Readings in Psychology; Foundations & Applications


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国第劇羅盟翡第目 ness, but in which the IOSS experience described below was absent. Phases of con- frontation Of IOSS occurred if the patient was considered to be actively engaged with the precipitating loss, as when the loss and associated fantasies appeared in consciousness with a vividness and a graphic detail such that there was imparted a quality 0f reliving the painful events; at the same time, the latent affect appro- priate tO the IOSS became manifest; and there was evidence Of a disruption in the patient's established behavior pattern—especially in those stereotyped mecha- nisms previously defined as defensive. By consensus, the workshop demarcated the onset and termination of such phases for all patients. ()n later phases of the research, the workshop also at- tempted tO define periods Of partial confrontation, when some, but not all, of these criteria were met. ) Phases Of recovery or resolution were defined as periods in which depressive symptomatology had abated, the loss and the pathological defenses against it were no longer operative, and the patient was again able to function and plan for her future. 10 8 2 4 ,kVCl,/fltu S し工 0 ー LI 十 2SD = 7.7 十 ISD = 6.3 MEAN = 4.9 ー ISD = 3.5 ー 2SD = 2.1 0 HOSPITAL 1 DAYS 45 25 40 20 30 35 CETS UNCOVERING DRUNK EDEMA SUICIDAL INTERVIEW THREAT RESOL - ′℃ ONFRONT - DEPRESSIVE "EQUILBRIUM" UTION ATION" Sx : HEADACHES & FATIGUE ACCEPTS LIMITS CON 日」 C 丁 WITH DR. GUILTY & WORTHLESS FEELINGS "DR. DOES CARE RECAPITULATES CONFLICT WITH A BOUT ME" MOTHER DEFENSES ・ 'l HAVE THE RIGHT "YOU い ON を T CARE" TO GET ANGRY" RETAINS "REBIRTH" FANTASY ・ 'IF ー DEFY YO し , YOU DEPENDENCY BIDS WILL THROVV ME DENIES RAGE AT MOTHER 0 し T ・ 彡 DEPRESS 15 10 5 S ト NA > じ 0 nl dO 工 S ノ MO ~ 一 HELP. HOPE WORTH ■ TOTAL 6 4 2 0 SDNIIVM S 、 IN AQISAM / 彡彡 Figure 1 LO 月 g 淑ⅲ endocrine の 1 日 psychiatric d 保 for Case 1. とゆ〃の・ bars 尾〃尾 se れ t urinary corticosteroid ( 17-OHCS) 0 4 ル t ⅲ川 g / 日ロ y. HO ZO れ t 記 solid lines 尾〃尾 s の社Ⅲ e の 1 Of 保〃 cor 日 cos 地 ro て )alues for this 卩ロ日の 1 ぢ or た 0 ~ 日 Ot 地日〃れ es ⅲ d たロ 0 s for 士 1 ロれ日 2 SD 斤 0 Ⅲ the 川 2 ロれ . Vertical s 制〃れ es 尾 p 尾 se れ t de 川 at ℃保日 0 れ points . for cl ⅲた司 phases as 日可の・ m ⅲ 2 日 by the psychotherapy て vor た s 〃 0 卩 . Brief psychiatric descriptions の℃ recorded for each が 1a 兜 . ( H ⅸ〃の - corticosteroid 0 司 s 社沼尾卩尾市 c 地日 for phases 0f CO れ一 斤 0 日 0 れ 0 ー loss. ) 0 て ver sets Of bars 尾卩尾 se れ t ロ se c 日 0 〃 0 / N12 尾 s 2 れ ts ' 社沼 e た一 y ratings 可日 e 〃尾 ss 池 2 symptomatology: tO ー sy 川卩 tO 川 score, 日 e 〃尾 ss れ尼ロ″ ec らロⅱ日 CO Ⅲ〃 OS e score for ん 2 ゆ ss , ん 0 卩 ess , のてじ or ss ル司ⅲ gs. Development 0 ー the lndividual 364

ln making these judgments about clinical phases, the workshop relied primarily on the summaries and tape recordings of psychotherapy sessions, and on the detailed nurses' notes. As stated before, the workshop predicted that for each patient phases of confrontation of the loss would be associated with higher mean corticosteroid levels than the other clinical phases in the patient's course. Results Endocrinological and psychological observations for each case will be reported in detail eIsewhere16. As an example of the data, Fig. 1 illustrates the endocrine and psychological changes in Case 1. Some general summary comments about the group 0f patients will be made here. CHARACTERISTICS OF PHASE OF CONFRONTATION OF LOSS COMPARED WITH OTHER PHASES Endocrine Changes ln five of the six cases, both the highest individual and highest mean corti- costeroid levels occurred during the phases designated as periods of confronta- tion of the loss (Table 1 ). The prediction that mean corticosteroid excretion during the confrontation period would be higher than adjacent periods designated depressive equilibrium or recovery held to the P < 0.005 level confidence. As indicated in TabIe 1 , the group data can be organized in 12 pairs 0f phases, with accompanying predic- tions as tO which phase in each pair should have the higher corticosteroid value. Using the Wilcoxon Signed Ranks Matched Pairs Test17 the hypothesis that the confrontation phases should have relatively higher corticosteroid excretion held to P < 0.005. As an even stricter test of the hypothesis recovery phases were omitted, and the analysis was confined tO depressive equilibrium —confrontation phase pairs. The hypothesis then held to the P < 0.01 level for the eight pairs ・ Table 1. Mean 17-Hydroxycorticosteroid 2 工 c 尾日 0 れ (mg/day) for clinical phases Phase Patient 2 1 3 4 イ 1 っ 4 「 0 4 ( 一 0 / 0 6.7 大 4.4 5.2 大 4.8 7.7 * *Phase of "confrontation of loss. Higher corticosteroid value pre- dicted (P < 0.005 ). 8 「 0 1 つ」′ 0 【 0 「 0 【 0 4 マ / 0 ・ っ / 「 / 7 っ 4 0 4 ・ 0 「 0 4 ・し 4 ・ 8.3 Corticosteroid Responses tO Psychotherapy 0 を Depressions 365

Table 2. D レ 0 0 ー〃ⅸⅲ d ⅲレ cor 行 cos 地 ro てわ 1 尾 0 tO clinical phase Cor cos 地「 0 / 日 values > 十 2 SD < 十 2 SD 7 22 1 158 8 180 Cor 日 COS ro 一日て 1 ロ ll イ es > 十 1 SD く十 1 SD 11 12 23 Clinical phase Confrontation Non-confrontation Total Total 29 159 188 To tal 29 159 188 Confrontation Non-confrontation Total 18 147 165 ln terms of individual corticosteroid values, for five of the six patients at least one value during the confrontation phase was greater than 2 SD above the patient's mean (Table 2 ). By contrast, in only one instance (Case 2 ) did a single value from a nonconfrontation phase exceed 十 2 SD. A similar analysis of the distribution of corticosteroid values greater than 1 SD above the mean reveals that 37.9 % of values occurring during confrontation periods were greater than 十 1 SD, as opposed to only 7.5 % of values occurring during nonconfrontation phases (Table 2 ). lt should be noted that these workshop judgments predicted periods of corticosteroid elevation much better than the resident's descriptive ratings of symptoms, which did not take into account the dynamic function of the symp- toms. Table 3 presents for each patient correlations of symptom ratings with mean corticosteroid values for the three days prior to and including the rating, using the Spearman Rank Correlation Test. 18 Only Case 1 showed good cor- relations throughout. (The generally poor correlations may also be due in part to the timing of ratings, which sometimes missed the transient periods of emotional and endocrine upheaval). Table 3. Cor 尾日 0 わ 2 れじ 2 の 1 corticosteroid 0 ロわ花 s ロ〃 d symptom ratingst Depr HeIp- Worth- Anx Anx Sum Hope- To t Psych Affec t less less less Somat Sx Anx 0.45 ー 0.26 ー 0.36 ー 0.14 0.64 ー 0.79 Sx = symptoms; Sum Anx sum Of anxiety psychic and somatic *Spearman Rank Correlation Coefficient. 17 す Modification of HamiIton Depression Scale. 13 Patient 0.67 ー 0.26 ー 0.41 ー 0.16 0.10 0.89 0.71 0.78 ー 0.38 ー 0.72 —O. 06 0.67 0.71 0.45 —0.10 ー 0.65 ー 0.34 ー 0.07 ー 0.45 0.71 0 0.63 ー 0.46 ー 0.24 0.30 0.82 0.20 ー 0.46 ー 0.32 0.02 ー 0.67 1 よっ 4 「 0 4 -0 ・ 0 ー 0.31 ー 0.70 0.21 0.67 ー 0.32 0.29 0.10 ー 0.97 tOtal anxiety. 366 Development 0 ー the lndividual