Defense and resistance in the psychoanalytic process.

"Defense" and "resistance" are usually regarded as two separate and distinct concepts, the first belonging to psychic functioning in general and the second to therapy, yet this distinction is far from constant. Clinical observations indicate a frequent overlapping of these two mental functions or positions. A patient's behavior may convey the meaning of either or both concepts, and a position or response that one assumes to bespeak resistance may reveal defense instead. This state of affairs may be seen in the analysis of patients with a relatively well-integrated neurotic identity, but its main import is in the analysis of psychosomatic patients and those with severe personality disorders. Insufficient holding experiences during the infancy of these patients do not enable them to develop functional structuralization. Deficient mothering in the first stages of life also prevents the stable differentiation between defense against threats from within and resistance against influence from outside.

Autodestruction and nonexistence: two distinct aspects of the death drive.

The concept of the death drive is more frequently employed by European than by American psychoanalysts, although it is not unanimously accepted even by the former. In recent years there have been attempts to disconnect the longstanding theoretical link between the drive and aggression, in keeping with the observations of various nondestructive components of the death drive. A hitherto unmentioned aspect of this drive is the yearning for nonexistence, a shadow-like counterpoise to life, expressed by two analysands. Both had childhood histories of life-threatening disease without sufficient compensatory maternal presence at the time. Both displayed massive dissociation from their own body and its vital functions, as well as from objects and their representations. The death drive could be viewed as a continuum with the autodestructive aspect, or the striving for death, at one end, and the component of nonbeing, or the yearning for nonexistence, at the other end.

The attitude of chronic hemodialysis patients toward dental treatment.

Dental care of hemodialysis and renal-transplant patients involves various psychological parameters. Their basic illness affects their dental anxiety, self-image, active motivation to cope with difficulties, and appreciation of oral health. These parameters were measured by four specific questionnaires in fifty subjects: 25 renal patients and 25 matched controls. Renal patients showed significantly less dental anxiety than did controls, and also less concern about oral health. Patients' coping with difficulties was equal to controls, while their self-image was even more stable. The unusual findings in these patients demonstrate the importance of dentists' cooperation with nephrologists and psychiatrists.

The elderly patient.

Elderly patients' age affects various bio-psycho-social parameters of their diseases. A patient's old age itself often evokes a multiform recoil in dentists, directly opposite to the required therapeutic attitude. The essential principle in gerodontics is dentist-patient cooperation, attainable only if the latter is approached in a holistic and respectful manner.

The death instinct.

The death instinct has always been a controversial concept, insufficient to account for actual dying, and usually taken to be fused with aggression. After dislodging it from the shadow of aggression in order to evaluate its function, the instinct turns out to be one of the components that form the death motivation. Human beings develop a complex motivation for death, one that is more than biology (instincts) or physics (entropy). It includes (a) the death instinct, the primary analogue; (b) sequellae of the universal experience of object-loss, with identification and fantasies of a restorative reunion; (c) guilt over hostile attitudes toward the lost object, with depression, longings for atonement , and self-punishment; (d) compliance with reality, like that of old age or grave sickness. Examined in light of the complementary series of Freud's aetiological equation, the death instinct turns into a precondition of the composition motivation. Death motivation is a comprehensive concept, since patients express various of its aspects during their psychoanalyses , and it facilitates a metapsychological understanding and refines the accuracy of interpretation.

Evaluating cosmetic results in maxillofacial prosthetics.

Fifty-two patients with maxillofacial prosthetic restorations answered questionnaires to measure their feelings of well being. Their overall scores averaged 38.6%. Subsequently, three independent observers reported their evaluation for each patient, yielding a combined improvement score of 35.1%. The apparently low figures reflect the strict criteria used. Men patients showed a greater response than women patients both in subjective questionnaire scores and objective evaluation rating. Greater improvement was reported in younger patients, yet the objective evaluators found better success in the older age group. The original etiology of the maxillofacial defect, i.e., traumatic injury, congenital malformation, or surgical tumor excision was the most important factor in the evaluation. Questionnaire scores were similar in all categories. However, the objective evaluation, especially that of the sculptor, who judged color slides alone, was significantly higher in the injury group than in cancer patients. Apparently, the inner desperation of many cancer patients is apparent in their facial appearance even after complete prosthetic rehabilitation. Such patients deserve greater psychologic attention during their treatment. Prosthodontists should realize their tendency to be hypercritical of their own treatment results. Their constant striving for improvement in their treatment results leads them to belittle their achievements and to underestimate their success. Public opinion, as represented by the artists, is significantly more enthusiastic about maxillofacial prosthetic achievements.

Assessment of children's anxiety throughout dental treatment by their drawings.

The handling of anxiety is of paramount importance during dental treatment of children. A simple and convenient method to measure this anxiety is based upon children's color drawings, prior and during the treatment course. One hundred and ninety-two drawings were done by fifty-five children, aged six to seven years, of whom forty-five children completed a full course of treatment. Their clinical behavior was also assessed and recorded. A combined analysis of the drawings and the clinical behavior pointed at an increase of anxiety after the first treatment session and a decline after the second one. After completion of treatment the rating of the children's behavior became similar to that of the initial visit; however, manifest anxiety was still expressed in their drawings. The analysis of the Dental Anxiety Scale (DAS) proved to be a sensitive and simple method for the pedodontist.

Stress, anxiety and the dental patient: the missing specification.

The importance of stress and anxiety as contributing to the complex aetiology of dental disease is becoming more widely recognized. Clinical examples of organic dental disease which were relieved when their psychological causes had been uncovered are described. It suggested that specialized psychiatric skills are not always necessary in dealing with such cases. The dentist's own personal life experience, his human understanding and his interest his patients' well-being are usually sufficient. Equal attention must be given to all data in both physical and psychological spheres if the patient's best interests are to be served.

Dental patients: motivation, resistance and cooperation.

Successful dental treatment depends on cooperation which is, in turn, influenced by the motivation (M') to receive therapy - as well as by recoil and resistance. M' reflects a patient's personality with all its complex patterns of psychological drives: natural (congenital?) tendencies and acquired habits, reactions to past dental experiences. Many of these factors remain unconscious in the patient. M' reflects the basic personality mechanisms, as well as actual needs, dental (healing) and non-dental, non-somatic. These latter needs are related to hypochondriacal insecurity, or to attempts to obtain a "secondary gain", etc. Some of the factors are not even related to the patient himself but rather to social forces, to the issue of payment, and to the dentist's characteristics. Aiming at maximal therapeutic efficiency, and for an optimal handling of patients' motivation, the dentist should pay attention to their personality patterns. His clear, openly expressed interest in their total life circumstances and their existence, as extension of his history taking and oro-dental examination, together with a firm, positive approach - these reduce anxiety and diminish resistance in many cases, for a better cooperation.