The hormone replacement therapy controversy

The issue of hormone replacement treatment for menopausal symptoms, osteoporosis, various cardiac problems, and other disorders has received a great deal of attention. Recent data concerning the benefits and risks have changed ideas about indications and contra-indications. In this paper we will consider the multiple factors that determine an individual woman's decision about taking or continuing to take hormone replacement therapy, not only the medical indications. We will discuss the established benefits of replacement therapy, conditions for which the benefits are not established, areas of controversy, risks of treatment, and factors underlying the decisions about undergoing the treatment.

Psychiatrist-patient boundary issues following treatment termination

OBJECTIVE

Psychiatrist-patient relationships after termination of treatment are fraught with complexities and are the subject of ongoing debate. The authors discuss the issue of boundary violation allegations that arise after treatment has ended, with the goal of explicating how these issues have been handled in psychiatric discussions as well as in broader sociolegal settings.

METHOD

Clinical illustrations and legal cases are used to illustrate how legal and administrative bodies have dealt with posttermination boundary issues.

RESULTS

Courts and regulatory bodies have tended to use the psychoanalytic concept of transference to decide issues in which there has been a complaint of impropriety-be it romantic, financial, or social in nature-arising after termination of treatment. However, a multitude of treatment approaches are currently employed in psychiatry, and often their practitioners either do not use the concept of transference or deny its validity. If the concept is used, it is often present in many settings outside therapy.

CONCLUSIONS

The concept of transference is subject to continuing debate and modification within psychoanalysis, and its use in judicial or quasijudicial settings raises questions about whether it meets standards of scientific acceptance. Using the concept of transference to decide posttermination issues results not only in confusion but also has the potential for many adverse consequences for practitioners and the profession.

Depression in women. Psychoanalytic concepts

I would now like to summarize the relationship between concepts about depression and formulations of feminine development and personality. What are women's vulnerabilities? 1. The particular vicissitudes of feminine development result in differences, in attachment and anxiety about loss of love and abandonment as part of the normal constellation of feminine personality. These derive, in part, from the difference in the process of separation-individuation and differentiation in women as compared with men. 2. The normal feminine personality includes responsiveness and/or dependency in relation to others and greater anxiety about loss of love. This sensitivity is important in the regulation of and fluctuations of self-esteem. 3. The pathways for development of aggression and its fate includes the powerful effect of social customs that prescribe passivity with consequent likelihood of helplessness and the relatively fewer pathways for activity and active mastery. 4. Problems of self-esteem, including those resulting from the recognition of aggression and also the development of an ego ideal that values sacrifice and service. Devaluation of the female body contributes. 5. Problems of identification with a devalued person as a woman--the mother--who is sometimes also depressed. 6. Sex-role stereotypes and life conditions that support devaluation, subservience, and helplessness and limit opportunities.

Anxiety, depression, and menstrual symptoms among freshman medical students

Based on data from a larger longitudinal study of medical students and physicians, this study establishes the incidence of some menstrual symptoms in a nonclinical population of 82 healthy, female, first-year medical students and investigates the correlation of self-reported anxiety and depression scores with these symptoms. Findings show that nearly half reported the frequent occurrence of at least one menstrual symptom that appeared to cause discomfort but did not interfere with performance. The data suggest an association between anxiety and depression scores and certain self-reported menstrual symptoms in this population. The study suggests the need for further investigation of the nature of the relationship between dysphoric moods and menstrual symptoms in healthy women.

Psychotherapy with the substance-dependent physician: pitfalls and strategies

Psychotherapy with substance-dependent physicians presents special problems. Accurate assessment and effective response is rendered difficult due to underrepresentation or denial by the patient and countertransference impediments to recognition and limit setting by the therapist. Case examples illustrate problems, pitfalls, and therapeutic strategies.

Factors influencing first-year medical students' perceptions of stress

This preliminary report from an ongoing longitudinal study of students at both Tufts and Harvard medical schools examined the relationship between premedical school demographic and stress variables and the numbers and types of stresses reported by students in open-ended interviews conducted during their first year of medical school. Analyses showed that the general categories of "medical school stresses" and "social stresses related to medical school" accounted for about two-thirds of the total number of stresses mentioned. The overall distributions of stresses across general categories were remarkably similar in all student groups studied, although significant differences were found between students from different background groups on a number of the specific types of stress. No significant differences were found between groups as to those reporting a high total number of stresses. There did appear to be differences in the degree to which students felt affected by the stresses they reported, suggesting the need for additional data on the meanings of different stresses for different students and the ways in which they cope with them.

A follow-up study of rape victims

Of 130 women initially seen in a general hospital emergency room after being raped, the authors were able to interview 41 of the women 1-21/2 years after the rape. Half of the women continued to fear being alone and three-quarters reported still being suspicious of others. Many also felt restricted in their daily lives and had self-reported episodes of depression and sexual problems, which they attributed to the rape; none had a history of mental or emotional disturbance. The authors recommend that short-term, issue-oriented therapy be made available for all rape victims, as well as resources for the treatment of long-term symptoms.

To marry or not to marry: a choice

The authors discuss the reasons for decisions to remain single or to marry, particularly for women today. They consider aspects of the life experience of single women and provide a developmental context for women's choices. The authors discuss the impact of marriage on women's lives and point out that marriage increases stress for women. The changing role of women in society and increased reproductive control have given women greater choice about the direction of their lives, including more freedom to make deliberate decisions about marriage.

Women in academic psychiatry: politics and progress

The progress of women in academic psychiatry depends in part on the social and institutionalized administrative patterns expressed through faculty attitudes, hiring practices, and other conditions of the field as they are currently structured. As the numbers of women increase, their specialness will decrease, and accommodations to particular needs and variations may become accepted as part of the system. This success in modifying the system will be self-perpetuating, proportional, and appropriate, leading to more participation of women in academic psychiatry.

Success or failure: psychotherapeutic considerations for women in conflict

The authors describe conflicts experienced by women who request therapeutic intervention because of symptoms of depression, anxiety, marital discord, difficulty in asserting themselves, or inability to complete work that would lead to advancement. They discuss the developmentally based difficulties experienced by women in making career choices, advancing their careers, and facing midlife issues. The therapist who deals with such patients must be aware of reality-based factors and of his or her own values and attitudes as they influence choice of therapeutic approach.

Outcome following therapeutic abortion

Psychological outcome of abortion was studied in 102 patients, measuring multiple variables over four time intervals. Five measured affects--anxiety, depression, anger, guilt, and shame-were significantly lower six months after the preabortion period. The following variables describe subgroups of patients with significant variations in patterns of responses as indicated by changes in affects: marital status, personality diagnosis, character of object relations, past psychopathologic factors, relationship to husband or lover, relationship to mother, ambivalence about abortion, religion, and previous parity. A complex multivariate model, based on conflict and conflict resolution, is appropriate to conceptualize, the unwanted pregnancy and abortion experience. Data suggest that women most vulnerable to conflict are those who are single and nulliparous, those with previous history of serious emotional problems, conflictual relationships to lovers, past negative relationships to mother, strong ambivalence toward abortion, or negative religious or cultural attitudes about abortion.

The rape victim: psychodynamic considerations

Rape challenges a woman's ability to maintain her defenses and thus arouses feelings of guilt, anxiety, and inadequacy. Women's individual responses are determined by life stage considerations as well as their defensive structures: concerns about separation-individuation may be aroused in the young woman; a divorced or separated woman may find her credibility questioned; older women's fears of sexual inadequacy may be compounded. In counseling, the victim's previous adjustment should be assessed, she should be given support and reassurance, and specific considerations related to her life circumstances should be acknowledged and dealt with.