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1/9. Is it organic or is it functional. Is it hysteria or malingering?

    Conversion hysteria, a common affliction, requires prompt diagnosis and treatment to prevent fixation of the incapacity and secondary contractures, and to protect the patient from unnecessary surgery. Diagnostic and therapeutic principles are outlined.
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2/9. Alexithymia and the effectiveness of psychoanalytic treatment.

    A subgroup of those patients who are not responsive to analytic treatment, despite meeting the usual criteria of analyzability, is considered. These patients typically have significant addictive, psychosomatic, and post-traumatic problems. They show a characteristic picture, now called "alexithymia." This involves an impairment of the ability to recognize, name, or verbalize emotions. The effects manifest themselves mainly in mixed physiological responses, which call attention to themselves rather than to their meaning or story. These emotions, which are less useable as signals, are dedifferentiated and resomatized. There is also a type of "operative thinking" with marked limitations in wishfulfillment and drive-related fantasy. There is a diminution of symbolization, and with it an impairment in the capacity to elaborate the kind of fantasies that underly neuroses and the related transferences. They also have a seriously diminished emotional involvement with their objects and a lowered capacity for empathy. Lastly, there are frequently associated problems such as anhedonia, impairments in the capacities for self-care, and affect tolerance. The impediments to psychoanalytic treatment resulting from this picture are considered, and some theories of its causation and therapeutic modifications calculated to enable these patients to benefit from psychotherapy are offered.
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3/9. Unthinkability and psychosomatic symptoms.

    W. R. Bion (1952) has pointed out a connection between alterations in the development of the "apparatus for thinking thoughts" and psychosomatic symptoms. Many authors have used this insight, from their own points of view, as a basis for describing this deficiency in thought and in the capacity to formulate images related to the development of psychosomatic symptoms (Krystal & McDougall 1979; Segal, 1950, 1958). This paper applies this hypothesis to a clinical case in which special emphasis is given to the symbolic deficiency, its effect on transference-countertransference, and its relation to falsification, "hyposymbolization," and to a specific phenomenon that could be called "hypersymbolization," in which many meanings are embodied in the same symbol.
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4/9. Nonorganic upper airway obstruction.

    Two cases of severe dyspnea and stridor with upper airway obstruction of obscure origin are discussed. Complete medical evaluation could identify no organic cause for the symptoms, and functional upper airway obstruction was diagnosed. Treatment with psychotherapy and relaxation techniques was successful. diagnosis can be made with pulmonary function studies. Flow-volume loops may show a lower inspiratory vital capacity than expiratory vital capacity and a discrepancy between inspiratory flow limitation and airway resistance. It is important to establish a functional etiology to prevent unnecessary treatment and provide proper care.
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5/9. Bion's 'protomental system' and psychosomatic illness in general practice.

    The work of Wilfred Bion, developing the psychoanalytic theories of Freud and Klein on the origins of anxiety in childhood, includes the hypothesis of a protomental system. This he defined as a matrix in the human organism in which physical and mental are at first undifferentiated. His postulate is that this system which equips human beings for life in a group is in conflict with their needs as individuals. The view of the world mediated by basic assumptions, relatively mindless, functioning by unconscious common consent, has a close association with psychosomatic illness. But individuals feel the need for a working relationship with others, where thought can be applied to problems before taking action. Within the family--a special case of a work group--the continuing experience by the infant of parental containment of its anxieties, through a process of projection and introjection, develops its capacity for thinking about frustration rather than evading it. The hypothesis is, that without this experience, frustration may lead to basic assumption mentality and psychosomatic illness rather than emotionality and thought. These ideas have been found useful in general practice as in the five cases described.
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6/9. metaphor as a diagnostic tool.

    A case study is reported wherein the patient's frequent use of metaphors was used as presumptive evidence that the patient had been misdiagnosed ten years earlier as having central nervous system disease. The ability to produce metaphors depends upon the capacity to condense several meanings into a word or two, and this in turn implies a rather active associative process. Concretism, not associative richness, characterizes central nervous system disease. The presumption as regards diagnosis was supported by subsequent data including the patient's response to psychotherapy.
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7/9. The treatment of contractures of the hand using self-hypnosis.

    The successful treatment of a man with severe posttraumatic contractures of the hand using a combined psychological and physical rehabilitation approach is reported. The contractures had functional and organic components, as did the treatment, which involved teaching the patient self-hypnosis exercises and the use of a splint. The patient obtained virtually complete return of movement after 3 1/2 years of total disability. The importance of identifying and mobilizing rather than challenging the patient's motivation for recovery using a rehabilitation approach is discussed. hypnosis can facilitate recovery in such psychosomatic disorders in patients with the requisite hypnotic capacity and motivation.
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8/9. fear of breakdown: a clinical example.

    This paper describes work with a patient whose unconscious fear of breakdown was increasingly undermining her capacity to function. The effective false-self defence which the patient had organized to deal with early trauma was breaking down into psychosomatic anxieties and disorders from which she had no will to recover. It was this feature that led her doctor to recommend psychoanalysis. As the transference became established the patient was able to reveal to the analyst in a concrete way the nature of the early trauma which had caused the original breakdown at a time when the patient's immature ego was not strong enough to encompass the experience. The traumatized child part of herself therefore became split off and defended against. The work of the analysis has been concerned with the gradual experiencing for the first time, with the support of the analyst, the pain and terror of the early breakdown. Over a period of years this has led to re-discovery and re-integration of the lost child into the patient's present ago organization. In the course of this work the patient remembered, and felt the need for, her transitional object. The original object was found and brought to the analysis, and eventually the patient established the link to the early good enough mother before the breakdown. There have been marked changes in the patient's health, and capacity for functioning. She is now able to contemplate the future, and the termination of her analysis in a realistic way. As already stated, work with this patient relied heavily on the theoretical formulations in Winnicott's paper noted below.
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9/9. Psychiatric problems in chronic facial pain.

    facial pain patients have been known to describe their life as "a living hell." By employing a biopsychosocial approach, the dental surgeon can often markedly reduce suffering and diminish the negative impact of chronic pain on the patient's day-to-day life, and enhance his or her capacity to deal long-term with this often complex clinical presentation.
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