Screen reconstructions: traumatic memory, conviction, and the problem of verification.

Just as formerly recalled screen memories may be remembered again in the course of psychoanalysis, so new screen phenomena can arise during the treatment process. This paper attempts to relate the process of reconstruction and the occurrence of a type of screening. It is proposed that, under certain circumstances, psychoanalysis can result in a mutually determined screen construction that both patient and analyst consider convincing and valid but which may, for the most part, actually be untrue as a result of the screen function. Screen memories arising during the reconstructive process resemble the déjà vu and déjà raconté situation in that the experience is felt with certainty to have actually occurred previously, although a degree of doubt about its having happened can consciously or unconsciously coincide. Factors contributing to the formation of screen constructions include regressive aspects of the analytic situation; superego elements and the experience of an injunction to remember; the wish to witness what took place in the past; direct or indirect suggestive influence by the analyst; a defensive identification with the analyst; and the analyst's theoretical orientation to reconstruction. Like a screen memory having some veridical content yet serving a masking function, a screen construction can have elements of truth. At the same time such constructions may function as a strong resistance of compromise against intense erotic, sadomasochistic, or narcissistic themes in the transference/counter-transference that were painful or conflictual in the past. If screen constructions are assumed to be historically real or valid, they may not be analyzed for their transferential screening role. A previously published case involving a presumably repressed memory of sexual molestation is considered from the perspective of the possible development of a screen reconstruction. Clinical and scientific aspects of seeking extra-analytic confirmation or falsification of reconstructions are discussed.

Suggestion and veridicality in the reconstruction of sexual trauma, or can a bait of suggestion catch a carp of falsehood?

Freud used the term suggestion in psychoanalysis in different ways, including suggestion as an integral part of the transference and suggestion in the sense of undue influence or technical error. This distinction can be expressed in terms of the patient's suggestibility (capacity for transference) and the analyst's unwarranted suggestion or persuasion representing countertransference, theoretical bias, or a departure from technical neutrality. Whether suggestion is explicit or implicit, the effects of suggestion and suggestibility may be mutual and reciprocal. To the extent that a psychoanalyst maintains the goal of technical neutrality, undue suggestion is likely to be minimal. To the extent that it occurs for transferential or countertransferential reasons, suggestion may itself be analyzed. Problems of suggestion are more likely to occur and persist when they are part of the analyst's theoretical orientation, influencing the course of the analysis and expressing compromise formations for both patient and analyst. At times, even tentatively stated words or unintended behaviors of the analyst can have a dynamic impact that may not be readily analyzed. The analytic situation itself may have retrospective (nachträglich) action. A previously published case is described in which an apparent enactment led the analyst to urge a reconstruction of sexual abuse even though the patient never actually recalled what was presumed to have been fellatio. The need for technical neutrality and alternative reconstructions in such cases is considered. The degree to which the personality and goals of the analyst influence the course of reconstruction remains a vexing issue for psychoanalysis as a scientific endeavor. There is a need for detailed analytic case studies in which alternative reconstructions can be compared by investigating opportunities for external confirmation or falsification.

Karl Abraham, Sigmund Freud, and the fate of the seduction theory.

Even after Freud had turned his attention away from the seduction theory of neurosogenesis, his close pupil and colleague, Karl Abraham, initially sought to investigate child sexual trauma further. In two of the very first articles on child sexual molestation, Abraham proposed that sexual abuse was particularly common among neurotic and psychotic patients as a result of a "traumatophilic diathesis," a trauma-related conceptual precursor of the repetition compulsion. In their correspondence, Freud trenchantly criticized many aspects of Abraham's papers on the subject of sexual trauma, in contrast to his public endorsement of Abraham's work in this area. For largely transferential reasons that this paper attempts to elucidate, Abraham did not encourage dialogue regarding persistent questions on the seduction issue, ceased publishing on that topic, and for some time controlled his apparently deep rankle over Freud's criticisms and failure to acknowledge Abraham's contribution to the concept of the repetition compulsion. Despite their close friendship and shared intellectual enthusiasm, Freud's response to Abraham's 1907 papers, as well as Abraham's almost uniformly positive disposition toward Freud, apparently prevented Abraham from further developing his observations and ideas on seduction and also lent background to their later clash. Subsequently, there was virtually no further psychoanalytic investigation of the subject of child sexual abuse until the issue arose briefly with Ferenczi in the early 1930s, and only occasionally after that for the next fifty years. The death of Abraham, and then Ferenczi, shortly after disputes with Freud may be among the factors that had an inhibiting effect on an earlier reconsideration of the seduction theory by others. Abraham's previously unheralded concept of traumatophilia has relevance to current clinical controversy regarding constitution and sexual trauma.

Differential constructions of trauma in cases of suspected child sexual molestation.

Despite increased attention within psychiatry and psychoanalysis to childhood sexual abuse, the problem of cases in which sexual abuse is suspected but cannot be verified has received relatively little consideration. Just as underattention to the possibility of molestation as a cause of sexual trauma can fail to address the child's environmental and therapeutic needs, so a premature conclusion that molestation did occur may skew the course of treatment and have adverse medicolegal ramifications. Although the occurrence of molestation may be verifiable, its absence generally cannot be proven. However, some cases of suspected or equivocal child sexual abuse may involve trauma other than frank molestation. In unclear or equivocal situations, extended diagnostic formulation or treatment with attention to reconstruction may lead to an explication of the symptoms that is at least plausible. In this report, cases thought to involve possible sexual molestation are presented to illustrate alternative formulations or constructions of the trauma. A psychoanalytic perspective can be useful in the approach to such cases.

The reconstruction of early childhood trauma: fantasy, reality, and verification.

The contrasting perspectives of historical (actual, material) truth as opposed to narrative (intrapsychic) truth in psychoanalytic reconstruction parallel the controversial shift in Freud's thinking from a traumatic theory of neurosogenesis to a greater emphasis on fantasy and psychic reality. Freud and analysts since have sought to tease apart psychic and material reality as they dovetail in the transference. However, published cases in which a patient's memory of a childhood trauma turned out to be a verifiable fantasy or false belief and not an actuality appear to be remarkably scarce. This paper describes a case in which the patient indicated that in early childhood she had been subjected to antimasturbatory measures and finally to clitoridectomy that had ongoing traumatic effects. The case strikingly illustrates how a false memory of shock trauma may represent effects of strain traumatization interacting with fantasy and the state of drives and ego development in early childhood. It also highlights issues in the areas of trauma and memory, historical and intrapsychic truth, and the theory and technique of psychoanalytic reconstruction. Although it may not always be possible in the psychoanalytic situation to differentiate actual and plausible past events, in some cases the distinction between these perspectives on truth has clinical relevance that is more than academic.

The concept of an organic dissociative syndrome: what is the evidence?

The question of whether organic conditions, such as complex partial seizures, can cause dissociative symptoms is controversial. Although a diagnostic category for organic dissociation is included in the tenth edition of International Classification of Disease, it has never been identified in the Diagnostic and Statistical Manual. Its inclusion in the upcoming DSM-IV is currently under debate. This article surveys representative literature regarding the role of organic factors in the causation of dissociative symptoms and considers the differential diagnosis of organic dissociation from current and historic perspectives. Dissociative symptoms and disorders (including amnesia, fugue, depersonalization, multiple personality, automatisms, and certain furors) can be induced by a variety of medications, drugs of abuse, and medical illnesses or conditions affecting cerebral function. Organic dissociation can be distinguished from intoxication, amnestic disorder, and delirium. Psychiatric nosology and our conceptualization of altered mental states and functions would benefit from use of the concept of an organic dissociative syndrome, which has clinical, neurophysiologic, and medicolegal significance. Such a category should be included in DSM-IV.

Pseudodementia and competency.

An increase in the number of challenges to competency determinations in probate cases parallels an increasingly aging population. In the literature on competency determination, there is little if any discussion of the implications of pseudodementing conditions, which can quite readily be misdiagnosed as true dementias, especially in the elderly. This case report describes a patient thought to have had a stroke with dementia and paresis who turned out to have had a pseudodementia. She later made a dramatic and somewhat surprising recovery. It subsequently came to light that a nearly successful attempt had been made to defraud her of her estate during her presumed dementia, which was thought to have been irreversible. The case underscores issues in competency determination, including matters of diagnosis, prognosis, and undue influence.

Organic dissociative syndrome associated with antimigraine pharmacotherapy.

This report describes an acute organic brain syndrome with a fugue-like state in association with antimigraine pharmacotherapy. The differential diagnosis of: 1. possible psychotoxic effects of the combination of propranolol, imipramine, and butalbital; 2. confusional migraine with amnesia; and 3. psychogenic dissociation is considered. Although organically induced dissociative states are of clinical, neuropsychological and medico-legal significance, the DSM-III and DSM-III-R have specific categories only for dissociative conditions that are strictly psychogenic in origin.

Substance-induced dissociative disorders and psychiatric nosology.

Transient amnesias, fugues, twilight states, automatisms, depersonalization, and furors or explosive disorders can occur in association with, or be caused by, various medications or substance-induced organic brain states. Agents capable of precipitating dissociative-like states include alcohol, barbiturates and similarly acting hypnotics, benzodiazepines, scopolamine, clioquinol, beta-adrenergic blockers, marijuana and certain psychedelic drugs, general anesthetics, and others. The presentations of substance-induced dissociative states may resemble those of functional dissociative disorders, or organic and psychogenic dissociative factors may coexist and be intertwined or indistinguishable. Organic dissociative states are distinct from intoxication, amnestic disorder, frank delirium, or other organic mental disorders as specified in DSM-III and DSM-III-R, yet these diagnostic manuals have no inclusive category or coherent nosological approach to dissociative states not strictly psychogenic in etiology. Substance-induced and other organic dissociative disorders can have clinical, medicolegal, and neuropsychological significance. They provide a unique opportunity for the study of mind-brain relationships and should be included in psychiatric nosology.