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Shapiro MA, John SA, Muzwagi AB, Silverman AL, Soda T. Ethical Dilemmas and Countertransference in Legally Mandated Reporting of Fatal Child Neglect. Psychodyn Psychiatry 2024; 52:189-205. [PMID: 38829226 DOI: 10.1521/pdps.2024.52.2.189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
In the fall of 2019, a much-publicized court case brought to national attention the issues of patient-doctor confidentiality when it comes to reporting the deaths of newborns in the United States. It is unclear whether the recent overturning of Roe v. Wade will lead to more cases like this. This article discusses issues of countertransference, as well as the ethical and legal implications were it to be a psychiatrist, in active treatment of such a patient, who would be required to make such a report. More specifically, as in the publicized court case, the patient could be a minor at the time, receiving treatment from a child psychiatrist. The implications of such a case include how countertransference affects the perception of fatal child neglect compared to intentional neonaticide; the ethical dilemma of generating a mandated report with the goal of child safety when such a report could lead to real legal consequences for a minor child; and considerations regarding continued treatment of a patient after such a report is made. It is likely that countertransference, shaped by attitudes toward mothers and idealized views on mothering, may play a large role in all these circumstances.
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Affiliation(s)
- Michael A Shapiro
- University of Florida College of Medicine Department of Psychiatry; Children's Hospital of the King's Daughters, Eastern Virginia Medical School
| | - Sheena A John
- University of Florida College of Medicine Department of Psychiatry
| | - Ashraf B Muzwagi
- University of Florida College of Medicine Department of Psychiatry
| | | | - Takahiro Soda
- University of Florida College of Medicine Department of Psychiatry
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Bottemanne H, Joly L. [Mother brain: Bayesian theory of maternal interoception during pregnancy and postpartum]. L'ENCEPHALE 2023; 49:185-195. [PMID: 36243551 DOI: 10.1016/j.encep.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 05/28/2022] [Accepted: 05/30/2022] [Indexed: 11/05/2022]
Abstract
The perinatal period, including pregnancy and postpartum, causes major morphological, endocrinal, and thermal transitions in women. As the fetus grows, abdominal muscle fibers stretch, internal organs such as the bladder or colon move, and the uterine anatomy changes. Many of these changes involve interoception, the perception of internal body signals such as muscle and visceral sensations. Despite the importance of these interoceptive signals, few studies have explored perinatal interoception. We propose an innovative theory of maternal interoception based on recent findings in neuroscience. We show that interoceptive signals processing during pregnancy is crucial for understanding perinatal phenomenology and psychopathology, such as maternal perception of fetal movements, maternal-infant bonding, denial of pregnancy, phantom fetal movements after childbirth, pseudocyesis or even puerperal delusion. Knowing the importance of these interoceptive mechanisms, clinicians in obstetrics, gynecology and mental health should be particularly vigilant to maternal interoception during the perinatal period.
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Affiliation(s)
- Hugo Bottemanne
- Department of Psychiatry, Sorbonne University, Pitié-Salpêtrière Hospital, DMU Neuroscience, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; Paris Brain Institute - Institut du Cerveau (ICM), Department of Neuroscience, UMR 7225/UMRS 1127, Sorbonne University/CNRS/INSERM, Paris, France; Sorbonne University, Department of Philosophy, SND Research Unit, UMR 8011, CNRS, Paris, France.
| | - Lucie Joly
- Department of Psychiatry, Sorbonne University, Pitié-Salpêtrière Hospital, DMU Neuroscience, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; Paris Brain Institute - Institut du Cerveau (ICM), Department of Neuroscience, UMR 7225/UMRS 1127, Sorbonne University/CNRS/INSERM, Paris, France
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Chechko N, Losse E, Stickel S. A case report involving the experience of pervasive pregnancy denial: detailed observation of the first 12 postpartum weeks. BMC Psychiatry 2022; 22:774. [PMID: 36494788 PMCID: PMC9732985 DOI: 10.1186/s12888-022-04377-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 11/08/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Pervasive pregnancy denial is a rare condition associated with distress and unassisted delivery. CASE PRESENTATION The case involves a 38-year-old woman (NN), with two older children (ages 8 and 11), who was unaware, until delivery, that she had been pregnant. The case is discussed in the context of a 12-week observation of postpartum mood, stress, and mother-child attachment. NN and other 558 non-depressed women (mean age 32.41 years) were selected from the pool of participants in the RIPOD (risk of postpartum depression) study. All participants were recruited within 1-6 days of delivery. In addition to surveying depressed mood at childbirth, remote assessments of mood, mother-child attachment, and perceived stress were conducted at 3, 6, 9, and 12 weeks postpartum. Every other day, the participants also reported their current perceived stress levels based on a scale from 1 (low) to 10 (high). During the entire period of postpartum observation, NN reported no symptoms on the Edinburgh Postpartum Depression Scale, similar to only 1.6% of the sample, no stress as 0.7% of the sample, and above-average mother-infant bonding akin to only 4.6% of the sample. Her daily stress levels showed no disturbance, which was the case for only 3.32% of the total sample. On the day of delivery, NN reported a stress level of 1 (the minimum possible level), which was reported by only 4.2% of the total sample. However, NN reported the experience of delivery to be traumatic given that the child had fallen to the floor. CONCLUSION The experience of a denied pregnancy did not appear to disturb NN at any time point, not even on the day of delivery. Compared to NN, the other non-depressed participants reported wide fluctuations in stress levels during the observation period. NN did not report any risk factors for denied pregnancy. Thus, she belonged neither to any group of typical pregnancy deniers, as reported in the literature, nor to a typical postpartum group. We postulate, therefore, that the extent to which pregnancy denial can be deemed a normal variation, unrelated to a psychological or physiological condition, depends largely on personal traits.
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Affiliation(s)
- Natalia Chechko
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany. .,Institute of Neuroscience and Medicine: JARA-Institute Brain Structure Function Relationship (INM 10), Research Center Jülich, Jülich, Germany. .,Institute of Neuroscience and Medicine, Brain & Behavior (INM-7), Research Center Jülich, Wilhelm-Johnen-Strasse, 52428, Jülich, Germany.
| | - Elena Losse
- grid.1957.a0000 0001 0728 696XDepartment of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Susanne Stickel
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany. .,Institute of Neuroscience and Medicine: JARA-Institute Brain Structure Function Relationship (INM 10), Research Center Jülich, Jülich, Germany.
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Muziki JD, Uwera T, Niyonsenga J, Nshimiyimana A, Sebatukura SG, Mutabaruka J. A qualitative analysis of negative feelings among incarcerated filicide mothers in Rwanda. BMC Psychiatry 2022; 22:432. [PMID: 35761308 PMCID: PMC9235198 DOI: 10.1186/s12888-022-04081-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 06/22/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Most of the research on filicide mothers suggests that they experience negative feelings before they kill their child. However, little is known about whether these negative feelings can be expressed after one-year post-offense among incarcerated filicide mothers with no history of psychiatric problems. In this study, we aimed to conduct a qualitative analysis to (a) understand negative feelings evolving from negative emotions such as anger, guilt, shame, depression, and anxiety among filicide mothers incarcerated in Nyarugenge Prison in Rwanda, (b) identify the impact of experienced negative feelings on their personal wellbeing, and (c) explore their coping strategies. METHODS This study adopted a phenomenology research design and face-to-face in-depth interviews to explore the problem among twenty filicide mothers selected from Nyarugenge prison. Data were audio recorded, transcribed verbatim, organized, and analysed by using ATLAS.ti 8 Windows. RESULTS Anxious and depressed participants experienced both physical and emotional negative feelings. Social withdrawal and cognitive problems were expressed by anxious participants, while avoidance behaviours were particularly experienced by depressed participants. Intolerance created anger, while self-blame, regret, and acute stress created guilt. In addition, avoidance behaviours and poor self-judgment emerged from shame. Participants felt disconnected from their community and worried about a variety of issues because of their negative feelings. To cope with negative feelings, participants reported that they used abnormal defense, surrender and support from community resources. DISCUSSION Our findings highlight the overall negative feelings of incarcerated filicide mothers, which can guide mental health professionals and different stakeholders to respond with appropriate interventions.
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Affiliation(s)
- Jean d’Amour Muziki
- grid.10818.300000 0004 0620 2260Department of Clinical Psychology, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Thaoussi Uwera
- grid.10818.300000 0004 0620 2260Department of Health Informatics, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Japhet Niyonsenga
- grid.10818.300000 0004 0620 2260Department of Clinical Psychology, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda ,grid.10818.300000 0004 0620 2260Mental Health & Behavior Research Group, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Augustin Nshimiyimana
- grid.10818.300000 0004 0620 2260Department of Clinical Psychology, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Siméon Gitimbwa Sebatukura
- grid.10818.300000 0004 0620 2260Department of Clinical Psychology, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Jean Mutabaruka
- grid.10818.300000 0004 0620 2260Department of Clinical Psychology, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
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Watson K, Angelotta C. The frequency of pregnancy recognition across the gestational spectrum and its consequences in the United States. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2022; 54:32-37. [PMID: 35576053 PMCID: PMC9321827 DOI: 10.1363/psrh.12192] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 04/05/2022] [Accepted: 04/05/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Katie Watson
- Associate Professor of Medical Education, Medical Social Sciences, and Ob/Gyn, Faculty, Medical Humanities & Bioethics Graduate ProgramNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Cara Angelotta
- Assistant Professor of PsychiatryNorthwestern University, Feinberg School of MedicineChicagoIllinoisUSA
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Towards a new understanding of pregnancy denial: the misunderstood dissociative disorder. Arch Womens Ment Health 2022; 25:51-59. [PMID: 34392438 DOI: 10.1007/s00737-021-01176-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 08/09/2021] [Indexed: 10/20/2022]
Abstract
Pervasive pregnancy denial is a misunderstood reproductive anomaly which compromises the health of both mother and the developing fetus. Because in extreme cases, the death of the neonate at the hands of his/her mother has criminal repercussions, research has attempted to explain the origins of this clinical phenomenon. The purpose of this review is to analyze the evolution of understanding the association between pregnancy denial and neonaticide. This paper identifies the consistent similarities in symptom presentation, particularly dissociation, when a denied pregnancy ends with the death of the newborn. The common thread across the progression of the literature over time serves as a foundation for considering the development of diagnostic criteria for future inclusion in the Diagnostic and Statistical Manual of Mental Disorders. This paper reviews the seminal research from 1969 to current research up to 2020 addressing pregnancy denial and its connection to neonaticide. Peer reviewed and published articles related to key terms around "pregnancy denial," "pregnancy concealment," "neonaticide," and "dissociation" were retrieved from major databases such as PubMed, PsychINFO, JSTOR, ProQEST, ScienceDirect, and Google Scholar. Reference lists of relevant articles were also scanned to search for further papers pertaining to similarities in symptom presentation across demographic profiles. Papers were excluded if they were not available in English, or if they did not contribute to identifying consistencies in clinical presentation when a pregnancy is denied. There are clear repetitive markers that occur across studies which pertain not only to the frequent absence of certain expected indicators of pregnancy, (i.e. no morning sickness, weight gain, or sensations of fetal movement), but also the misattribution of pregnancy-related symptoms, and the consistent experience of a dissociative episode while giving birth that can unintentionally result in neonaticide. This paper concludes that dissociation is a consistently seen symptom in pervasive pregnancy denial. Dissociation, in addition to other commonly seen symptoms across cases, suggests specific diagnostic criteria that lend themselves to inclusion in the Diagnostic and Statistical Manual of Mental Disorders.
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Nto-Ezimah UA, Nto NJ, Esom EA, Okwor CJ, Adiri C. Unexpected delivery: a case report of cryptic pregnancy in Nigeria. Pan Afr Med J 2020; 36:205. [PMID: 32963671 PMCID: PMC7490131 DOI: 10.11604/pamj.2020.36.205.23790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 06/23/2020] [Indexed: 11/11/2022] Open
Abstract
The etiology of cryptic pregnancy has not been fully elucidated and there exist misconceptions about this phenomenon in our contemporary Nigerian society. This case presents the first case report of cryptic pregnancy in sub-Saharan Africa. A case of a 19 year old overweight female student who presented to the sick bay at 01: 30 hours with a 3-day history of lower back pain, abdominal discomfort and constipation. At the sick bay the general practitioner on call asked if she was pregnant and she vehemently said no, recounting that she sees her menstruation regularly. Abdominal examination however, revealed a gravid uterus of about 36 weeks and vaginal examination showed a fully dilated cervix. She was surprised, terrified and confused and only remembered having unprotected sexual intercourse many months earlier. Barely two hours later, she gave birth via spontaneous vaginal delivery, to a live female infant at 03: 14 hours. This case emphasizes the need for general practitioners and specialists in sub-Saharan Africa to be aware of the phenomenon of cryptic pregnancy, which involves women not being conscious of their gravid state until final weeks of gestation or at delivery, to reduce neonatal and maternal complications.
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Affiliation(s)
- Uloaku Akubueze Nto-Ezimah
- Department of Chemical Pathology, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nsukka, Nigeria
| | - Nto Johnson Nto
- Department of Anatomy, Faculty of Basic Medical Sciences, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nsukka, Nigeria
| | - Emmanuel Anayochukwu Esom
- Department of Anatomy, Faculty of Basic Medical Sciences, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nsukka, Nigeria
| | - Chika Juliet Okwor
- Department of Chemical Pathology, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nsukka, Nigeria
| | - Charles Adiri
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Nsukka, Nigeria
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Delcroix MH, Gomez C, Bayle B, Paraf F, Rusch E, Braillon A. [Total denial of pregnancy and childbirth: The death of the newborn is not criminal]. Presse Med 2019; 48:1580-1582. [PMID: 31757734 DOI: 10.1016/j.lpm.2019.09.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 09/30/2019] [Indexed: 11/19/2022] Open
Affiliation(s)
- Michel-Henri Delcroix
- APPRI maternité sans tabac à l'établissement public de santé mentale des Flandres, 59270 Bailleul, France
| | | | - Benoit Bayle
- Établissement public de santé Barthélémy-Durand, 91152 Étampes, France
| | - François Paraf
- Service de médecine légale, CHU Dupuytren, 87042 Limoges cedex 6, France
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Nanjundaswamy MH, Gaddapati S, Thippeswamy H, Thampy M, Vaiphei K, Kashyap H, Kishore T, Ganjekar S, Chandra PS. Denial of Pregnancy: Psychopathology and Clinical Management. Psychopathology 2019; 52:271-274. [PMID: 31593965 DOI: 10.1159/000503151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 09/02/2019] [Indexed: 11/19/2022]
Abstract
Denial of pregnancy (DOP) is a challenging condition with poorly understood psychopathology. DOP is reported to be associated with problems such as severe psychological conflicts, obstetric complications, risks to the newborn, and difficulties in bonding with the infant. In this paper, we present and discuss the clinical manifestations of a severe form of DOP that lasted until the time of delivery with resultant multifaceted complications. Our paper highlights the severity of psychopathology and the need for coordinated management. Descriptions from different cultural backgrounds would improve the conceptual understanding of DOP.
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Affiliation(s)
- Madhuri H Nanjundaswamy
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India
| | - Sravani Gaddapati
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India
| | - Harish Thippeswamy
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India,
| | - Mareena Thampy
- Department of Clinical Psychology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India
| | - Kimneihat Vaiphei
- Department of Psychiatric Social Work, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India
| | - Himani Kashyap
- Department of Clinical Psychology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India
| | - Thomas Kishore
- Department of Clinical Psychology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India
| | - Sundarnag Ganjekar
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India
| | - Prabha S Chandra
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India
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Affiliation(s)
| | - David Bervini
- Service de Neurochirurgie, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne (Unil), Lausanne, Switzerland
| | - Mathilde Morisod Harari
- Service Universitaire de Psychiatrie de l'Enfant et de l'Adolescent (SUPEA), Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne (Unil), Lausanne, Switzerland
| | - David Baud
- Service de Obstétrique, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne (Unil), Lausanne, Switzerland
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Abstract
Pregnant students are the population group most likely to commit neonaticide, murder of an infant younger than 24 hours old. Denial by the student, lack of early pregnancy detection, and poor social support contribute to this disorder. As the health care professionals with whom the student has the most contact, school nurses are in an excellent position to prevent neonaticide through provision of health education, early detection of pregnancy, and intervention with students and their families to assist them in making healthy choices.
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Reactive-homeostasis as a cybernetic model of the silhouette effect of denial of pregnancy. Med Hypotheses 2011; 77:782-5. [DOI: 10.1016/j.mehy.2011.07.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 07/18/2011] [Indexed: 11/22/2022]
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Kent LK, Blumenfield M. Psychodynamic psychiatry in the general medical setting. ACTA ACUST UNITED AC 2011; 39:41-62. [PMID: 21434742 DOI: 10.1521/jaap.2011.39.1.41] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
For more than half a century analytically trained psychiatrists have been making observations about psychodynamic factors impacting on medical illness and treatment. Some of these reports have been subsequently supported by evidence-based research while others have been found to be clinically useful to varying degrees even if not substantiated by research. In this article we have presented some of the highlights of the application of psychodynamics to the treatment of physical illness in the general medical setting. It is not meant to be a comprehensive review but we hope it will demonstrate how psychodynamic thinking has permeated many aspects of care in the general medical setting. Topics considered include onset of disease (giving up complex, specificity, role of stress, anniversary reactions), reactions to illness (psychological defenses, fantasies, role of psychotherapy), specific conditions (pregnancy, cancer, human immunodeficiency virus, conversion and alexithymia, heart disease, death and dying), and the doctor-patient relationship.
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Affiliation(s)
- Laura K Kent
- Columbia Presbyterian Medical Center/New York State Psychiatric Institute, New York, NY 10032, USA.
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