Body self. Development, psychopathologies, and psychoanalytic significance.

Ego development or, more broadly, the sense of self has at its core a cohesive, distinct, and accurate body self. Compromise of body self development as a result of early overstimulation, empathic unavailability or nonresponse of the caretaker, and inconsistency or selectivity of response can lead to specific developmental arrests, including body-image distortions, nonintegration of body self and psychological self, and difficulties in the regulation of tension states and affect. The individual may then attempt to repair those disrupted developmental needs by such symptomatic expressions as eating disorders, compulsive exercise, substance abuse, and the creation of physical danger, as a step toward integration of mind and body as well as a defensive antidote to painful affect. In the psychoanalytic treatment of these patients, the need for the analyst's attunement to the patient's development of body self as well as psychological self development is illustrated by clinical vignettes of the enactments and attempted restitution of specific developmental trauma.

On compulsive shopping and spending: a psychodynamic inquiry.

Compulsive shopping and spending, an impulse disorder, form a specific psychodynamic complex with common developmental precursors of pathological narcissism. Compulsive shopping and spending are distinguished from other symptomatic uses of money and impulsive acts. Four cases illustrate some psychodynamic considerations and therapeutic implications.

Recurrent fever of unknown origin, coma, and meningismus due to a leaking craniopharyngioma.

A cyclic leaking craniopharyngioma was found to be the source of recurrent fevers, meningismus, and coma. A sterile persistent neutrophilic pleocytosis with normal glucose and protein was the only clue in an extensive workup. Three head computed tomographic scans, including double contrast with 5-mm cuts, failed to locate the large suprasellar cyst outlined finally by head computed tomographic scan with metrizamide. A handful of case reports exist about leaking central nervous system cysts, but their presentation tended to be different: increased protein, lymphocytosis, and positive cranial imaging. It is believed this is a unique case that adds to the spectrum of chronic neutrophilic meningitis.

Achievement inhibition in contemporary women: developmental considerations.

With a decrease in recent years in the external impediments which prevent women from realizing their full potential has come a better view of internal factors. The author explores developmental and psychodynamic issues in the paradoxical situation in which women fear to achieve what they have long desired. The author describes clinical manifestations of success phobia, and analyzes symptom origin within a developmental and psychodynamic framework, and illustrates the types of success inhibition arising from family and early social variables, separation-individuation problems, pathological narcissism, and Oedipal conflict.

Childhood parent loss: developmental impact and adult psychopathology.

A large number of cases in analytically oriented psychotherapy and psychoanalysis were studied to determine the developmental consequences of parent loss by death or continuous separation in childhood. The cumulative evidence from this data is that the meaning, impact, and consequences of parent loss on emotional development are determined both by the phase-sensitive issues impacted, as well as the unique interpretation by the child of the fantasied cause and effect of the loss event. Specific issues arising in treatment as a derivative of earlier parent loss are presented as they relate to developmental diagnosis, therapeutic alliance, transference, countertransference, mourning, and termination.

Physical findings in a psychiatric outpatient clinic.

To determine the frequency of previously undiagnosed, positive physical findings in a psychiatric outpatient clinic population, the authors examined the case records of 910 consecutively admitted patients who had been given screening physical examinations including urinalyses. They found that 20.4% of the patients had some medical abnormality that was previously undiagnosed, and they encourage psychiatrists to make the physical examination a routine part of their total psychiatric evaluation.

Stressful life events and the return to heroin use.

Patients on methadone maintenance were studied to determine which factors influence the continuation of heroin-free treatment, as opposed to the return to drug abuse. Psychosocial data, a Zung Depression Scale, and the Social Readjustment Rating Scale (SRRS) were collected on those patients who returned to heroin use while on a methadone maintenance program during the one year of study (n = 48); they were compared to a control group as well as to themselves during a heroin-free maintenance period. The group of patients returning to heroin use showed the existence of such events as recent loss, depression, and exacerbation of intense affect coinciding with the occurrence of heroin use. Furthermore, their SRRS scores and number of SRRS items were significantly higher than those of the control group and than their own steady-state scores. The number and magnitude of stressful life events seem significantly related to patients' not adhering to methadone maintenance and returning to heroin use. The understanding of the importance and adaptive function of drugs to the addict in regulating and ameliorating otherwise overwhelming and catastrophic affective states is underscored otherwise overwhelming and catastrophic affective states is underscored by this study. The total number of life stress events as well as the specificity of meaning to the patient are both emotionally important in understanding, intervening, and treating these patients.

Emotional rehabilitation of the physical rehabilitation patient.

Emphasis on the process and content of the emotional aspects of rehabilitation are presented as a process interwoven with a patient's physical rehabilitation. The impact of trauma and subsequent rehabilitation involves for patients the resolution of these stages: shock, denial, depressive reaction, reaction against independence, and adaptation. Factors which facilitate and impede the negotiation of these steps on both the part of the patient and attending staff are examined from the prospective of the psychiatrist as a member of the medical rehabilitation team.

Accidents masking suicide attempts.

Two case reports presented describe situations in which a patient presented in trauma due to an accident which masked a suicide attempt. Factors which obscure the suicide intent of an 'accident' include a dangerous vocation, lifestyle, or hobby, and absence of overt depression. These factors may aid in the identification of and appropriate intervention methods for patients presenting with masked suicide attempts.

Patient suicide: model for medical student teaching and mourning.

The molding of the physician's role and identity takes place during crucial clinical years in medical training. This professional identity is influenced by experiences and models. The suicide of a medical student's patient provides a natural experiment for observing and working with important aspects of the developmental process of physicians in integrating the affective component of clinical work and learning. The facilitation of grief and mourning in a medical student and his five colleagues assigned to the same outpatient psychiatric rotation are important aspects of the clinical, educational, and professional developmental issues raised by the patient's death.

The depressed patient.

SAdness and normal grief are distinguished from pathological grief and depression by intensity, duration, precipitating events, and the quality of psychopathological features. Depression is evaluated as a final common pathway of potential psychodynamic, genetic, psychosocial, physiological, and personality characteristics or events. The clinical entity of depression is diagnosed by describing some of each of the affective, behavioral, and cognitive changes concomitant with depression. The clinical entity of depression is further differentiated for purposes of treatment into the categories of bipolar depression (manic-depressive illness), unipolar depression (psychotic depressive reaction or involutional melancholia), neurotic depression, and secondary depression (secondary to somatic disease, drugs, or to other psychiatric disorders). The immediate treatment depends on the type of depression diagnosed. Unipolar and bipolar depressions respond to specific pharmacologic therapy and supportive care. Neurotic and characterologic depressions respond to supportive or insight psychotherapy with possible brief adjunctive anti-anxiety or hypnotic medication. All of the treatment modalities, with the possilbe exception of insight psychotherapy, can be effected very adequately by the primary care physician who is given clear diagnostic and assessment guidelines with specific treatment approaches.

Clinical considerations in the prescription of group, brief, long-term, and couples psychotherapy.

Differential clinical considerations for treatment prescription as an aspect of outpatient evaluation for psychotherapy is presented in overview. The indications and contraindications presented for each of the treatment modalities of group therapy, brief therapy, long-term therapy and couples therapy are based on psychotherapy evaluation, selection criteria and outcome research to date. The information and fund of knowledge of the psychiatrist about appropriate treatment prescription matched to the patient, his problems, and his motivation to work psychotherapeutically is an essential aspect of the initial evaluation.

Symptom passing in a transvestite father and three sons.

Three sons of a transvestite father engaged in cross-dressing beginning in early adolescence. The literature suggests that observation may play a role in determining the specificity of the symptoms of conflicted sexual identity. These cases of transvestism in offspring are unusual in that the father played an important role in symptom choice and modeling. It is hoped that in future studies of transvestism in the father will be examined in a more intensive way as a figure with whom an active identification process may evolve.

Unilateral ptosis as a conversion reaction.

This case report affords the dynamic understanding of a patient's conversion reaction of unilateral ptosis of the eye. The specificity of this manifestation of psychopathology is shaped by the patient's unconscious ideas about disease and the suitability of this symptom for the symbolic representation of her primary conflict.

Suicide attempts by rock-climbing falls.

The true intent of a suicidal act is sometimes masked by it appearing as an "accident". Two cases are reported that present a unique opportunity to study suicide attempts that took the form of rock-climbing "falls" and to study the two people who chose this way to die. Rock-climbing falls, occasionally speculated about as possible suicidal equivalents yet having no recognition as such in the literature, are illustrated as methods used by these impulsive, action-oriented and risk-taking people.