El estadio del espejo y la psicopatología / The mirror stage and psychopathology

En este trabajo se muestra cómo Lacan añade a la experiencia con las imágenes, que se presentan en el estadio del espejo, un tercer elemento que porta el orden simbólico. Ello supone añadir la palabra a los fenómenos ya dados, pudiendo de este modo revisarlos y corregirlos; este suceso añadido permite reconducir los aspectos más siniestros del espejo. En este sentido, el gran Otro consigue consolidar las identificaciones logradas, apaciguar la agresividad y construir el ideal del yo. A partir de estas apreciaciones lacanianas ha sido posible estudiar ciertos aspectos de la psicopatología con una luz completamente nueva, observándose cómo existen puntos específicos en los que asientan las producciones sintomáticas. Del mismo modo, la psicopatología permite confirmar aspectos relativos al estadio del espejo formulados por Lacan. Se descubre entonces que las patologías más graves aparecen cuando no se llega a formar la imago unitaria o bien cuando esta se encuentra amenazada, falla el reconocimiento especular y, sobre todo, cuando decae la mediación simbólica. Cualquiera de estas posibilidades puede resultar enloquecedora para el ser humano. (AU)

In this paper, we show how Lacan adds a third element to the experience with the images that appear in the mirror: the holder of the symbolic order. This involves adding the effects of the word to the already given phenomena, allowing thus to review and correct them. This event gets to redirect the most sinister aspects of the mirror. In this sense, the great Other consolidates achieved identifications, placates aggression and builds the ego ideal. Starting from these Lacanian findings, it has been possible to study certain aspects of psychopathology in a whole new light, showing how there are specific points on which symptoms settle. Similarly, psychopathology can confirm aspects of the mirror stage as formulated by Lacan. We then discover that the most serious diseases appear when one does not get to form the image, or this unit is threatened, specular recognition fails, or, especially, when symbolic mediation decays. Any of these possibilities might produce disorders in humans. (AU)

El estadio del espejo: antecedentes y fenomenología / The mirror stage: background and phenomenology

En este trabajo dedicado al estadio del espejo de Lacan, se exponen los antecedentes y luego se analizan los complejos fenómenos que se producen durante el mismo. Aunque el autor presenta su teoría a la comunidad científica en 1936, existían precedentes que provenían de la biología, la etología, la psicología, la filosofía e incluso la cultura de la época. Lacan realiza una síntesis admirable entre ellos y aporta al psicoanálisis contenidos de otras disciplinas, lo cual resulta completamente novedoso. El estadio del espejo muestra cómo el niño va a pasar por una serie de experiencias constituyentes cuando se enfrenta a su reflejo especular, anticipando la unidad corporal de la que carece. La imagen se convierte en la matriz del ego, que, a partir de entonces, va a mostrar un destino enajenado e ilusorio. El cuerpo es el protagonista de este proceso, ya que, en este momento fundacional, es cuando el niño resuelve el grave problema de la “fragmentación corporal” para alcanzar una imagen de "totalidad". (AU)

In this paper about the mirror stage of Lacan, we expose its background and then we analyze the complex phenomena that occur in it. Although the author showed his theory to the scientific community in 1936, there were already precedents that came from biology, ethology, psychology, philosophy, and even the culture at the time. Thus, this contribution extends the psychoanalytic field with content derived from other disciplines. The mirror stage shows how the child goes through structuring experiences when confronted with his reflection in the mirror, and anticipates his body unit. This image becomes the matrix of the ego, which thereafter will show an alienated and illusory destination. The body is the main protagonist of this process, since in this founding moment the child solves the serious problem of “bodily fragmentation” to achieve an image of "totality". (AU)

La distimia femenina y los fenómenos de amor y desamor / Female dysthymia and the phenomena of love and heartbreak

Aunque el término distimia fue acuñado por Kahlbaum, su significado actual se inició en 1980, cuando aparece en el Manual Diagnóstico de la Asociación Americana de Psiquiatría (DSM) designando una depresión crónica de leve intensidad, distinguible de la depresión mayor. Objetivo: En este trabajo se estudian los casos de dos mujeres con este diagnóstico (según CIE-10) y se examinan los "componentes subjetivos" que sustentan los síntomas depresivos y que habitualmente no se mencionan en las publicaciones. Material y métodos: Se emplea el "Método de Abordaje de la Subjetividad" (MAS), consistente en realizar entrevistas no-directivas y registrar las expresiones verbales de modo fiel, al tiempo que se prescinde de cualquier alusión a teorías, creencias particulares, juicios de valor, etc. Resultados: Se reconoce en estas pacientes una desinserción sentimental respecto al objeto de amor, un convivir desencantado con sus parejas e imposibilidad de separación, al tiempo que aparecen insidiosamente los síntomas depresivos. Este fenómeno tiene como base la caída del "ideal romántico" al que aspiran, que sostiene sus vidas y que funciona como una "agarradera" o "ancla de personalidad", razones por las que no mejoran su sintomatología. Estas originales apreciaciones cuestionan la noción clásica sobre el duelo. Conclusiones: Para que este tipo de pacientes mejoren sintomáticamente hace falta que hablen y se den cuenta de lo que realmente les está sucediendo. El estudio aquí descrito muestra las coordenadas subjetivas que se requiere conocer para poder conducir una adecuada intervención psicoterapéutica.

Objectives: Although the term dysthymia was coined by Kahlbaum, its current clinical meaning originated in the 1980s, when it appears in the American Psychiatric Association Diagnostic and Statistical Manual (DSM) designating a chronic mild depression distinguishable from Major Depression Disorder. In this article, the cases of two female patients with this disorder (according to the CIE-10) are presented and the "subjective components" that sustain the depressive symptoms, not usually mentioned in the publications, are examined. Material and methods: The Approach to Subjectivity Method (MAS) was used; it consists of non-directive interviews writing down the patient’s exact verbal expressions, and avoiding any allusion to theories, particular beliefs, values, judgments, etc. Results: We concluded that these two women have a sentimental distancing from their love object, even though they are unable to separate from or leave him while depressive symptoms appear in an insidious way. This drives them to fall off the romantic ideal they were looking for as a guide for their lives and an anchor of their personality, and it can also explain why their symptoms do not improve. This point of view questions to some extent the classic notions about "mourning". Conclusions: To improve symptomatically, the dysthymic patients need to talk about and realize what is really happening to them. What is found here shows the subjective coordinates that are necessary in order to conduct an adequate psychotherapeutic intervention.

Expert consensus on the management of breakthrough cancer pain in older patients. A Delphi study.

OBJECTIVES: We aimed to generate expert-based recommendations on the management of breakthrough cancer pain (BTcP) in older patients with cancer. MATERIAL AND METHODS: A two-round multidisciplinary Delphi study. Specialists rated their agreement with a set of statements using a nine-point Likert scale (one = totally disagree and nine = totally agree). Statements were classified as appropriate (median ranged from seven to nine), irrelevant (median ranged from four to six) or inappropriate (median ranged from one to three). Consensus was established when at least two thirds of the panel scored within any of the ranges. RESULTS: A total of 64 specialists from pain units (44.4%), palliative care units (25.4%), medical oncology (19.1%), geriatric medicine (7.9%) and others (3.2%), participated in two consultation rounds. Specialists agreed that effective coordination between the different specialties and levels of care is essential for proper management of BTcP. Most participants (81.3%) supported the assessment of frailty and resolved (96.8%) that frailty status is a better indicator of patient needs than biological age. Participants agreed (75.8%) in the application of the Davies algorithm for diagnosis of BTcP in older patients. A strong consensus was achieved regarding which pharmacological treatment (transmucosal fentanyl) and dosing method (start low and go slow) are the most suitable for the older population. No agreement was reached on how interventionist techniques should be integrated into the therapeutic strategy for BTcP. CONCLUSIONS: The present Delphi has generated a set of recommendations that will help healthcare professionals in the management of BTcP in older patients.

Aspectos subjetivos de la mujer con dismenorrea primaria / Subjective aspects of women with primary dysmenorrhea

En el presente trabajo estudiamos la dismenorrea primaria, un cuadro bastante aparatoso para el que se han venido postulado numerosas hipótesis, predominando las de índole biológica. No obstante, una serie de autores se han referido a la intervención de factores psicológicos en el cuadro. El objetivo que nos mueve consiste en descubrir cuáles son los componentes subjetivos que favorecen la aparición y/o mantenimiento del dolor en estas mujeres, más allá de las directrices biológicas. Para lograrlo tomamos un grupo de jóvenes (entre 17 y 25 años) que, aunque consultaron por otros problemas, el dolor menstrual era un síntoma importante, y a las que se trató mediante psicoterapia. Las entrevistas realizadas con ellas, aparte de ayudarlas a mejorar, nos permitieron obtener un material verbal que era expresivo del síntoma. Este proceder nos permitió desentrañar los diferentes aspectos subjetivos propios de la alteración, entre ellos destacan: la escasa tolerancia al dolor, la respuesta emocional exagerada y, sobre todo, el rechazo referido a la maduración como mujer y a los desempeños propios de ésta. Estos últimos factores se sostienen en significados personales erróneos y sustentados en los mensajes recibidos por la paciente y aceptados como propios.

In this paper we study primary dysmenorrhea, a rather cumbersome disorder for which numerous hypotheses have been postulated, predominantly of biological nature. However, a number of authors have referred to the intervention of psychological factors in these clinical symptoms. The goal that moves us is to find out which subjective components favor the appearance and maintenance of pain in these women, beyond the biological guidelines. To achieve this we take a group of young women (between 17 and 25 years old). Although they consulted for other problems, the menstrual pain was an important symptom, and they were treated with psychotherapy. The interviews realized with them, apart from helping them to get better, allowed us to obtain a verbal material that was expressive of the symptom. This procedure allowed us to unravel the different subjective aspects own of the alteration. Among them are stand out: the low tolerance to pain, the overreacted emotional answer and, above all, the rejection of the development as woman and the assumption of her corresponding role. The last factors mentioned are sustained by those erroneous personal meanings in the patient that were accepted as own.

The prevalence of mental disorders in Spanish prisons.

BACKGROUND: The prevalence of mental disorders among prisoners has been researched in a few countries worldwide but never previously in Spain. AIM: Our aim was to estimate the lifetime and last month prevalence of mental disorders in a Spanish prison population. METHODS: This is a descriptive, cross-sectional, epidemiological study of 707 male prisoners. Sociodemographic, clinical and offending data were collected by interviewers. Offending data were confirmed using penitentiary records. Mental disorders were assessed with the clinical version of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition Axis I Disorders, and personality disorders were assessed through the Spanish version of the International Personality Disorders Examination. RESULTS: The lifetime prevalence of mental disorder was 84.4%. Substance use disorder (abuse and dependence) was the most frequent disorder (76.2%) followed by anxiety disorder (45.3%), mood disorder (41%) and psychotic disorder (10.7%). The period (last month) prevalence of any mental disorder was 41.2%. Anxiety disorder was the most prevalent (23.3%) followed by substance use disorder (abuse and dependence; 17.5%), mood disorder (14.9%) and psychotic disorder (4.2%). CONCLUSION: Although period prevalence figures, which are those generally provided in research into rates of mental disorder among prisoners, are useful for planning improvements to services within prisons, the fact that almost all of these men had a lifetime prevalence of at least one mental disorder suggests a much wider need for improving services, including community services, for this group.

Aproximación al «esquema L» de Lacan y sus implicaciones en la clínica (parte II) / What the «schema L» consists of? (Part II)

En la segunda parte del trabajo intentamos presentar el funcionamiento global del «esquema L» y demostrar su utilidad práctica en el tratamiento analítico. En este sentido, en las relaciones sociales es el «yo» el que tiene todo el protagonismo, mientras el «sujeto» queda excluido de las mismas; de ahí que estos contactos cotidianos se muestren como la incomunicación más radical, aunque parezca lo contrario. El tratamiento que realizamos, por contra, debe escapar a esos parámetros, pues durante el mismo se procura que el «imaginario» facilite progresivamente la manifestación del «sujeto del inconsciente» en toda su dimensión, traspasando las constantes y molestas interferencias yoicas. Este procedimiento, si se realiza adecuadamente como Lacan nos enseña, permite que la «palabra plena» fluya entre paciente y analista, de modo tal que el contacto que se produzca sea de «sujeto» a «sujeto», mientras que en las relaciones sociales las conexiones se formulan en términos de «ego» y «alter ego». Para lograrlo, quién se coloque al lado del paciente debe saber que ha de ocupar el lugar de la alteridad radical, del «Otro», y no del «otro» especular (AU)

In the second part of this work we try to present the global function of the «schema L» and also to show its application in the psychoanalytical work. In this sense, it's in social relationships where the ego gets the leading role as the subject remains excluded from them, resulting in a lack of communication. The treatment we provide must scape from those parameters trying the imaginary to facilitate the unconscious subject display going through ego's interferences. To carry out this procedure properly according to Lacan's teaching lets the «true word» flows between the patient and the analyst as a «subject» to «subject» meeting, contrary to what occurs in social relations in which the connection goes from «ego» to «alter ego». To get this purpose, the analyst must take the place of a radical «Other» and not the specular «other» (AU)

Aproximación al «esquema L» de Lacan y sus implicaciones en la clínica (parte I) / What the «schema L» consists of? (Part I)

A lo largo de la obra de Lacan es común encontrar diferentes diagramas que pueden entenderse como intentos de formalizar ciertos aspectos de la teoría psicoanalítica; estos últimos deben quedar claros, al menos desde el punto de vista teórico, para poder actuar correctamente en el trabajo analítico. En esta ocasión, vamos a centrarnos en uno de ellos: el «esquema L», cuya presentación se produce en uno de sus seminarios orales, dedicado a la posición del «yo» en la teoría de Freud y que captó la atención de facultativos y especialistas de aquella época. En él su autor trabaja, de un modo ciertamente original, el funcionamiento de las relaciones intersubjetivas en sus conexiones con el lenguaje. En la primera parte del trabajo, vamos a estudiar los componentes del «esquema L» y las dos relaciones fundamentales que se establecen entre ellos y que forman los ejes «imaginario» y «simbólico». Lacan los considera en oposición pues se interfieren mutuamente, de modo tal que el mensaje inconsciente queda interrumpido o cortocircuitado constantemente por la relación imaginaria, formada por el «yo» y su semejante, el «otro» (AU)

Along Lacan's work it's usual to find several diagrams that can be understood as an attempt to conceptualize some aspects of the psychoanalytic theory. The latter ones must be clear, at least from the theoretical point of view, to be able to a properly psychoanalytic work. At this time, we are going to centred on one of them: schema L, whose presentation take place at one of Lacan's seminar about the ego position in Freud's theory and which catch the eye of specialist of that time. It's also an original way of expound the performance of the inter- subjective relations in its connections with the language. In the first part of this work we study the components of the «schema L» and two of the main relations among themselves that form the two axis: «imaginary» and «symbolic». Lacan consider these to be in opposition since they interfere with each other so that the unconscious message is broken by the imaginary relation between the ego and its equal «the other» (AU)

Psychological problems derived from mastectomy: a qualitative study.

Advances in treatment of breast cancer have not avoided using mastectomy in all cases, and when this happens, we are dealing with a woman who is suffering from psychological problems. In order to study this issue we have carried out a research with the collaboration of The Andalusian Association of Women with Mastectomies (AMAMA) in Seville, which provided us with a sample of 46 mastectomized women. The objective of this study is to analyze in depth the psychological reaction of women to mastectomy through its different stages from diagnosis to surgical treatment. We chose a cualitative method so as to explore the subjective components of psicologycal respons. As a result, we found in studied women: (a) The "fracture" of the "corporal imaginary" related to the disappearance of a valuable organ, linked to the feeling of loss of personal attractiveness, low self-esteem and avoidance of social relationships. (b) The problem with "femininity" has been linked to the issue of "desirability", something innate in the "feminine position". (c) Many of them keep in mind the idea of mutilation, as a "hole" which is impossible to integrate. (d) Finally, we demonstrate how certain features of personality made them especially vulnerable to the explained phenomena.

¿Por dónde seguir investigando en psicopatología? / No disponible

Las nuevas tendencias dentro de la psiquiatría le están quitando a la psicopatología el protagonismo que siempre ha tenido, alejándose esta última de las pretensiones de los autores clásicos que la fundaron como ciencia. En este artículo pretendemos darle su lugar y, sobre esta base, desarrollar una metodología apta para investigar en su campo y que ya hemos utilizado en algunos casos antes con resultados satisfactorios. Indagar en este terreno nos lleva a la observación y recogida del discurso del paciente en estado natural, sin interposición de nada y sin forzarlo. Ahora bien, la observación implica siempre que quién la realice se encuentre en una posición en la que no pueda «contaminar» el material recogido con sus conocimientos, creencias, valoraciones o incluso preocupaciones. Para lograr esta asepsia, el observador se colocará en una actitud en la que no presupondrá absolutamente nada, al tiempo que se abstendrá de cualquier juicio previo; de no actuar así, lo obtenido será aquello que ya se conoce, cayendo inexorablemente en la repetición. Lo descubierto tiene siempre un carácter novedoso que provoca cierta conmoción o asombro al ser hallado y su estatuto epistemológico es de «pendiente de asimilación». Finalmente, resta indicar que al material obtenido es posible aplicarle métodos formales, pero tienen que ser cualitativos y, para ello afortunadamente, las matemáticas modernas cuentan con numerosos modos de trabajar de este tipo (AU)

The current trends in psychiatry are taking off the psychopathology the leadership that it always has had, to distance themselves from the classical pretensions of the authors who founded it as a science. In this work we try to give it its place, so we are developing the methodology which should be used in order to examine the psychic symptoms, used previously by us with satisfactory results. In order to investigate in this field we are led to the observation and collection of the patient’s speech in this natural environment, without being forced to express himself. Now then, observation implies for the person who is taking it to remain in an objective position in order to not «infect» the research by being influenced by his knowledge, beliefs, evaluation or even his worries. In order to achieve this purification the observer will place himself in a distant position in which he will not assume anything, avoiding at the same time giving an early verdict; the consequences of not acting like that is coming back to what is already known, that is, returning inevitably to repetition. It is added to the matter that the research this study is based on is complex as well as having to divide it into small pieces; this is something which happens in a spontaneous manner when the act of speaking takes place, since any given speech proposes a peculiar characteristic of the issue. What is discovered has an innovative quality that may provoke either shock or astonishment once it is found out and whose statute is «waiting for assimilation». Eventually, needless to say that the formal methods can be applied to the obtained material in this research, but it is important to clarify these need to be qualitative too. For that reason, fortunately, modern mathematics rely on diverse ways which deal with this type of methods (AU)

Assessment study of insight ARTHRO VR (®) arthroscopy virtual training simulator: face, content, and construct validities.

The aims of this study were to test the face, content, and construct validities of a virtual-reality haptic arthroscopy simulator and to validate four assessment hypothesis. The participants in our study were 94 arthroscopists attending an international conference on arthroscopy. The interviewed surgeons had been performing arthroscopies for a mean of 8.71 years (σ = 6.94 years). We explained the operation, functionality, instructions for use, and the exercises provided by the simulator. They performed a trial exercise and then an exercise in which performance was recorded. After having using it, the arthroscopists answered a questionnaire. The simulator was classified as one of the best training methods (over phantoms), and obtained a mark of 7.10 out of 10 as an evaluation tool. The simulator was considered more useful for inexperienced surgeons than for surgeons with experience (mean difference 1.88 out of 10, P value < 0.001). The participants valued the simulator at 8.24 as a tool for learning skills, its fidelity at 7.41, the quality of the platform at 7.54, and the content of the exercises at 7.09. It obtained a global score of 7.82. Of the subjects, 30.8% said they would practise with the simulator more than 6 h per week. Of the surgeons, 89.4% affirmed that they would recommend the simulator to their colleagues. The data gathered support the first three hypotheses, as well as face and content validities. Results show statistically significant differences between experts and novices, thus supporting the construct validity, but studies with a larger sample must be carried out to verify this. We propose concrete solutions and an equation to calculate economy of movement. Analogously, we analyze competence measurements and propose an equation to provide a single measurement that contains them all and that, according to the surgeons' criteria, is as reliable as the judgment of experts observing the performance of an apprentice.

Ecografía de lesiones malignas de la mama en el Hospital V I Lenin / Breast Malignant Processes Echography at V I Lenin Hospital

Se realizó un estudio descriptivo de corte transversal en pacientes con el diagnóstico presuntivo de lesiones malignas en las mamas, provenientes de la consulta multidisciplinaria de cáncer de mama del Hospital VI Lenin en el período enero de 2004 a diciembre de 2005, a las cuales se les realizó ecografía de mama, con el objetivo de profundizar en su diagnóstico ecográfico. Existió predominio en mujeres premenopáusicas, siendo la mama izquierda y el cuadrante supero externo los sitios de localización más frecuentes. El patrón ecográfico más sugestivo de lesión maligna fue la imagen hipoecoica con cambios en su eco- estructura, ecos leves en su interior y de bordes irregulares. En cuanto a los resultados de la mamografía la presentación más frecuente fue la visualización de una mama densa de contornos irregulares con espiculaciones. Existió correspondencia diagnóstica entre ecografía y mamografía, y se consideró que constituye un método de elección en la evaluación inicial de lesiones malignas de mamas...(AU)

A descriptive and cross-sectional study was carried out in patients with a presumptive diagnosis of breast malignant processes . The patients came from the breast cancer consulting room at V I Lenin Hospital from January 2005 to December 2005. A breast ultrasound imaging was done aimed at deepening in the diagnosis which was predominant in pre- menopausal women , being the left breast external upper quadrant the most frequent site of localization. The most suggestive echography pattern of malignant processes was the image with changes in its echostructure, soft echos in its inner part and irregular edge were observed. According to the mammography results the most frequent presentation was the visualization of a thick breast of irregular edge with spicule formations. There was a diagnostic correspondence between the echogram and the mammography considering that this is an adequate method for the initial evaluation of breast malignant processes...(AU)

¿Qué hay de la calidad asistencial en la sanidad penitenciaria? Una revisión sistemática / Healthcare quality assessment in prisons. A systematic review

Objetivo: Realizar un diagnóstico de la situación de la calidad de la asistencia sanitaria en prisiones por medio de una revisión sistemática de la literatura científica disponible. Material y método: Se ha realizado una búsqueda en las principales fuentes bibliográficas disponibles (Medline, Excerpta Medica, Índice Médico Español, Biblioteca Cochrane) y en las páginas web de las administraciones penitenciarias de diferentes países. Se ha recogido datos sobre los modelos de organización de esta asistencia en distintos países, los sistemas de evaluación utilizados y cuáles son los resultados conseguidos respecto a su nivel de calidad. Resultados: La bibliografía disponible es escasa, la mayor parte publicada por administraciones públicas. Existen diferentes modelos de organización de la asistencia sanitaria tanto entre países como dentro de un mismo país. No existe un modelo común de evaluación de la calidad asistencial en prisiones. La metodología de evaluación más elaborada es la que presenta la administración penitenciaria de Inglaterra y Gales. No se ha encontrado ningún documento que describa un proceso completo de evaluación donde se controle desde el análisis de oportunidades de mejora hasta la comprobación del efecto de las soluciones propuestas. Conclusiones: La documentación publicada al respecto es escasa y está poco difundida. Existen varios modelos de cobertura sanitaria en prisiones. No se ha encontrado un método de evaluación que analice esta asistencia y aporte resultados. Es prioritario impulsar herramientas capaces de detectar necesidades en este medio para luego aplicar un método de evaluación encaminado a la mejora de la calidad asistencial en prisiones

Objective: To analyze healthcare quality assessment in prisons through a systematic review of the available scientific evidence. Material and method: A literature search was performed in Medline, Excerpta Medica, Índice Médico Español, the Cochrane Library, and the official web pages of prison administrations in various countries. Data on the organizational model of healthcare in prisons in different countries, the methods used in quality assessment and results were gathered. Results: There is little documentation on the subject, and it is not widely disseminated. Models of healthcare organization differ both among different countries and within the same country. There is no common model for evaluating healthcare quality in prisons. The most highly developed system is used in the prison administration of England and Wales. No article describing the whole evaluation process in prisons, including analysis of opportunities for improvement to evaluation of the results of the solutions proposed, was found. Conclusions: Few documents were found on healthcare quality in prisons. Various models of healthcare organization are used in the correctional setting. There is no common methodology to assess healthcare quality and results. Tools for needs' detection should be a priority as part of a broader model aimed at improving healthcare quality in prisons