George Haycock, MB, BChir, FRCP, FRCPCH, DCH

• Emeritus Professor of Paediatrics, Guy?, King?, and
• Sr. Thomas?Hospitals School of Medicine, King? College,
• University of London
• Emeritus Consultant Paediatrician and Paediatric
• Nephrologist, Guy? and Sr. Thomas?NHS Foundation Trust,
• London, United Kingdom

If I look back to-day at my early findings anxiety medication list generic pamelor 25 mg free shipping, they strike me as being the first rough outlines of what is probably a far more complicated subject anxiety medication 05 mg order pamelor online. I should have been very glad if I had been able anxiety symptoms and menopause discount 25 mg pamelor with visa, later on anxiety while pregnant discount pamelor online visa, to make a psycho-analytic examination of some more cases of simple juvenile neurasthenia anxiety 5 steps purchase 25 mg pamelor, but unluckily the occasion did not arise anxiety symptoms gastro purchase cheap pamelor online. To avoid misconceptions, I should like to make it clear that I am far from denying the existence of mental conflicts and of neurotic complexes in neurasthenia. All that I am asserting is that the symptoms of these patients are not mentally determined or removable by analysis, but that they must be regarded as direct toxic consequences of disturbed sexual chemical processes. During the years that followed the publication of the Studies, having reached these conclusions upon the part played by sexuality in the aetiology of the neuroses, I read some papers on the subject before various medical societies, but was only met with incredulity and contradiction. Breuer did what he could for some time longer to throw the great weight of his personal influence into the scales in my favour, but he effected nothing and it was easy to see that he too shrank from recognizing the sexual aetiology of the neuroses. He might have crushed me or at least disconcerted me by pointing to his own first patient, in whose case sexual factors had ostensibly played no part whatever. But he never did so, and I could not understand why this was, until I came to interpret the case correctly and to reconstruct, from some remarks which he had made, the conclusion of his treatment of it. His attitude towards me oscillated for some time between appreciation and sharp criticism; then accidental difficulties arose, as they never fail to do in a strained situation, and we parted. An Autobiographical Study 4204 Another result of my taking up the study of nervous disorders in general was that I altered the technique of catharsis. I abandoned hypnotism and sought to replace it by some other method, because I was anxious not to be restricted to treating hysteriform conditions. Increasing experience had also given rise to two grave doubts in my mind as to the use of hypnotism even as a means to catharsis. The first was that even the most brilliant results were liable to be suddenly wiped away if my personal relation with the patient became disturbed. It was true that they would be re-established if a reconciliation could be effected; but such an occurrence proved that the personal emotional relation between doctor and patient was after all stronger than the whole cathartic process, and it was precisely that factor which escaped every effort at control. And one day I had an experience which showed me in the crudest light what I had long suspected. It related to one of my most acquiescent patients, with whom hypnotism had enabled me to bring about the most marvellous results, and whom I was engaged in relieving of her suffering by tracing back her attacks of pain to their origins. The unexpected entrance of a servant relieved us from a painful discussion, but from that time onwards there was a tacit understanding between us that the hypnotic treatment should be discontinued. I was modest enough not to attribute the event to my own irresistible personal attraction, and I felt that I had now grasped the nature of the mysterious element that was at work behind hypnotism. In order to exclude it, or at all events to isolate it, it was necessary to abandon hypnotism. While I was in this perplexity there came to my help the recollection of an experiment which I had often witnessed while I was with Bernheim. When the subject awoke from the state of somnambulism, he seemed to have lost all memory of what had happened while he was in that state. No doubt this seemed a more laborious process than putting the patients into hypnosis, but it might prove highly instructive. So I abandoned hypnotism, only retaining my practice of requiring the patient to lie upon a sofa while I sat behind him, seeing him, but not seen myself. But along with the change in technique the work of catharsis took on a new complexion. Hypnosis had screened from view an interplay of forces which now came in sight and the understanding of which gave a solid foundation to my theory. How had it come about that the patients had forgotten so many of the facts of their external and internal lives but could nevertheless recollect them if a particular technique was appliedfi It was impossible not to conclude that that was precisely why it had been forgotten that is, why it had not remained conscious. The amount of effort required of the physician varied in different cases; it increased in direct proportion to the difficulty of what had to be remembered. The expenditure of force on the part of the physician was evidently the measure of a resistance on the part of the patient. It was only necessary to translate into words what I myself had observed, and I was in possession of the theory of repression. We should have expected the mental conflict which now arose to take the following course. In a neurosis, however (for reasons which were still unknown), the conflict found a different outcome. The ego drew back, as it were, on its first collision with the objectionable instinctual impulse; it debarred the impulse from access to consciousness and to direct motor discharge, but at the same time the impulse retained its full cathexis of energy. I named this process repression; it was a novelty, and nothing like it had ever before been recognized in mental life. It was obviously a primary mechanism of defence, comparable to an attempt at flight, and was only a forerunner of the later-developed normal condemning judgement. In the first place the ego was obliged to protect itself against the constant threat of a renewed advance on the part of the repressed impulse by making a permanent expenditure of energy, an anticathexis, and it thus impoverished itself. On the other hand, the repressed impulse, which was now unconscious, was able to find means of discharge and of substitutive satisfaction by circuitous routes and thus to bring the whole purpose of the repression to nothing. In the case of conversion hysteria the circuitous route led to the somatic innervation; the repressed impulse broke its way through at some point or other and produced symptoms. The symptoms were thus results of a compromise, for although they were substitutive satisfactions they were nevertheless distorted and deflected from their aim owing to the resistance of the ego. An Autobiographical Study 4207 the theory of repression became the corner-stone of our understanding of the neuroses. I showed my recognition of the new situation by no longer calling my method of investigation and treatment catharsis but psycho-analysis. It is possible to take repression as a centre and to bring all the elements of psycho-analytic theory into relation with it. The outcome of psycho-analytic investigations, on the other hand, showed that these phenomena were the result of dynamic factors of mental conflict and of repression. This distinction seems to me to be far-reaching enough to put an end to the glib repetition of the view that whatever is of value in psycho-analysis is merely borrowed from the ideas of Janet. I always treated Janet himself with respect, since his discoveries coincided to a considerable extent with those of Breuer, which had been made earlier but were published later than his. But when in the course of time psycho-analysis became a subject of discussion in France, Janet behaved ill, showed ignorance of the facts and used ugly arguments. There was no help for it, however, and this idiosyncrasy of the philosophers could only be disregarded with a shrug. Experience (gained from pathological material, of which the philosophers were ignorant) of the frequency and power of impulses of which one knew nothing directly, and whose existence had to be inferred like some fact in the external world, left no alternative open. One did not hesitate to ascribe mental processes to other people, although one had no immediate consciousness of them and could only infer them from their words and actions. The further question as to the ultimate nature of this unconscious is no more sensible or profitable than the older one as to the nature of the conscious. It would be more difficult to explain concisely how it came about that psycho-analysis made a further distinction in the unconscious, and separated it into a preconscious and an unconscious proper. It will be sufficient to say that it appeared a legitimate course to supplement the theories that were a direct expression of experience with hypotheses that were designed to facilitate the handling of the material and related to matters which could not be a subject of immediate observation. The subdivision of the unconscious is part of an attempt to picture the apparatus of the mind as being built up of a number of agencies or systems whose relations to one another are expressed in spatial terms, without, however, implying any connection with the actual anatomy of the brain. But since these experiences of childhood were always concerned with sexual excitations and the reaction against them, I found myself faced by the fact of infantile sexuality once again a novelty and a contradiction of one of the strongest of human prejudices. Such occasional sexual activities as it had been impossible to overlook in children were put down as signs of degeneracy or premature depravity or as a curious freak of nature. Few of the findings of psycho- analysis have met with such universal contradiction or have aroused such an outburst of indignation as the assertion that the sexual function starts at the beginning of life and reveals its presence by important signs even in childhood. And yet no other finding of analysis can be demonstrated so easily and so completely. An Autobiographical Study 4210 Before going further into the question of infantile sexuality I must mention an error into which I fell for a while and which might well have had fatal consequences for the whole of my work. Under the influence of the technical procedure which I used at that time, the majority of my patients reproduced from their childhood scenes in which they were sexually seduced by some grown-up person. With female patients the part of seducer was almost always assigned to their father. I believed these stories, and consequently supposed that I had discovered the roots of the subsequent neurosis in these experiences of sexual seduction in childhood. My confidence was strengthened by a few cases in which relations of this kind with a father, uncle, or elder brother had continued up to an age at which memory was to be trusted. If the reader feels inclined to shake his head at my credulity, I cannot altogether blame him; though I may plead that this was at a time when I was intentionally keeping my critical faculty in abeyance so as to preserve an unprejudiced and receptive attitude towards the many novelties which were coming to my notice every day. When, however, I was at last obliged to recognize that these scenes of seduction had never taken place, and that they were only phantasies which my patients had made up or which I myself had perhaps forced on them, I was for some time completely at a loss. My confidence alike in my technique and in its results suffered a severe blow; it could not be disputed that I had arrived at these scenes by a technical method which I considered correct, and their subject-matter was unquestionably related to the symptoms from which my investigation had started. When I had pulled myself together, I was able to draw the right conclusions from my discovery: namely, that the neurotic symptoms were not related directly to actual events but to wishful phantasies, and that as far as the neurosis was concerned psychical reality was of more importance than material reality. I had in fact stumbled for the first time upon the Oedipus complex, which was later to assume such an overwhelming importance, but which I did not recognize as yet in its disguise of phantasy. Moreover, seduction during childhood retained a certain share, though a humbler one, in the aetiology of neuroses. An Autobiographical Study 4211 It will be seen, then, that my mistake was of the same kind as would be made by someone who believed that the legendary story of the early kings of Rome (as told by Livy) was historical truth instead of what it is in fact a reaction against the memory of times and circumstances that were insignificant and occasionally, perhaps, inglorious. When the mistake had been cleared up, the path to the study of the sexual life of children lay open. It thus became possible to apply psycho-analysis to another field of science and to use its data as a means of discovering a new piece of biological knowledge. It begins by manifesting itself in the activity of a whole number of component instincts. Thus at first the sexual function is non-centralized and predominantly auto-erotic. Later, syntheses begin to appear in it; a first stage of organization is reached under the dominance of the oral components, an anal-sadistic stage follows, and it is only after the third stage has at last been reached that the primacy of the genitals is established and that the sexual function begins to serve the ends of reproduction. In the course of this process of development a number of elements of the various component instincts turn out to be unserviceable for this last end and are therefore left on one side or turned to other uses, while others are diverted from their aims and carried over into the genital organization. I gave the name of libido to the energy of the sexual instincts and to that form of energy alone.

Regularity effects arise when the direct and indirect routes produce an output at about the same time anxiety zoloft dosage cheap pamelor american express, so that conflict arises between the irregular pronunciation proposed by the lexical route and the regular pronunciation proposed by the sublexical route anxiety symptoms joint pain purchase pamelor in india. However anxiety symptoms children generic pamelor 25 mg with mastercard, it is not clear how a race model where the indirect route uses grapheme-phoneme conversion can explain lexical effects on reading nonwords anxiety symptoms at bedtime cheap pamelor 25mg visa. It has recently been discovered that skilled readers have a measure of attentional or strategic control over the lexical and sublexical routes such that they can attend selectively to lexical or sublexical information (Baluch & Besner anxiety symptoms one side order cheap pamelor online, 1991; Monsell et al anxiety symptoms but dont feel anxious generic pamelor 25mg without prescription. High-frequency exception words were pronounced faster when they were in pure blocks than when they were mixed with nonwords. Participants also made fewer regularization errors when the words were presented in pure blocks (when they can rely solely on lexical processing) than in mixed blocks (when the sublexical route has to be involved). At first sight, then, this experiment suggests that in difficult circumstances people seem able to change their emphasis in reading from using lexical information to sublexical information. However, Jared (1997a) argued that people need not change the extent to which they rely on sublexical information, but instead might be responding at different points in the processing of the stimuli. However, there is further evidence for strategic effects in the choice of route when reading. Using a primed naming task, Zevin and Balota (2000) found that nonword primes produce a greater dependence on sublexical processing, but low-frequency exception word primes produce a greater dependence on lexical processing. Coltheart and Rastle (1994) suggested that lexical access is performed so quickly for high- 7. We must distinguish between acquired disorders (which, as a result of head trauma such as stroke, operation, or head injury, lead to disruption of processes that were functioning normally beforehand) and developmental disorders (which do not result from obvious trauma and which disrupt the development of a particular function). Disorders of reading are called the dyslexias; disorders of writing are called the dysgraphias. Damage to the left hemisphere will generally result in dyslexia, but as the same sites are involved in speaking, dyslexia is often accompanied by impairments to spoken language processing. It is convenient to distinguish between central dyslexias, which involve central, high-level reading processes, and peripheral dyslexias, which involve lower-level processes. Peripheral dyslexias include visual dyslexia, attentional dyslexia, letterby-letter reading, and neglect dyslexia, all of which disrupt the extraction of visual information from the page. As our focus is on understanding the central reading process, we will limit discussion here to the central dyslexias. In addition, we will only look at acquired disorders in this section, and defer discussion of developmental dyslexia until our examination of learning to read. If the dual-route model of reading is correct, then we should expect to find a double dissociation of the two reading routes. That is, we should find some patients have damage to the lexical route but can still read by the non-lexical route only, whereas we should be able to find other patients who have damage to the non- lexical route but can read by the lexical route only. The existence of a double dissociation is a strong prediction of the dual-route model, and a real challenge to any single-route model. Surface dyslexia People with surface dyslexia have a selective impairment in the ability to read irregular (exception) words. Marshall and Newcombe (1973) and Shallice and Warrington (1980) described some early case histories. Surface dyslexics often make over-regularization errors when trying to read irregular words aloud. In terms of the dual-route model, the most obvious explanation of surface dyslexia is that these patients can only read via the indirect, non- lexical route: that is, it is an impairment of the lexical (direct access) processing route. The effects of brain damage are rarely localized to highly specific systems, and, in practice, patients do not show such clear-cut behaviour as the ideal of totally preserved regular word and nonword reading, and the total loss of irregular words. She showed completely normal accuracy in reading nonwords, and hence her nonlexical route was totally preserved. Other patients show considerably less clear-cut reading than this, with even better performance on irregular words, and some deficit in reading regular words. If patients were reading through a non-lexical route, we would not expect lexical variables to affect the likelihood of reading success. Kremin (1985) found no effect of word frequency, part of speech (noun versus adjective versus verb), or whether or not it is easy to form a mental image of what is referred to (called imageability), on the likelihood of reading success. The more pure cases, known as Type I patients, are highly accurate at naming regular words and pseudowords. Phonological dyslexia was first described by Shallice and Warrington (1975, 1980), Patterson (1980), and Beauvois and Derouesne (1979). He was not the most extreme case possible of phonological dyslexia, however, because there was also an impairment to his lexical route; his performance was about 85% correct on words. Those patients who also have difficulty in reading words have particular difficulty in reading the function words that do the grammatical work of the lan guage. Low-frequency, low-imageability words are also poorly read, although neither frequency nor imageability seems to have any overwhelming role in itself. Derouesne and Beauvois (1979) suggested that phonological dyslexia can result from disruption of either orthographic or phonological processing. Another group of patients are better at reading pseudohomophones than non-pseudohomophones, but show no effect of orthographic complexity. Friedman (1995) distinguished between phonological dyslexia arising from an impairment of orthographic-to- phonological processing (characterized by relatively poor function word reading but good nonword repetition) and that arising from an impairment of general phonological processing (characterized by the reverse pattern). Following this, a three-stage model of sublexical processing has emerged (Beauvois & Derouesne, 1979; Coltheart, 1985; Friedman, 1995). Third, in the phonemic blending stage the sounds are assembled into a phonological representation. There are patients whose behaviour can best be explained in terms of disruption of each of these stages (Lesch & Martin, 1998). Patients with disrupted graphemic analysis find nonwords in which each grapheme is represented by a single letter easier to read than nonwords with multiple correspondences. People with phonological dyslexia show complex phonological problems that have nothing to do with orthography. Indeed, it has been proposed that phonological dyslexia is a consequence of a general problem with phonological processing (Farah, Stowe, & Levinson, 1996; Harm & Seidenberg, 2001; Patterson, Suzuki, & Wydel, 1996). If phonological dyslexia arises solely as the ability to translate orthography into phonology, then there must be brain tissue dedicated to this task. This implies that this brain tissue becomes dedicated by school-age learning, which is an unappealing prospect. The alternative view is that phonological dyslexia is just one aspect of a general impairment to phonological processing. This proposal also explains why pseudohomophones are read better than non- pseudohomophones. An important piece of evidence in favour of this hypothesis is that phonological dyslexia is never observed in the absence of a more general phonological deficit (but see Coltheart, 1996, for a dissenting view). A general phonological deficit makes it difficult to assemble pronunciations for nonwords. Words are spared much of this difficulty because of support from other words and top-down support from their semantic representations. Repeating words and nonwords is facilitated by support from auditory representations, so some phonological dyslexics can still repeat some nonwords. However, if the repetition task is made more difficult so that patients can no longer gain support from the auditory representations, repetition performance declines markedly (Farah et al. This idea that phonological dyslexia is caused by a general phonological deficit is central to the connectionist account of dyslexia, discussed later. There is, however, another even more surprising type of dyslexia called deep dyslexia. Patients have great difficulty in reading nonwords, and considerable difficulty in reading the grammatical, function words. However, the defining characteristic of deep dyslexia is the presence of semantic reading errors or semantic paralexias. Note that just an imageability effect in reading does not mean that patients with deep dyslexia are better at all tasks involving more concrete words. There has been some debate about the extent to which deep dyslexia is a syndrome (a syndrome is a group of symptoms that cluster together). Coltheart (1980) argued that the clustering of symptoms is meaningful, in that they suggest a single underlying cause. However, although these symptoms tend to occur in many patients, they do not apparently necessarily do so. A few patients make semantic errors but very few visual errors (Caramazza & Hillis, 1990). Such patients suggest that it is unlikely that there is a single underlying deficit. Like phonological dyslexics, deep dyslexics obviously have some difficulty in obtaining non-lexical access to phonology via grapheme- phoneme recoding, but they also have some disorder of the semantic system. One possibility is that the different symptoms of deep dyslexia arise because of an arbitrary feature of brain anatomy: different but nearby parts of the brain control processes such as writing and auditory short-term memory, so that damage to one is often associated with damage to another. As we will see, a more satisfying account is provided by recent connectionist modelling. Shallice (1988) argued that there are three subtypes of deep dyslexia that vary in the precise impairments involved. Input deep dyslexics have difficulties in reaching the exact semantic representations of words in 7. Central deep dyslexics have a severe auditory comprehension deficit in addition to their reading difficulties. Output deep dyslexics can process words up to their semantic representations, but then have difficulty producing the appropriate phonological output. In practice it can be difficult to assign particular patients to these subtypes, and it is not clear what precise impairment of the reading systems is necessary to produce each subtype (Newton & Barry, 1997). The right-hemisphere hypothesis Does deep dyslexia reflect attempts by a greatly damaged system to read normally, as has been argued by Morton and Patterson (1980), among othersfi Or does it instead reflect the operation of an otherwise normally suppressed system coming throughfi Instead, people with deep dyslexia might use a reading system based in the right hemisphere that is normally suppressed (Coltheart, 1980; Saffran, Bogyo, Schwartz, & Marin, 1980; Zaidel & Peters, 1981). This right-hemisphere hypothesis is supported by the observation that the more of the left hemisphere that is damaged, the more severe the deep dyslexia observed (Jones & Martin, 1985; but see Marshall & Patterson, 1985). Furthermore, the reading performance of deep dyslexics resembles that of split-brain patients when words are presented to the left visual field, and therefore to the right hemisphere. Under such conditions they also make semantic paralexias, and have an advantage for concrete words. After recovery she retained some reading ability, but her performance resembled that of deep dyslexics. In spite of these points in its favour, the righthemisphere reading hypothesis has never won wide acceptance. In part this is because the hypothesis is considered a negative one, in that if it were correct, deep dyslexia would tell us nothing about normal reading. In addition, people with deep dyslexia read much better than split-brain patients who are forced to rely on the right hemisphere for reading. The right- hemisphere advantage for concrete words is rarely found, and the imageability of the target words used in these experiments might have been confounded with length (Ellis & Young, 1988; Patterson & Besner, 1984). Finally, Roeltgen (1987) described a patient who suffered from deep dyslexia as a result of a stroke in the left hemisphere. He later suffered from a second left hemisphere stroke, which had the effect of destroying his residual reading ability. If the deep dyslexia had been a consequence of right hemisphere reading, it should not have been affected by the second stroke in the left hemisphere. The crucial issue is whether or not its symptoms must necessarily co-occur because they have the same underlying cause. So far they seem to be; in all reported cases semantic paralexias have been associated with all the other symptoms.

One morning anxiety symptoms restless legs 25mg pamelor amex, for example anxiety symptoms in women buy generic pamelor from india, when I was passing through a room in my dressing-gown with straw slippers on my feet anxiety symptoms 35 buy cheap pamelor online, I yielded to a sudden impulse and hurled one of my slippers from my foot at the wall anxiety symptoms mimic ms purchase 25mg pamelor amex, causing a beautiful little marble Venus to fall down from its bracket anxiety yoga poses generic pamelor 25 mg without prescription. One of my family was gravely ill anxietyzone symptoms proven 25 mg pamelor, and secretly I had already given up hope of her recovery. The choice of the Venus of Medici for this sacrifice was clearly only a gallant act of homage towards the convalescent; but even now it is a mystery to me how I made up my mind so quickly, aimed so accurately and avoided hitting anything else among the objects so close to it. Another case of breaking something, for which I once again made use of a pen-holder that slipped from my hand, likewise had the significance of a sacrifice; but on this occasion it took the form of a propitiatory sacrifice to avert evil. I had once seen fit to reproach a loyal and deserving friend on no other grounds than the interpretation I placed on certain indications coming from his unconscious. He was offended and wrote me a letter asking me not to treat my friends psycho-analytically. While I was writing this letter I had in front of me my latest acquisition, a handsome glazed Egyptian figure. I broke it in the way I have described, and then immediately realized that I had caused this mischief in order to avert a greater one. Luckily it was possible to cement both of them together the friendship as well as the figure so that the break would not be noticed. On one occasion the thin metal got damaged, through no fault of mine, and was badly repaired. Soon after the stick came back, I used the handle in a mischievous attempt to catch one of my children by the leg with the natural result that it broke, and I was thus rid of it. The equanimity with which we accept the resulting damage in all these cases can no doubt be taken as evidence that there is an unconscious purpose behind the performance of these particular actions. It was among the many presents including objects of value which had been sent to him in the past by a (married) woman patient. When a psychosis became manifest in her, he restored all the presents to her relatives except for this far less expensive vase, with which he could not bear to part, ostensibly because it was so beautiful. But this embezzlement cost a man of his scrupulousness a considerable internal struggle. He was fully aware of the impropriety of his action, and only managed to overcome his pangs of conscience by telling himself that the vase was not in fact of any real value, that it was too awkward to pack, etc. Once again the self- reproaches made their appearance; and he suffered some momentary anxiety in case the relatives discovered what could be called his embezzlement and brought it against him during the legal proceedings. For a while indeed the first factor (his self-reproaches) was so strong that he actually thought of renouncing all claims on a sum of perhaps a hundred times the value of the vase a compensation, as it were, for the object he had appropriated. What is more, this was after he had made up his mind on the previous evening, though not without considerable hesitation, to put precisely this vase, filled with flowers, on the dining-room table before his guests. He had remembered it only just before it got broken, had noticed with anxiety that it was not in his living-room and had himself brought it in from the other room. After his first moments of dismay he picked up the pieces and by putting them together was just deciding that it would still be possible to make an almost complete repair of the vase, when the two or three larger fragments slipped from his hand; they broke into a thousand splinters, and with that vanished all hope for the vase. He fell ill of a neurosis whose main theme was that he was to blame for the misfortune ("he had broken a lovely vase"). Moreover, he had no further relations with women and took a dislike to marriage and lasting love- relationships, which unconsciously he thought of as being unfaithful to his dead wife but which he consciously rationalized in the idea that he brought misfortune to women, that a woman might kill herself on his account, etc. In the course of the session in which he gave an account of breaking the "earthenware" vase, he happened much later to be talking once more about his relations with women and said he thought he was quite unreasonably hard to please; thus for example he required women to have "unearthly beauty". This is surely a very clear indication that he was still dependent on his (dead, i. What strikes me, however, as more interesting is the consideration that the presence of several, at the least of two, motives (which probably operated separately out of the preconscious and the unconscious) is reflected in the doubling of the parapraxis his knocking over the vase and then letting it fall from his hands. The interpretations attached to salt being spilt, a wine-glass being knocked over, a dropped knife sticking in the ground, etc. I shall not discuss till later the question of what claims such superstitious interpretations have to being taken seriously. Here I need only remark that individual clumsy actions do not by any means always have the same meaning, but serve as a method of representing one purpose or another according to circumstances. Recently we passed through a period in my house during which an unusually large amount of glass and china crockery was broken; I myself was responsible for some of the damage. On such festive occasions it used to be the custom deliberately to break some utensil and at the same time utter a phrase to bring good luck. This custom may have the significance of a sacrifice and it may have another symbolic meaning as well. When servants drop fragile articles and so destroy them, our first thought is certainly not of a psychological explanation, yet it is not unlikely that here, too, obscure motives play their part. Nothing is more foreign to uneducated people than an appreciation of art and works of art. Our servants are dominated by a mute hostility towards the manifestations of art, especially when the objects (whose value they do not understand) become a source of work for them. On the other hand people of the same education and origin often show great dexterity and reliability in handling delicate objects in scientific institutions, once they have begun to identify themselves with their chief and to consider themselves an essential part of the staff. I could not help agreeing with him and added half jokingly, referring to an incident the week before: "Let us hope that the machine will go wrong again so that we can stop work and go home early. The man conducting the experiment stood by the manometer and when the right pressure was reached called out a loud "stop! The double meanings that language attaches to these expressions are enough to indicate the kind of phantasies involved, which can be represented by such losses of bodily equilibrium. I can recall a number of fairly mild nervous illnesses in women and girls which set in after a fall not accompanied by any injury, and which were taken to be traumatic hysterias resulting from the shock of the fall. Even at that time I had an impression that these events were differently connected and that the fall was already a product of the neurosis and expressed the same unconscious phantasies with a sexual content, which could be assumed to be the forces operating behind the symptoms. The Psychopathology Of Everyday Life 1255 We can also count as bungled actions cases of giving a beggar a gold piece instead of a copper or small silver coin. In this way our parapraxes make it possible for us to practise all those pious and superstitious customs that must shun the light of consciousness owing to opposition from our reason, which has now grown sceptical. A good example from my own experience of a few years ago shows how an apparently clumsy movement can be most cunningly used for sexual purposes. In the house of some friends I met a young girl who was staying there as a guest and who aroused a feeling of pleasure in me which I had long thought was extinct. At the time I also endeavoured to discover how this came about; a year before, the same girl had made no impression on me. She was nimbler than I was and, I think, nearer to the object; so she took hold of the chair first and carried it in front of her with its back towards her, gripping the sides of the seat with both hands. As I got there later, but still stuck to my intention of carrying the chair, I suddenly found myself standing directly behind her, and throwing my arms round her from behind; and for a moment my hands met in front of her waist. Nor does it seem to have struck anyone how dextrously I had taken advantage of this clumsy movement. I know from my psycho-analyses of neurotics that what is described as the naivete of young people and children is frequently only a mask of this sort, employed so that they may be able to say or do something improper without feeling embarrassed. In a most curious way I contrived in doing so to undo the bow that held her loose morning- gown together. I was conscious of no dishonourable intention; yet I carried out this clumsy movement with the dexterity of a conjurer. We shall not be surprised, therefore, to see from a fresh example how a writer invests a clumsy movement with significance, too, and makes it foreshadow later events. This affection blossoms into passion, so that Melanie finally leaves her husband and gives herself entirely to the man she loves. Precisely for this reason it is an especially interesting question whether mistakes of considerable importance which may be followed by serious consequences for example, mistakes made by a doctor or a chemist -(are in any way open to the approach presented here. As I very rarely find myself undertaking medical treatment, I can report only one example from my personal experience of a bungled action of a medical kind. Two bottles are always prepared for me: a blue one with the collyrium and a white one with the morphine solution. During the two operations my thoughts are no doubt usually busy with something else; by now I have performed them so often that my attention behaves as if it were at liberty. I had put the dropper into the white bottle instead of the blue one and had put morphine into the eye instead of collyrium. I was greatly frightened and then reassured myself by reflecting that a few drops of a two per cent solution of morphine could not do any harm even in the conjunctival sac. I was under the influence of a dream which had been told me by a young man the previous evening and the content of which could only point to sexual intercourse with his own mother. Such incongruities always appear when a phantasy that fluctuates between two periods is made conscious and so becomes definitely attached to one of the two periods. Here again the bungled action was a harmless one; of the two possible errors, using the morphine solution for the eye or the eye lotion for the injection, I had chosen by far the more harmless one. This still leaves the question open of whether we may admit the possibility of an unconscious intention in mistakes that can cause serious harm, in the same way as in the cases which I have discussed. Here then my material leaves me in the lurch, as might be expected, and I have to fall back on conjectures and inferences. It is well known that in the severer cases of psychoneurosis instances of self- injury are occasionally found as symptoms and that in such cases suicide can never be ruled out as a possible outcome of the psychical conflict. I have now learnt and can prove from convincing examples that many apparently accidental injuries that happen to such patients are really instances of self-injury. What happens is that an impulse to self-punishment, which is constantly on the watch and which normally finds expression in self-reproach or contributes to the formation of a symptom, takes ingenious advantage of an external situation that chance happens to offer, or lends assistance to that situation until the desired injurious effect is brought about. Such occurrences are by no means uncommon in cases even of moderate severity, and they betray the part which the unconscious intention plays by a number of special features -. Formerly self-injury was a customary sign of mourning; at other periods it could express trends towards piety and renunciation of the world. The Psychopathology Of Everyday Life 1259 Instead of a number of cases I will give a detailed report of only a single example from my medical experience. A young married woman broke her leg below the knee in a carriage accident, so that she was bed-ridden for weeks; what was striking was the absence of any expressions of pain and the calmness with which she bore her misfortune. This accident introduced a long and severe neurotic illness of which she was finally cured by psycho-analysis. In treating her I learnt of the circumstances surrounding the accident and of certain events that had preceded it. The young woman was staying with her very jealous husband on the estate of a married sister, in company with her numerous other sisters and brothers with their husbands and wives. Her youngest sister wanted her baby and its nurse to go in the carriage with her; my patient vigorously opposed this. Although after learning these details we can hardly remain in doubt that this accident was really contrived, we cannot fail to admire the skill which forced chance to mete out a punishment that fitted the crime so well. For it had now been made impossible for her to dance the can-can for quite a long time. The Psychopathology Of Everyday Life 1260 As regards self-injuries of my own, there is little that I can report in uneventful times; but in extraordinary circumstances I find that I am not incapable of them. One of my boys, whose lively temperament used to make it difficult to nurse him when he was ill, had a fit of anger one day because he was ordered to spend the morning in bed, and threatened to kill himself, a possibility that was familiar to him from the newspapers. In the evening he showed me a swelling on one side of his chest which he had got by bumping against a door-handle.

Thus anxiety symptoms stuttering order genuine pamelor on-line, a renewed focus on the concept of injury prevention and a multidisciplinary approach to the rehabilitation of injured athletes has been made anxiety insomnia order genuine pamelor online, Figure 13 anxiety attacks symptoms treatment discount pamelor 25mg overnight delivery. In collegiate lacrosse men alized multimodal approach appears especially appropri- wear helmets anxiety symptoms stomach cheap pamelor 25 mg without a prescription, whereas women do not anxiety disorder pamelor 25 mg amex, which has initiated a ate in the context of making return-to-play decisions with debate regarding the use of head protection in the sport anxiety symptoms in 9 year old boy purchase pamelor 25 mg otc. In addition, neuropsychological profiles of ath- letes may help us understand their specific strengths and weaknesses and how they may cope with sports-related ter protective equipment and devises, rule changes, and concussions. As scientists and researchers provided in- pooling of information into a comprehensive concussion creasing evidence for an organic basis to the clinical symp- data bank to better define safe return-to-play criteria should toms of concussion, it became evident that the clinical be the focus of sports medicine in the new millennium. What is the epidemiol- postconcussion cognitive assessments, and further valida- ogy of the sports-related concussion injuries and how they tion of computerized assessment measures. What neuropsycho- paucity of research on female and youth athletes, there is logical tests are best suited to assess concussionsfi What is evidence that female athletes are at greater risk for injury the gold standard for grading concussionsfi Who is most than male athletes, and that concussions may affect chil- susceptible to sports-related concussionfi What return-to- dren and young adolescents differently than older adoles- play guidelines are most practicalfi Sideline, baseline, and postconcussion We believe neuropsychologists play, and will continue assessments have become prevalent in documenting prein- to play, an important role in assembling this complex puz- jury and postinjury performance, recovery rates, and zle. That football and soccer of the athletic arena and of various sports they may be can involve potential mechanical forces to the head that asked to cover. At that level, many ele- play an important and rewarding role in this growing field mentary school, high school, and college players are par- in the future (Zillmer, Schneider, Tinker, & Kaminaris, ticularly vulnerable to the developmental delays related to 2006). In severe head injuries, the patient is comatose and neuropsychological symptoms, including headache, when the medical emergency unit arrives. However, medics establish a respiratory airway, often freeing the analogous situations with acceleration/deceleration of the pharynx from blood and other obstructions. Many not establish an airway, anoxia will result, adding to the sports involve speed and the potential for collision. Alterations in breathing may be related ling) that were originally thought to be relatively benign, to brainstem dysfunction. Medics then evaluate circula- actually have measurable neuropsychological conse- tory status by examining blood gases and blood pressure. These collisions may not only They initiate intravenous infusion, including blood re- diminish the performance of players on the field but can placement. Then, once the patient has been medically sta- also compromise their health off the field. If the patient remains in a coma, the impact places them at risk for losing consciousness even team may hospitalize him or her in a neuro-intensive care when experiencing relatively minor concussive forces to unit, which has a specialized environment that facilitates the head. Steroid therapy may prevent in- which is a neurologic event synonymous with cerebral con- tracerebral edema. Only recently have researchers examined the neu- controlled with heating/cooling blankets, because ele- rologic aspects of amateur boxing, where duration of vated body temperature increases metabolic rate and hy- fights, rules, and protective devices differ from profes- pothermia leads to other medical complications. At age 20, Theresa being victimized because of an inability to An inability to make decisions can result in suffered a head injury when a drunk driver adequately protect himself or herself from victimization, unwanted pregnancies, and struck her car as she waited at a red light. After a head injury, the often-ambiguous complex decisions requiring judgment, John experiences hemiplegia, difficulty in rules and rituals pertaining to sex can be- insight, preplanning, reasoning, organiza- planning for future events, and memory and come even more difficult. John and Theresa enjoy to changes in sex drive and various male and neuropsychologist serves two main roles. More recently, tion to the neurologic, physical, and emo- formal testing of cognitive and functional John and Theresa have become interested in tional effects on sexuality are cognitive strengths and weaknesses, can assess an a physically intimate relationship. The last issue is a concern for the agency changes can affect sexuality in a variety of Second, the neuropsychologist can recom- that provides their rehabilitative services. Neuropsychologists routinely test head the cerebral metabolic rate and constricts cerebral vessels. A final measure is to remove part of the brain to make Most recovery after severe head injury occurs within the space available. They range from patient reports of when started as early as medically possible (Levin et al. Neuropsychol- ogists play an important role in objectively assessing Anterograde and Retrograde residual ability after mild, moderate, and even severe Amnesia head injuries, once the patient has been medically stabi- Memory problems constitute a major deficit for people lized and is no longer in a coma or in acute medical care. In this way, neuropsychologists education, sexual experience, or both are ing to sexual activity (Kennedy, 2003). However, individuals who have not with neurologic damage in regaining impor- make a capacity determination based on yet obtained general knowledge about tant parts of their lives, not least of which will prescribed legal criteria for consent. Theresa easily passed all aspects of the quences of sexual activity, and basic safety the third criterion, however, basic safety assessment, whereas John showed signifi- skills to be deemed capable of consenting skills, appears to be the most significant cant difficulty with the concepts of sexually (Kennedy & Niederbuhl, 2001). Although, hurdle for individuals with moderate to transmitted diseases and protection against taken together, these criteria determine the severe head injuries. John was declared not capable of capacity of any given individual, each crite- ropsychological task appears to be an giving consent until he could successfully rion is also a separate entity directly related executive decision that involves a complex complete an educational program dealing to cognitive abilities that neuropsychologists string of decision making, reasoning, judg- specifically with diseases and methods of can measure. Subse- activity, are a function of crystallized intelli- Zillmer, 2005), the Modified Wisconsin Card quently, the rehabilitation facility worked gence (knowledge that has been acquired Sorting Test, and word fluency are able to with John and Theresa about establishing over the years) in most adults. That is, correctly classify cognitively impaired individ- privacy, and their subjective quality of life is individuals who have had previous sexuality uals who are and are not capable of consent- vastly improved. Conversely, antero- typically brief and serves to assess whether the patient can grade amnesia is the loss of memory for events after tolerate more formal, longer testing. Although the patient may have baseline of overall cognitive abilities for future compar- residual short-term memory impairment from the head isons. An example of such a neuropsychology consult is as injury, as well as other cognitive deficits, neuropsycholo- follows: gists have established retrograde and anterograde amne- sia as a relatively robust measure of the severity of trauma Neuropsychology Note. The patient was able to follow simple com- length and depth of coma, which may relate to isolated mands involving two-step learning. No other psychiatric symptoms were noted ing neurons or neuronal systems or rely on some redun- (hallucinations, delusions). Psychiatric consult should be ordered, and reloca- sider the following factors when evaluating infiuences on tion to psychiatric ward should be considered to better man- recovery: age suicide threats when the patient is medically stable. Location and extent of damage and psychological evaluation within the next four weeks to 2. Age (brain plasticity) his previous employment as a manager include his ability to 4. Premorbid intellectual level function independently in life, and his need for outpatient 5. Premorbid functional level outpatient basis and should be repeated over a 6- to 9-month 7. Zillmer, Neuropsychologist Behind most theories of neuropsychological recovery and rehabilitation lies the premise that if functions are In general, the long-term neuropsychological effects of not completely ablated, there is a chance that they can head trauma may vary considerably and depend on the be restored through the ability of the brain to heal and strength of the trauma and the medical condition of the adapt. Not all head traumas pro- cover versus needing aid via neuropsychological rehabil- duce significant neuropsychological deficits. First, insult to the brain Diaschisis (first described by von Monakow, 1911) refers can result in different effects depending on the site and to an unmasking of function after temporary neuronal mechanism of damage. This transience of function inhibition implies that the neu- Axonal and Collateral ronal systems have not been permanently damaged. Sprouting Therefore, diaschisis differs from restitution in that it is a One way in which the brain reorganizes is through the re- passive process of uncovering working systems rather than growth of neurons that have been only partially damaged. As the As mentioned in Chapter 4, unlike axons in the periph- condition causing the dysfunction is removed, the behav- eral nervous system, those in the central nervous system ioral function re-emerges. However, Researchers have proposed that diaschisis represents an axons that have been sheared may resprout, and collateral imbalance between excitatory and inhibitory mechanisms sprouting can occur from nearby intact neurons. An interesting demon- organisms appear to have the greatest potential for axonal stration in animals (Poppel & Richards, 1974) provides an regrowth. Although researchers have documented that ax- in the left visual field results; however, if the left superior onal and collateral sprouting does occur, they do not yet colliculus is destroyed, sight is restored. Excessive sprouting may even hinder behavioral hibit each other while each occipital lobe excites its ipsilat- functioning. Denervation Supersensitivity However, when the right occipital lobe is damaged, the right superior colliculus, which no longer is receiving input If an area of the brain is lesioned, any remaining neurons from its occipital lobe, cannot moderate the left superior in that area may become hypersensitive to the neurotrans- colliculus. This may the left is removed, the right becomes functional again and result in a greater excitatory or inhibitory potential, de- some sight is restored. According to the theory of diaschisis, this imbalance be- Overview of the tween excitation and inhibition resolves spontaneously. The philosophy of a rehabilitation center is very do with the plasticity of the brain. Most research for the patient and does not require the patient to be ac- on plasticity has tested animals, leaving the relation be- tive in treatment. Rehabilitation centers expect the pa- tween neuronal reorganization and behavioral organiza- tient and family to take a more active role in retraining, tion unclear in humans. Rehabili- much more plastic than those of adults; children show tation settings also use rehabilitation teams of specialists less behavioral effect and recover faster from brain injury. This section considers the various specialties in pubescent children may be caused by the adaptability of more detail. The final goal of rehabilitation is to reintegrate people back into the community at the high- Although most neuropsychologists in rehabilitation work est level of functioning possible. Practicing re- acute-care hospitals that have rehabilitation units and habilitation psychologists may treat people who have focus on early evaluation before transfer to a specialized suffered non-neurologic problems such as burns, facility. The haps while emerging from coma or recovering from brain focus is on applying psychological principles to recov- surgery. Also, such, the focus is on the process of recovery, adjust- acute care rehabilitation neuropsychologists conduct pre- ment, and rehabilitation of brain disorders. The condi- operative and postoperative assessments to document the tions most often seen on brain injury units of rehabilitation level of change in cognitive functioning. Therefore, neu- Less often, rehabilitation units treat patients recovering ropsychological evaluation becomes a valuable part of the from brain tumor or brain disease. Neuropsychologists design the pre- survival rate of heart attack victims, rehabilitation cen- screening process for entry into a rehabilitation program ters are experiencing a greater infiux of anoxic/hypoxic to select patients whom they consider to have potential for injuries resulting from loss of oxygen to the brain be- treatment success and enough social support for postreha- fore resuscitation. In fact, admission to a rehabilitation program Rehabilitation hospitals are specialty hospitals, which in itself suggests the absence of a medical life-threatening admit patients who fit a restricted group of diagnoses, crisis and the potential for further recovery. Length of inpatient stay varies but has short- the rehabilitation hospital is the primary setting for ened dramatically since the advent of managed care. A large proportion of neuropsychologists cognitive confusion, and their families do not yet under- work in rehabilitation settings where they apply knowl- stand the condition and the caretaking responsibilities. The team teaches the means to maximize inde- training are generally not considered ready for compre- pendence both for survivor and family caretaker. The goal hensive rehabilitation and may be sent to a continuing care for a patient is not to live in the rehabilitation hospital, center until they are more able. Where brain injury is involved, there is usually a preponderance of young men in their teens and 20s re- Neuropsychology covering from head injuries, gunshot wounds, or spinal Neuropsychologists are active in the rehabilitation process cord injury. He or she may also evaluate func- Goal Setting, Treatment, tional neuropsychological skills such as meal planning and and Evaluation preparation, ability to plan and self-administer medica- Once a patient is accepted for admission, the typical proto- tion, driving, or work-related tasks. Treatment teams are often directed by the functional level of the individual and serve as a baseline to physiatrist, but may also be directed by psychologists or document impairment.

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