Sanford Gifford

Psychological observations of patients undergoing mitral surgery: A study of stress☆

Summary Thirty‐two patients with mitral stenosis who had mitral surgery were interviewed by psychiatrists preoperatively and also postoperatively. An understanding of long‐term adaptation to progressive limitation of activities provided the necessary background for the recognition of emergency defenses as they developed in the hospital situation both before and after operation. The interviewing technique focused on emotionally meaningful material concerning the adjustment to limitation of activities and on the feelings and phantasies about the operation. Complete tape recordings were made of all the interviews. This information was then condensed to the essential preoperative and postoperative observations and charted with a brief interpretation of the psychological defenses illustrated by each case. The most important medical and surgical events during hospitalization were also reviewed. The patients were grouped according to the clinical classification of Harken and Dexter as follows: Group I, o; Group II, 5; Group III, 18; Group IV, 9 (in 4 of these, mitral insufficiency rather than mitral stenosis was predominant). There were 23 females and 9 males. The median age was 37 years. The medical histories were summarized and charted. The effect on the patient of learning that he had heart disease depended on the stage of his emotional development, his life circumstances, and his personality. The awareness of dyspnea was found to be a realistic response to the increasing disturbance of the cardiovascular function but was also influenced by experiences to which the patient was psychologically vulnerable. The attitude of the patients toward limitation of activity was influenced by the meaning of the illness to them. Long‐term psychological defenses included narcissism, submission to a higher power, and activity. Emergency defenses included immobilization, hysterical amnesia or depersonalization, belligerence, excitement, and desperate denial. In some instances the stress was so severe that the patients seemed virtually defenseless and were close to panic. In others the psychological defenses were inadequate and unsuccessful to such an extent that the patients bordered on psychosis. All of these complained of pain to such an exaggerated extent that it seemed to represent a masochistic clinging to suffering. The transference to the surgeon is described and psychotherapy is discussed.

Adrenal steroid excretion patterns in eighteen healthy subjects, tentative correlations with personality structure.

&NA; A correlative study of adrenal steroid excretion patterns and personality in 18 healthy young college men indicated (1) that the 24‐hr. urinary excretion rates of 17‐hydroxycorticosteroids and 17‐ketosteroids were relatively constant over a period of 5 wk.; (2) that individuals maintained the same relative position throughout this period of observation in regard to the others within the group studied according to an identifiable steroid excretion pattern; and (3) that the level of output of 17‐hydroxycorticosteroids could, in a general way, be related to certain aspects of personality. The analysis of variance technique was used to analyze the data statistically. The subjects were studied psychologically by means of tape‐recorded personal interviews with senior psychiatrists and also by psychological tests of perception including the Rorschach. The steroid values of the individual subjects did not vary significantly from day to day; nearly all of the variance was produced by the differences in mean levels from one subject to another. The 17‐hydroxycorticosteroid rather than the 17‐ketosteroid levels were used as a basis for psychophysiological correlation. The data suggested the tentative hypothesis that the more a person reacts emotionally, the higher the level of the 17‐hydroxycorticosteroids. The more guarded the individual, the more that control is exercised over feelings, the lower the 17‐hydroxycorticosteroids. At one extreme of a psychophysiological continuum are the individuals with vivid personal feelings who experience a sense of emotional urgency and, at the other extreme, those who.are relatively guarded and withdrawn.

Sleep, Time, and the Early Ego; Comments on the Development of the 24-Hour Sleep-Wakefulness Pattern as a Precursor of Ego Functioning:

After a brief review of the theoretical background, the purpose of this paper is to present the following hypotheses: 1. The adaptation of sleep and wakefulness to the 24-hour rhythm of night and day is an indication of early ego development, because instinctual needs are modified in accordance with periodic changes in the environment. 2. The %-hour sleep rhythm evolves as an interaction between the infant’s innate patterns of neurophysiological maturation and his relationship with his mother, mediated through diurnal variations in her response to his needs. 3. This adaptation to time, experienced as a periodicity in maternal responsiveness, reflects a primitive awareness of reality, before the infant’s differentiation between himself and his environment is complete. These hypotheses are derived from Kleitman and Engelmann’s (59) continuous observations on nineteen normal infants from the third to the twenty-sixth week of life. I have interpreted their statistical data as indicating three developmental phases, approximately corresponding to hypothetical phases of ego maturation. Using the continuity of the sleep-wakefulness pattern as a

An Unusual Adverse Reaction to Self-Medication with Prednisone: An Irrational Crime during a Fugue-State

During five years of self-medication with Prednisone, a forty-one-year old asthmatic businessman experienced periods of euphoria, psychomotor hyperactivity, and poor judgment; a period of depression and anxiety during temporary steroid withdrawal; and finally, with resumption of Prednisone, episodes of grandiosity and bizarre fugue-like behavior, with adoption of a second identity and culminating in an irrational crime. Steroids were then withdrawn, and the patient resumed his premorbid personality, but had amnesia for much of his previous behavior. The literature on hysterical fugues and corticosteroid-induced mental disturbance is reviewed. The patients reactions are analyzed in terms of his premorbid neurotic conflicts, the psychological stresses acting upon him, and the effects of Prednisone on his central nervous system.

Psychophysiological correlation of 17-ketosteroids and 17-hydroxycorticosteroids in 21 pairs of monozygotic twins ☆

Abstract Twenty-one pairs of healthy monozygotic male twins of college age have been observed in an attempt to correlate individual personality structure with characteristic and relatively enduring patterns of pituitary adrenocortical function. Ten pairs of comparable dizygotic male twins have been studied by the same methods. High levels of 17-OHCS excretion were found in individuals with forceful yearnings for close personal involvement or with active defenses against the threat of intimacy. Individuals with low 17-OHCS levels were more effectively isolated by well-organized neurotic defenses. High 17-KS levels were found in energetic, ambitious individuals with strong aggressive drives and equally strong defenses against them. Those with low 17-KS were over-controlled with apparently limited innate drive endowment. A one way analysis of variance was computed for both monozygotic and dizygotic. twins. The F ratio indicated that height, 17-KS mean values, and day-to-day variation in 17-KS might be influenced by genetic factors. The intra-class correlation in 17-OHCS means was just as great in dizygotic as in monozygotic pairs but the correlation in 17-KS means in monozygotic pairs was much higher than in dizygotic pairs. A contingency table was constructed by grouping the variation in 17-OHCS and 17-KS into quartiles. In 14 out of the 21 pairs of monozygotic twins both members of the pair were in the same quartile for 17-OHCS and 17-KS and both members of all the other pairs were in adjoining quartiles. The pyschological characteristics shared by all of the subjects in each contrasting quartile suggest meaningful correlations of steroid patterns with different but interrelated quantifiable ranges of psychological response corresponding respectively to the mean levels of the 17-OHCS and of the 17-KS.

SOME PSYCHOANALYTIC THEORIES ABOUT DEATH: A SELECTIVE HISTORICAL REVIEW

Freud made many contributions to the understanding of death, from his early speculations about magic thinking and the omnipotence of hostile wishes to his clinical observations on normal and pathologic reactions to bereavement. Two of his theories will be reexamined here in the light of questions raised by subsequent knowledge and experience. The first (Freud, 1915b) is his concept that in the unconscious there is no representation of one’s own individual death. This found some confirmation in the clinical studies of others on dying patients and children’s attitudes toward death, where it contributed to the understanding of various forms of denial. The present question is raised by certain historic experiences of the past 30 years, in which large groups were exposed to extreme situations, in extermination camps and the saturation bombing of urban populations, that included the certainty of death. Although it is well known that these situations mobilized extreme defenses, the possibility that some exceeded familiar forms of denial would require revisions in Freud’s concept of unconscious immortality. The second is the concept of the death instinct (Freud, 1920), which formed the basis for a dual instinct theory, that of sexual and aggressive drives, and remained an integral part of Freud‘s final theoretic revisions. The dual instinct theory was generally accepted, but the death instinct evoked “a genuine uneasiness” (Hartmann et al., 1949) or “a true shock reaction” (Brun, 1953) at the time and is still ignored “by perhaps the majority” (Brenner, 1955) of analysts today. Although Freud clearly defined the death instinct as a biologic, not a clinical, theory, it has exerted a perennial fascination on certain analysts, who have returned to it periodically with critiques, reevaluations, and attempts at clinical application. The question to be reexamined is the concept as a biologic theory of death, avoiding clinical issues and omitting a consideration of the concept as a biologic theory of aggression, which would require a different paper. Our focus will be on the biologic theories used by Freud and on the advances in present-day biology that have modified the basis for some of his speculations. The concept of the death instinct does not lend itself readily to an overall judgment but, in examining its various speculative aspects separately, some prove untenable, some find unexpected confirmation, and some can be admired for their qualities as pure speculation. The aim of this inquiry will be to suggest possible ways of looking at Freud’s theory today, for each to choose according to his own scientific and personal requirements.

A CLINICAL, PHYSIOLOGIC AND PSYCHOLOGIC STUDY OF 20 GERIATRIC CLINIC PATIENTS

Excerpt The establishment of the Pearl Geriatric Clinic at the Peter Bent Brigham Hospital promoted a focus of interest on the ambulatory elderly patient within a separate clinic activity. At the o...

Transient Disturbances in Perception: Two Psychoanalytic Observations:

Recent contributions to tlie problem of perception have been made by Deutscli (3, 4), Berman ( l ) , Linn (12), Fisher (7), Knapp (11) and Calef (2). Transient changes in perception, from sensory hyperacuity to severe unreality feelings, occur in states of inner conflict, under conditions of external danger or deprivation, and in response to certain drugs and hormones. Similar disturbances are often observed during psychoanalysis. Felix Deutsch (5) describes tlie shifting threshold of perceptual awareness as “a mirror of tlie instinctual equilibrium,” with increased responsiveness, to certain sensory stimuli when specific pregenital conflicts are mobilized. Two brief examples will illustrate different types of perceptual disturbance and their relationship to the patient’s cliaracteristic manner of handling sensory experience.

Book Reviews: Psychoanalytic History: PUTNAM CAMP: SIGMUND FREUD, JAMES JACKSON PUTNAM, AND THE PURPOSE OF AMERICAN PSYCHOLOGY. By George Prochnik. New York: Other Press, 2006, 455 pp.,

Over thirty years have elapsed since Nathan Hale’s admirable biographical sketch of James Jackson Putnam, which introduced his publication of the Freud-Putnam correspondence (1971). Putnam, hailed by Freud as the first American to interest himself in psychoanalysis, served as the reluctant founder and president of the American Psychoanalytic Association in 1911. Lesser figures in the history of psychoanalysis have received lengthy biographies, and at last George Prochnik has filled the gap in full measure. He happens to be the ideal author for this task, as the great-grandson of Putnam himself, familiar with the New England traditions of the Putnam family camp from his