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PubMed1991

Withdrawing life-sustaining treatment from severely brain-damaged persons.

Ventilator support is commonly withdrawn from unconscious patients who cannot breathe when it is reasonably certain that their condition is permanent and further medical treatment is futile. However, there is no consistent practice with permanently unconscious patients who can breathe but cannot swallow, despite the fact that ongoing treatment of these patients is similarly futile. In both groups of patients, the withdrawal of treatment is not euthanasia, and the cause of death is properly considered to be the underlying illness. A review of the medical, legal and ethical literature shows that there is much disagreement about when and how to withdraw tube feeding from patients with severe brain damage. Criteria for withdrawal of treatment should include the permanent unconsciousness of the patient, the permanent absence of a life-sustaining function, the elapse of sufficient time to be certain about the prognosis, the concurrence of at least one independent and qualified medical specialist, and the informed consent of the patient's family or other legally qualified agents.

Australia↗
PubMed1975

[I. Induced abortions and spontaneous abortions. Psychopathological aspects apropos of a preliminary sample of 411 requests for pregnancy interruption].

Since 1975 (17th January), abortion is free and legal in France. The authors analyse 411 first cases of women requiring for an abortion (seen over a period of 11 weeks). Most of them are young women, single, many begin their sexual life. Unwanted pregnancy indicates absence of contraception by ignorance, refusal or ambivalence (never used = 184 cases). 105 women used archaic and inefficient contraceptive means. Modern contraceptive means was used by 154 women but ill applied, ill tolerated and/or discarded (pill = 103 cases, I.U.D. = 14, diaphragme = 2, condoms = 35). Unwanted pregnancy and abortion signify failure of contraception. We compare psychologic and psychopathologic features of women requiring repeated induced abortion with those of women suffering of repeated spontaneous abortion and infertility. These women have frequently (same) problems of feminine identity, bad maternal imago, absence of father, unhappy, and conflictive childhood, immature sexuality and personnality. Contradiction between conscious and unconscious wishes create the two opposite situations and intrapsychic conflicts (spontaneous abortion = conscious willing of pregnancy + unconscious rejection of unbearable pregnancy; induced abortion = strong but unconscious wish of pregancy + conscious and volontary rejection of maternity). Psychotherapy should improve sexual and affective life and in both cases. The authors compare infanticide and abortion behaviors, contraceptive means, and psychological problems of doctors who are asked abortion.

Abortion Applicants↗
PubMed2002

Effect of propofol anaesthesia on the event-related potential mismatch negativity and the auditory-evoked potential N1.

BACKGROUND: Studies on the effects of anaesthesia on event-related potentials and long latency auditory-evoked potentials (AEP) are sparse. Both provide information on cortical processing and may have potential as monitors of awareness. We studied the effect of propofol on the event-related potential mismatch negativity (MMN) and the long-latency AEP NI. METHODS: Twenty-one patients received 1 microgram ml-1 stepped increases in the target concentration of propofol using Diprifusor until a maximum of 6 micrograms ml-1 was achieved or the patient had lost consciousness. Neurophysiological responses (MMN and N1) and the patients' level of consciousness were recorded before the administration of propofol and at a target effector site concentration of propofol of 1, 2, 3, 4, and 6 micrograms ml-1. Grand average evoked potentials were computed at baseline, before the administration of propofol (A); at the highest propofol concentration at which each patient was responsive (B); and at the concentration of propofol at which the patient became unconscious (C). RESULTS: Patients lost consciousness at different target concentrations of propofol, all being unresponsive by 4 micrograms ml-1. The response to the deviant stimuli used to elicit duration-shift MMN was significantly more negative than to the standard stimuli at A (mean difference 2.58 microV, P = 0.0011) but this difference was virtually abolished at point B, before the patients lost consciousness (mean difference 0.63 microV, P = ns). The amplitude of N1 evoked by standard stimuli was negative compared with electrical baseline at both point A (mean amplitude -3.81 microV, P < 0.001) and at point B (mean amplitude -2.2 microV, P = 0.002), but was no longer significantly different to baseline at point C (mean amplitude 0.51 microV, P = ns). The change in the mean amplitude of N1 from last awake (point B) to first unconscious (point C) was also significant (mean difference in amplitude 1.69 microV, P = 0.02). CONCLUSIONS: MMN is unlikely to be a clinically useful tool to detect awareness in surgical patients. In contrast, the loss of N1 may identify the transition from consciousness to unconsciousness and deserves further study.

Adult↗
PubMed2002

[Relapse of Creosote poisoning: report of a case taking Seirogan tablets].

A thirty-eight year old man took about 180 tablets of Seirogan. He was unconscious and had dyspnea with dark brown urine on admission. He recovered gradually after initial treatment. Seirogan contains a phenolic component. Symptoms and signs of poisoning are unconsciousness, convulsion, digestive tract disorder, pulmonary edema, hepatic failure, renal failure, and miosis. Clinical features include dark brown urine. On day 7, he again showed signs of creosote poisoning: relapse of unconsciousness and dark colored urine. Plasma concentration of phenol determined on the day before the relapse was much higher than that expected from the half-life of blood phenol. It is reported that Creosote poisoning results in a decrease in the intestinal peristalsis, or paralytic ileus. We would like to emphasize that a relapse of Creosote poisoning may occur due to possible delayed absorption of the Seirogan tablets.

Acute Disease↗
PubMedDate not supplied

On the psycho- in psychophysiology: notes for a history of the mind-body effect.

One hundred and twenty-five years of the dialogue between psychology and physiology reveal a vibrant discussion about the mind-body effect--the ability of waking consciousness to influence its own normally unconscious physiology through conscious intention, and conversely, the reciprocal effect of physiology on consciousness. In the early phase, the data remained largely anecdotal. Scientific study of the emotions then opened the door to dynamic theories of the subconscious. Such formulations, however, were repeatedly overshadowed by concurrent advances in brain neurophysiology, which rejected not only any exploration of the unconscious that relied on the method of symbolism, but also the reality of the unconscious itself. Nevertheless, scientific advances at the interface between psychology and physiology persisted. Since the 1950s, however, there has been an explosion of new work in the neurosciences at the interface between molecular genetics, endocrinology, neurology, immunology, and psychiatry. This has fueled both new research and renewed discussion about the mind-body effect, a dialogue that is now, in part, also a response to a counter-culture revolution occurring at the interface between the delivery of clinical services throughout the healthcare professions and an increasingly sophisticated consumer demand for alternative and complementary therapies.

Consciousness↗
PubMed2004

Vasovagal syncope: an enigma.

Syncope is a common clinical problem affecting 3.5% of the general population. About 40% of cases remain undiagnosed and 30% experience recurrent episodes. The article presents an update on the etiopathogenesis and theories of syncope. The pathophysiology of syncope remains elusive. Lewis introduced the term "vasovagal" implying therein that both vasodilatation and bradycardia were involved in the response. Individuals susceptible are unable to maintain adaptive neurocardiovascular responses to upright posture for prolonged periods of time. A complex hemodynamic response develops, with marked hypotension, bradycardia and a loss of consciousness. The "empty ventricle theory", first proposed by Sharpey - Schafer, widely accepted for several years, has been challenged and various other aspects of the vasovagal response have now been studied and implicated in contributing to the episode of unconsciousness. These include baroreflex dysfunction, neuro - endocrine responses, role of respiration and cerebrovascular dysfunction. An episode of syncope represents an episode of unconsciousness. Even a single episode of unconsciousness in the present day lifestyle is a source of distress to a patient, warranting a workup and diagnosis. The etiopathogenesis of the simple faint is complex and we may well be dealing with a constellation of responses and a more detailed classification than hitherto imagined.

Baroreflex↗
PubMed1992

Paranoid-schizoid or symbiotic?

This critique of Mahler's derivation of a developmental stage of normal symbiosis from her work with psychotic children reveals some clear parallels with Klein's description of the paranoid-schizoid position. The defence mechanisms of splitting, and of projective and introjective identification are already operative in the symbiotic stage and imply some distinction between self and other in the unconscious. Both theorists described the same confusion between self and other, but they attributed different explanations to the phenomenon. Whereas Mahler described the experience of feeling at one with the other, Klein elucidated the unconscious psychic mechanisms which operate to create this experience. The separation-individuation process has been redefined as the developing awareness of a sense of self, as distinct from earlier unconscious processes.

Child↗
PubMed1991

[Prinzmetal angina and syncope].

Authors report an unusual case of variant angina associated with unconsciousness. They were able to prove by coronary angiography the vasospasm of the circumflexus artery which was responsible for the morning attacks of the 35 year old patient with unconsciousness, ST segment elevation and high degree AV block. Unconsciousness was the first and earliest sign of the coronary vasospasm.

Adult↗
PubMed1991

A perversion named desire.

Inspired by the title of the work, A Streetcar Named Desire by Tennessee Williams, the author argues that desire and perversion are equivalent, based on the following. (1) The notion of infanatile sexuality as polymorphously perverse, and whose components constitute the 'core of our unconscious' and the ultimate 'matter' of unconscious desire. (2) The perspective of narcissism, which establishes desire, supported by the theory that maternity implants an illusion of completeness which culture promotes, despite the fact that such an ideal conflicts with the laws governing the foundation of culture. (3) The resulting forms of the oedipal complex and the castration complex, whether man or woman, imply a visible or unapparent violence with regard to the original 'call' of desire. (4) The traditional structures refer to the possibility of the mother imagining herself as completed by the child: the blocking of that illusion is associated with psychosis; the weakness of the desire, once established, demands, in the context of perversion, the presence of the figure of plenitude. Neurosis prefers its absence on the level of the apparent while insuring its permanence on the unconscious level.

Drama↗
PubMed1987

[Hypnotically active blood level of midazolam].

Midazolam was administered to seven healthy adult volunteers by microprocessor controlled infusions that generated 3 cycles of lineary increasing plasma levels with an anticipated slope of 20 ng ml-1 min-1. When a deep unconscious status was obtained as indicated by no response to loud verbal stimuli, the concentrations were kept constant at that plateau for 30 min. Thereafter, the infusions were stopped and restarted when the volunteers were again fully responsive to acoustic stimuli of normal intensity. Frequent venous blood samples were obtained during and after the infusions to evaluate venous threshold concentrations of induced sleep and recurrence of orientation, loss and recurrence of eyelid-reflex (and corneal reflex), and unconsciousness and recovery of responsiveness to loud verbal stimuli. From the first to the third infusion cycle a slight, but not significant increase of mean threshold concentrations could be observed. Hence, they were averaged over all infusion cycles. In detail, the following concentrations (in ng/ml; mean +/- SD) resulted: asleep: 251 +/- 110 and oriented: 277 +/- 107, loss: 543 +/- 173 and recurrence of eye-lid reflex: 532 +/- 120, unconsciousness: 575 +/- 128 and recovery to responsiveness: 555 +/- 151. In all but one volunteer, the corneal reflex could be triggered at any time. Hence, a mean threshold concentration of that, observation could not be obtained. Phenomena of acute tolerance that should lead to significant increases of threshold concentrations from the first to the last infusion cycle could not be demonstrated.

Adult↗
PubMed1983

Mild head injury.

The pathology of mild head injury, its common behavioral sequelae, the nature of the recovery process, and the psychosocial consequences are reviewed. Acceleration-deceleration head trauma, causing brief unconsciousness, and leaving no frank neurological deficit, is associated in primates with axonal and terminal degenerative changes in brain stem nuclei. Although the presence of clinical demonstrable neurological abnormality increases the likelihood of subsequent deficits, their absence does not guarantee full recovery. Among mildly injured children, the relationships between persistent behavioral deficits and their age of onset correspond closely with those observed in children with overt damage, making it unlikely that psychological-behavioral deficits are attributable to non-neurological aspects of the injury. Deficits observed include distractability, irritability, headaches, inability to maintain a prior level of cognitive competence, and impulsivity. Although longer periods of unconsciousness are associated with permanent memory deficits, minimal unconsciousness is also followed by consistent deficits in complex memory tasks. Detailed neuropsychological testing of mildly injured children has revealed persisting deficits even after 5 years. Furthermore, deficits arising from repeated injuries are cumulative. The importance of adequate neuropsychological assessment and accurate information to the patient are stressed as important in helping satisfactory adjustment.

Adolescent↗
PubMed1982

Neuroses and character disorders.

This paper emphasizes the importance of understanding and treating the aged with neuroses and character disorders. Although they are often neglected by mental health workers, the aged with these emotional problems form a far larger group than the psychotic aged who receive a greater share of attention. Stereotyped attitudes and commonly accepted myths regarding the aged encourage an attitude of therapeutic nihilism and pessimism. The unconscious motivation for ignoring the obvious distress of older people is discussed. Certain specific myths, such as the "rigidity" of the aged and the tendency to "wastebasket" and to view all pathology as organic or caused by aging alone, are discussed. The fear of the devouring older person is also explored, as well as the myth of "family rejection." A number of clinical examples are given of the types of emotional problems frequently seen among the noninstitutionalized older population. Each case is described from the standpoint of dynamic understanding and management. A trial of observation and psychotherapy is recommended in all situations, since even "organic" signs may be reversed. Generalizations concerning the aged as a group are avoided in the belief that they lead to further stereotyping and the discouragement of scientific investigation. Individual assessment and understanding are emphasized. The persistence of unconscious attitudes, fantasies, and wishes from childhood is pointed out, but it is emphasized that they may not always carry the same value and meaning throughout life. Certain patients achieve insight through treatment, along with a greater capacity to enjoy life than they had before. Others are comforted by the relationship with the therapist for both its "real" and unconscious meanings. Some require assistance in accepting and tolerating more regressive behavior, while others need help in accepting and assimilating their changing feelings about their goals, objects, and sexuality in old age. Reminiscences are emphasized as important sources of elevating self-esteem. Concerns about death and common countertransference problems in work with the aged are examined. The need to be flexible but not to "lean over backward" is emphasized. Patients understand a genuine offer of involvement and concern as the most precious gift.

Aged↗
PubMed1981

Theories of pathogenesis.

Theories of pathogenesis can be influenced by shared unconscious fantasies. This may determine the speedy enthusiasm with which some theories are accepted. In keeping with primitive, pleasure-seeking trends, it is appealing to blame illness on others and to view pathogenesis in terms of the intrusion into the self of some alien, noxious agent. These ideas can be seen in certain current theories that ascribe pathogenesis to inadequate, unempathic mothering. Such theories influence psychoanalytic technique. Analysis becomes a form of replacement therapy, in which the analyst facilitates normal development by serving as an appropriate object. This approach may gratify unconscious needs in analyst and analysand alike. The attempt to isolate one specific pathogenic factor as crucial fails to do justice to the complexity of pathogenesis and may lead to the failure to recognize the role of unconscious conflict and to analyze resistances.

Fantasy↗
PubMed1981

Character traits and object relationships.

Character traits have in the past been viewed as "discharge" phenomena and compromise formations. Many traits can be better understood, however, as devices for evoking particular types of response in others in order to actualize the wished-for relationships existing in unconscious fantasy. Moreover, some "evocative" character traits create the unconscious illusion of the presence of the love objects. The concept of unconscious illusion can also be used to clarify the notion of "introject," which may be understood as an illusory object perceived outside normal consciousness.

Character↗
PubMedDate not supplied

[Castration anxiety and oral envy in sexual relations. Analytic studies with ethnological observations].

Ethno-psychoanalysis is the study of the unconscious in foreign cultures. It can however also be of use in understanding unconscious elements operative in our own culture. To illustrate the point, the author describes the "Koro" epidemic which occurs periodically on the island of Hainan off the south of coast of China. This epidemic largely affects young unmarried men and the author pinpoints the unconscious conflicts underlying this collective phenomenon. It transpires that the epidemic is in effect a species of rite of passage in which a group of young males make the communal attempt to overcome castration anxieties which are themselves the product of covert gender envy. In the second section, Gerlach reports on his psychoanalytic encounter with a young man in Germany displaying similar symptoms. The profounder dimensions of this condition were only comprehensible to the author on account of his knowledge of "Koro".

Adult↗
PubMed1993

[The son of man. Freud's Oedipus myth].

In formulating his psychology of the unconscious, Freud makes constant reference to Sophocles' version of the Oedipus myth. The author provides detailed proof of the fundamental differences between the two versions, demonstrating that Freud's interpretation does violence to the source. Bollack marshals impressive evidence to substantiate his contention that from the early letters to Fliess all the way up to Moses and Monotheism Freud's sole concern was to point up the ubiquitous power of the unconscious (incestual desire, patricide) within the "holy" (nuclear) family, whereas Sophocles was preoccupied with an entirely different problem. In Bollack's view, Oedipus rex is the drama of the self-destruction of a royal family, a drama in which incest and murder have no very essential significance. Freud, by contrast, set out to de-mystify the fate that dogs the royal family from one generation to the next and to naturalise it into a form of unconscious behaviour--a tendency which Bollack sees as deriving from the tradition of the "drama of destiny", a genre prevalent in the 19th century.

Freudian Theory↗
PubMed1996

Treatment of cyanide poisoning in an industrial setting.

Thirty-seven employees were exposed to cyanide between 1956 and 1985. One was found dead. Thirty-six employees were treated; most were given nitrite and oxygen. Some received oxygen alone. All recovered completely. One-third of these employees were unconscious. One was convulsing. Most were discharged home at 6 h post-exposure. Some employees remained at the plant to work an additional shift. Amyl nitrite and/or oxygen were the only agents used with 33 employees. Forced oxygen was administered to the unconscious, apneic employees. Three employees were given sodium nitrite and sodium thiosulfate iv. Treatment generally began within 3 min. In 5 to 20 min all of the unconscious employees reacted positively to the use of forced oxygen and forced amyl nitrite or sodium nitrite. There were no residual effects except headache and transient loss of appetite. Amyl nitrite and oxygen have been effective tools in the treatment of cyanide intoxication at this plant site. There have been no intercurrent or residual drug effects that outweigh the life-saving capacity of these agents. Sodium nitrite should be employed if the use of oxygen and amyl nitrite fail to improve the cardiovascular status/level of consciousness in 5-10 min.

Amyl Nitrite↗
PubMed1996

[Acute subdural hematoma caused by professional boxing].

Knockout in boxing entails deliberate production of the state of unconsciousness. Acute subdural hematoma which is the most common acute brain injury in boxing, accounts for 75% of all acute brain injuries and is the leading cause of boxing fatalities. The aim of this study is to evaluate acute subdural hematoma caused by professional boxing by analyzing the content of bouts, the level of consciousness on admission, CT scan, therapy and outcome 3 months after admission. Fifteen boxers who had suffered from acute subdural hematoma were classified into three groups according to the pattern of loss of consciousness. Transient unconsciousness type (Transient type): boxers who had returned to alertness within an hour from the time of injury. Lucid interval type: neurological deterioration appeared with a lucid interval from ten minutes to an hour after knockout. Deterioration of consciousness type (Deterioration type): A state of unconsciousness appeared and worsened from a few minutes after knockout. Analyzing the number of rounds in bouts indicated that the hematoma occurred most frequently in bouts of 10 rounds. All of our subjects presented subdural hematomas without cerebral contusions on CT scan. With regard to the location of the hematomas, 9 hematomas involved the left side, 3 the right, 2 the suboccipit and 1 the interhemisphere. Transient type was found in 7 patients who had GCS scores of 14, 15 on admission. Since CT scan revealed thin subdural hematoma with or without mild midline shift, conservative therapy was carried out in all patients. All patients had a good recovery. Five patients of lucid interval type with an admission GCS score of 4, 6 and 7 demonstrated thicker hematoma compared to that presented by the transient type with significant midline shift on CT scan. All patients required surgery. Outcome of this type was good recovery (n = 2), moderate disability (n = 1), persistent vegetative state (n = 1), death (n = 1). Three patients of deterioration type had GCS scores of 5, 6. Because of subdural hematoma with remarkable midline shift on CT scan, all patients underwent surgery. Outcome was good recovery (n = 1), moderate disability (n = 1), persistent vegetative state (n = 1). Overall outcome was good recovery 66.7%, moderate disability 13.3%, persistent vegetative state 13.3%, death 6.7%. Furthermore, 8 patients who underwent surgery with a GCS score of less than 8 exhibited good recovery 37.5%, moderate disability 25%, persistent vegetative state 25%, death 12.5%. CT scan of lucid interval and deterioration type showed a tendency to show thick subdural hematoma and remarkable midline shift compared to transient type. Outcomes of lucid interval and deterioration type were worse than those of transient type. This result suggests that the influence of repeated head injury and diffuse brain injury might make a difference between these groups. Repeated head injury means that further impacts repeatedly damaged the injured brain after bleeding in the bouts. Overall outcome was better than that published in previous reports and also than that observed in other head injuries, for example, traffic accident and fall. The reasons for this could be that the patients were younger, that there was immediate surgical treatment, and that brain injury without cerebral contusion had contributed to better outcome. Finally, the best medical management intervention seems to be to diagnose and treat the lesions as early as possible after occurrence of subdural hematoma.

Acute Disease↗