The uses of moral ideas in the mastery of trauma and in adaptation, and the concept of superego severity.

The power of moral ideas, here equated with superego strength, has been explained in increasingly complex terms over the course of the development of psychoanalysis. At first regarded mainly as useful in opposing oedipal instinctual demands, morality came to be seen also as opposed to aggressive wishes while at the same time capable of gratifying aggressive and libidinal forces. In this paper, I discuss the contribution to the strength of morality that comes from the effects of painful ("traumatic") experiences and from the use of moral ideas for social, adaptational purposes. In addition I consider the possibility that unchanging moral ideas can have changes in function in clinical work. A case is presented to illustrate these points.

The contribution of Hartmann's adaptational theory to psychoanalysis, with special reference to regression and symptom formation.

My experience of clinical work is consistent with the conclusion that both practice and theory are improved by applying the contributions of Heinz Hartmann. His work provides an important conceptual bridge to understanding the adaptive and pathologic changes that appear in the course of human development. The specific details of those changes are just as much an issue demanding the analyst's attention as is the tracing of patterns of childhood instinctual life. In this paper, I will point to some areas of controversy where renewed attention to Hartmann's ideas might be useful, and I will attempt to illustrate the clinical utility of his theoretical contributions.

Cognitive difficulties in psychoanalysis.

The author rises a number of questions about cognitive difficulties in relation to psychoanalysis. He presents the case of an adult patient in whom previously unrecognized childhood cognitive difficulties were discovered during the course of analysis. Their relationship to the patient's problems in adulthood is discussed. Some suggestions and speculations about the questions raised are presented with the hope of stimulating further exploration of what the author considers to be an interesting and important subject for psychoanalysis.

On examination dreams.

The literature concerning examination dreams is reviewed, and the case of a patient who had a number of examination and examination-like dreams is described. Examination dreams are related to traumatic dreams, "idiosyncratic" dreams, and various behavioral expressions. In addition, constitutional factors involving impulse-defense imbalance, childhood experiences with physical difficulties and medical examinations, and ambivalent identifications and object relations seem to find representation in these dreams.

Pancreatic disease.

New tests and test methods aid in the diagnosis of pancreatic disorders. Pancreatic carcinoma, especially, may have an improved prognosis with earlier detection as a result of refinements in arteriography, cytology, pancreatic radioisotopic scanning, and endoscopic retrograde cholangiopancreatography. Acute pancreatitis results most commonly from alcoholism, biliary tract disease, and trauma. Management is directed primarily at decreasing pancreatic exocrine secretion. Surgery is usually best avoided in the acute phase. Chronic pancreatitis is most often a result of recurrent attacks of acute pancreatitis. Diabetes and malassimilation become manifest as pancreatic destruction progresses. Management consists of replacement of pancreatic enzymes and diet supplements. Once chronic pancreatitis is established, surgery can only be directed at complications of the disease. Pancreatic ascites is usually associated with a break in the pancreatic ductal system. Ascites caused by trauma responds well to surgical intervention, but the alcoholic type is less amenable to treatment.