The wooden shell. The legend as representative of the early stage of development.

Legends serve as an important means of expressing fears, wishes, and fantasies. One of the best known and beloved legends worldwide is the nineteenth-century tale of Pinocchio, the wooden puppet who becomes a "real boy," or, as eventually becomes apparent, the boy enclosed in a wooden shell. This protective shell is an extremely interesting symbol and may be the reason the story holds a special place in the human experience. This paper discusses the significance of the wooden shell in the early protection of the developing psyche against invasive stimuli. In cases of normal development, this rigid enclosure is eventually discarded as the psyche matures. However, in pathological situations, it may remain a static, inhibitive shield. We describe the case of O., whose shell prevented his healthy interaction with the environment, and discuss how his problem was managed in the context of the legend. We also discuss related theories of the envelope of the ego.

Correlation of work structure and job satisfaction among Israeli family physicians.

BACKGROUND: Physicians need a professional environment that is conducive to efficient and satisfying work. Little has been published about the effect of work structure on the satisfaction that family physicians derive from their work. OBJECTIVES: To assess the structure and the positive and negative job components of family physicians in Israel, as well as the effect of these components on their satisfaction with their work. METHODS: A questionnaire was sent to a random selection of members of the Israel Society of Family Physicians (n = 225). RESULTS: Altogether 183 questionnaires were returned. Specialist family doctors, practice medical directors and salaried doctors were involved in more activities than non-specialist doctors, trainees and self-employed doctors. Overall satisfaction was highest for specialists and lowest for non-specialists. Work overload, insufficient resources and abundant paperwork were most frequently cited as negative work components. The opportunity to utilize medical knowledge, challenging work and work variety scored highest as positive components. CONCLUSIONS: The more professionally active physicians were also the more satisfied. Clinical work and teaching provided the most satisfaction, while administrative work and lack of time were the main causes of dissatisfaction.

Psychiatric liaison with a primary care clinic--14 years' experience.

An analysis is presented of the experience of a psychiatric liaison team that visited one primary care community health center on a monthly basis for 14 years. The content of the liaison changed character over time, starting as a teaching relationship and developing successively into case discussions, tripartite consultations with joint interviews, a satellite psychiatric clinic, a Balint group, observation of routine general practice consultations and, finally joint assessments of video-tapes of routine consultations. The primary care team of nurses and doctors developed insight into the complexities of their relationships with each other and with their patients. The psychiatric team developed a more holistic view of psychological distress in the community and of the therapeutic potential of routine primary care. The patient population benefited from the improved accessibility of psychiatric care and from the increased psychological sensitivity of their doctors and nurses.

Mianserin, a 5-HT2a/2c and alpha 2 antagonist, in the treatment of sexual dysfunction induced by serotonin reuptake inhibitors.

Sexual dysfunction is commonly encountered in patients treated with antidepressants. The exact mechanism responsible for the sexual impairment is as yet unclear, although activation of the serotonergic system has been implicated. In the present study, we examined the effect of the 5-HT2a/2c and alpha 2 antagonist mianserin in the treatment of patients with sexual dysfunction induced by serotonin reuptake inhibitors (SRIs). Mianserin 15 mg was coadministered to 15 male subjects with new-onset sexual dysfunction who were under treatment with SRIs. Four major domains of sexual activity-desire, erection, orgasm, and satisfaction-were assessed once weekly for 4 weeks. At the end of the study, 9 of the 15 subjects reported a marked improvement in their sexual functioning, 2 reported partial improvement, and only 4 subjects showed no improvement at all. The beneficial effects were prominent in the areas of orgasm and satisfaction and were usually noted within the first and second week of mianserin treatment. The addition of mianserin to the treatment regimen was not associated with either improvement or worsening of the basic psychiatric clinical status. It appears that the coadministration of low-dose mianserin may be an additional option in the treatment of sexual dysfunction induced by SRIs.

The candidate and the patient: some transferential and counter-transferential aspects of the reality of apprenticeship.

This paper examines the impact of apprenticeship on the analytic process. It describes how the reality of the apprenticeship appears in or even intrudes into the transference-counter-transference dialogue. The clinical examples illustrate the use of candidate-analyst's reality as a defence. In the authors' opinion, the realistic aspects of the apprenticeship should be analysed as a part of the transference and counter-transference. The candidate is in a narcissistically vulnerable position between the analysand and the institute, and therefore prone to a Talion-like response and to displacement of aggression. An appropriate working through of apprenticeship difficulties should take place in a double dialectical process between candidate and analysand, and between candidate and institute representatives.

Working through the experience of time in time-limited therapy.

The experience of time is a component in the psychic reality that can be understood from four standpoints: the cognitive, the dynamic, the existential-affective, and the life-span linked. This article presents a time-limited therapy in which the stress was on the constant interaction between the therapeutic content, which focused on the topic of time, and the singular setting of time-limited therapy. The discussion addresses the requisite conditions for turning short-term therapy into an active container for working through the sense of time, its meanings and its derivatives.

The third party in general practice consultations.

OBJECTIVE: To describe the impact of outside agents in doctor-patient consultations. DESIGN: In-depth group discussions with psychoanalytically oriented leadership. SETTING: A Balint group which met weekly for two years. SUBJECTS: 15 senior general practitioners with an interest in teaching. FINDINGS: Outside agents are almost invariably present in general practice consultations. The "third party" in the consultation fitted four separate categories according to its helpful or disturbing, real or projected characteristics. CONCLUSION: The dyadic nature of general practice consultations is illusory. The third party is an inherent component of the consultation and may be used consciously to gain extra insight into the needs of patients and their doctors.

Changes in the therapist's working theory.

Theory, a system of ideas aimed at explaining clinical data, has in psychoanalysis (and in psychotherapy) a preponderant and subjective status in the mind of the analyst. It is a part of the conscious and unconscious world of the analyst and intertwines with his personality. A free, fluent therapeutic process demands a constant dialectical movement between theory and practice. Dogmatic or rigid application of theory, or its ever possible use as a defence or counter-resistance, freeze the dialectical movement. Two short vignettes illustrate the use and misuse of theory. The discussion focuses on how to bring together the vertex of the analyst and the vertex of the patient, the already-known theoretical knowledge with the not-yet-known discourse of the patient. Free floating theorization (Aulagnier) enables a bridging of the gap and will make a flexible use of theory possible.

Psychotherapy of an Arab patient by a Jewish therapist in Israel during the Intifada.

Fragments of a psychotherapy of an Arab patient by a Jewish psychotherapist in Israel, during an exacerbation of a historical political conflict, are presented. In addition to the delineated characteristic difficulties embedded in a cross-cultural/ethnic/national psychotherapy, an Arab-Jewish dyad evokes a complicated interaction between external political reality and the therapeutic space, confusing and obscuring the discourse, the transference, and the countertransference. We believe that the complex and intricate relationship between external reality and inner psychic reality, as it appeared in the therapeutic space, endangered the psychotherapeutic process by blurring the boundaries and creating a fertile ground for projective identification. Both the use of political reality as a defense, or its denial may preclude the possibility for a real dialogue. Implications for emphasizing the differences between patient's and therapist's ethnic affiliations, guarding sensitively the authenticity of interaction, and strengthening both participants' identity in all the relevant levels are pointed out to facilitate the dialectic process of the psychotherapy.

The doctor and his feelings: a course for residents in family medicine.

A course on the doctor and his feelings was presented as part of a programme for family medicine residents. The course was led by family physicians and behavioural science professionals who taught as an integrated team. Various teaching techniques were utilized to highlight emotional aspects of the doctor-patient relationship to inexperienced residents. Pre- and post-course assessments suggested there were benefits in a short intensive course of this nature. Possible explanations for the findings are discussed.

Hypochondriasis, acting out and counter-acting out.

The clinical picture of hypochondriasis is clear, the psychopathological structure less so. Hypochondriasis is characterized by a particular kind of acting out, basically medical, which in turn is likely to evoke medical counter-acting out on the part of the therapist. Acting out may be 'broad', as a character trait, and 'narrow', in close connection with the psychotherapeutic process. The medical acting out of the hypochondriac, 'broad' prior to therapy and occurring outside of the therapy situation, in the course of therapy becomes 'narrow' and contained within the boundaries of therapy.

Behavioral treatment of essential hypertension: a comparison between cognitive therapy and biofeedback of heart rate.

The efficacy and the mechanisms of action of two behavioral treatments for essential hypertension were compared: cognitive group therapy for anger control and biofeedback for heart rate control. The cognitive therapy aimed at lowering the "general anger" level and helping overt expression of "anger out;" heart rate biofeedback aimed at slowing heart rate in stress situations. Ninety-seven essential hypertensive patients were randomly assigned to three groups; after 20 dropouts, 77 patients fully participated in the study: cognitive treatment (N = 30), biofeedback (N = 27), and control (no treatment, N = 20). The treatments were held in 17 weekly sessions; during treatment, blood pressure was measured once a month, and during follow-up after 1 and 6 months. The anger level and heart rate control were assessed at the beginning and the end of treatment. The main results were: 1) a significant decrease of blood pressure for both treatments as compared with control, 2) a significant decrease of blood pressure with heart rate biofeedback as compared with cognitive therapy, and 3) a better control in anger achieved with cognitive therapy and a lesser control in heart rate as compared with biofeedback.

Khat-induced hypnagogic hallucinations.

Khat is a plant whose leaves are chewed for their stimulating effect. This effect is attributed to cathinone, an alkaloid identical to dextroamphetamine. Khat chewing is widespread among eastern African and Yemenite populations and is believed to be innocuous. Our experience shows, however, that a substantial number of chronic khat chewers experience persistent hypnagogic hallucinations - a symptom that has not yet been described. Three vignettes illustrates this phenomena, which often interferes with psychiatric diagnosis. Different explanatory models are discussed, among them chronic suppression of REM sleep.

Peripheral benzodiazepine binding sites on platelet membranes are increased during diazepam treatment of anxious patients.

Reduced (24%) [3H]PK 11195 binding capacity to platelet membranes was observed in anxious patients in comparison to age- and sex-matched normal controls. Four weeks of diazepam treatment induced elevation (69%) in the maximal number of binding sites, and 1 week of drug withdrawal resulted in a slight decrease (16%) in 'peripheral' benzodiazepine binding sites as compared to their level during treatment.

[The concept of madness in Talmudic literature and its commentaries]. / Le concept de fou et ses implications dans la littérature talmudique et ses exégèses

In spite of their spatial and temporal dispersion, the talmudic literature and its commentaries proceed from a fundamental unity. On one hand, the definition of madness are, a priori, extremely rigid; originally, they were exemplaries, quoted to resolve practical problems. On the other hand, the handling of these definitions requires a very important suppleness in the jurisprudence of legal implications of madness. Obviously, the dialectics of the rabbis show the care to respect the personal life of the individual and the spiritual life of the community. And if these conceptions have still an application nowadays, that is because the Talmud speaks of the mad and not of the mental ill without any cross-checking between the socio-legal model of madness and the medical model.