship between these variables and the development of DCI was analyzed by means of the Cox proportional hazards model. RESULTS: The univariate hazard ratio (HR) for the development of DCI in patients who had lost consciousness for >1 hour was 6.0 (95% CI 3.0 to 12.0) compared with patients who had no loss or a <1-hour loss of consciousness. The presence of any risk factor for atherosclerosis yielded an HR of 1.4 (95% CI 0.6 to 3.5). The HR for unconsciousness remained essentially the same after adjustment for other risk factors for DCI. The HR for a poor World Federation of Neurological Surgeons score (grade IV or V) on admission was 2.9 (95% CI 1.5 to 5. 5); that for a large amount of subarachnoid blood on CT was 3.4 (95% CI 1.6 to 7.3). CONCLUSIONS: The duration of unconsciousness after subarachnoid hemorrhage is a strong predictor for the occurrence of DCI. This observation may contribute to a better understanding of the pathogenesis of DCI and increased attention for patients at risk.

Arteriosclerosis↗
PubMed2001

An empirical study of seriously disturbed suicidal patients.

Aspects of unconscious processes in a group of seriously disturbed psychiatric patients are examined in an effort to predict near-lethal suicide attempts and explore psychoanalytic formulations of suicide. The Rorschach Inkblot Test, the most widely used projective measure in suicide research (Bongar 1991), was chosen for its potential to shed light on specific unconscious processes. Psychic states commonly associated with suicide were measured by psychoanalytic Rorschach analog scales and then subjected to a progression of statistical analyses in order to predict future occurrence and lethality of suicide attempts. On the basis of a priori hypotheses, the authors developed a suicide index comprising four psychoanalytic Rorschach signs that predicted, with considerable accuracy, which patients would later make near-lethal suicide attempts. The best predictors were unconscious processes indicative of penetrating affective overstimulation, disturbance in the capacity to maintain adequate ego boundaries, and depressive affective states characterized by a morbid preoccupation with death and inner decay. These findings provide empirical support for several well-known formulations of the unconscious motivations for suicide.

Adult↗