Psychiatric pain and deliberate suffering

In public opinion and in medical practice the suffering of psychiatric patients is often considered self‐induced. Freudian psychoanalysis embraced this notion but managed to reconcile it with the pleasure principle only by positing an instinctual craving for death, to which Freud reduced instances of deliberate and repetitive suffering. In a simultaneous but separate line of thought, he also reduced all habits, including self‐destructive ones, to masturbation and all inhibitions of constructive drives to inhibitions of masturbation. This article explores this seeming paradox.

The transition from a paranoid‐schizoid position to a depressive one begins with the dawning assumption of ownership of certain aspects of one's being, with the correlative attribution of other aspects to the world outside the self. Inevitable errors in this process create tensions that may be discharged by suffering, either by atonement or by assuming ownership of the pain that one's dependency might otherwise inflict on one's objects. Eros serves Thanatos to preserve self‐ownership. Pragmatically, owning one's fate can feel more important than enjoying it, a fact the author dubs the “Principle of Ownership”; and illustrates with a number of literary and clinical vignettes.

The idea that psychiatric suffering is self‐induced contributes to the stigma that so commonly attends it. Ironically, this same idea makes psychological treatment possible: if painful adjustments replace relationships, then new relationships may have the power to correct them.     

Terrified by suffering,tormented by pain*

Ferenczi’s understanding of the primitive defenses required to cope with trauma, such as introjection, identification with the aggressor, atomization and reckoning, supports the author’s clinical observations of patients who introject a pain mother. Introjecting a pain mother assures that the terrorism of the original external event of a suffering mother keeps the internal suffering going, resulting in being tormented by pain. Such an introjection creates technical difficulties for the analyst. A clinical case is presented to demonstrate.     

Empathy gaps for social pain: why people underestimate the pain of social suffering

In 5 studies, the authors examined the hypothesis that people have systematically distorted beliefs about the pain of social suffering. By integrating research on empathy gaps for physical pain (Loewenstein, 1996) with social pain theory (MacDonald & Leary, 2005), the authors generated the hypothesis that people generally underestimate the severity of social pain (ostracism, shame, etc.)--a biased judgment that is only corrected when people actively experience social pain for themselves. Using a social exclusion manipulation, Studies 1-4 found that nonexcluded participants consistently underestimated the severity of social pain compared with excluded participants, who had a heightened appreciation for social pain. This empathy gap for social pain occurred when participants evaluated both the pain of others (interpersonal empathy gap) as well as the pain participants themselves experienced in the past (intrapersonal empathy gap). The authors argue that beliefs about social pain are important because they govern how people react to socially distressing events. In Study 5, middle school teachers were asked to evaluate policies regarding emotional bullying at school. This revealed that actively experiencing social pain heightened the estimated pain of emotional bullying, which in turn led teachers to recommend both more comprehensive treatment for bullied students and greater punishment for students who bully.     

Conceptualizing institutions

Being part of the life of institutions requires a considerable amount of conceptual knowledge. In institutional settings, we must learn the relevant concepts to act meaningfully, and these concepts are internal in a peculiar way, namely, they are strictly relative to the rules of a given institution because they are constituted by those rules. However, institutions do not come out of nothing: They are inscribed in a social setting and this setting determines, at least in a broad sense, what is the nature of the institution. Our social life therefore creates more or less defined contexts for meaningful institutional activities, and these contexts in their own turn involve concepts. In this paper, I address this question by distinguishing between three kinds of concepts relevant for an institution and trying to identify the different relations that these concepts have with constitutive rules. I then proceed to explain how this distinction can improve our understanding of practical reasoning in institutional context.     

Conceptualizing Personal and Extrapersonal Associations

We recently introduced the term ‘extrapersonal associations’ and defined them as information that is available in memory but that does not contribute to one's attitudes toward a given object ( Olson & Fazio, 2004 ). Here, we review our conceptualization of the term, contrast it to our conceptualization of attitudes as personal associations, and briefly summarize evidence that the Implicit Association Test, as it is traditionally employed, is influenced by extrapersonal associations. We discuss recent critiques of the concept and in so doing, elaborate upon the essence of the personal versus extrapersonal distinction. We conclude with speculations on the nature of extrapersonal associations, their origins, and relationship to attitudes.     

Distinction between mental pain and psychic suffering as separate entities in the patient's experience

Abstract

Mental pain and psychic suffering are herein defined as two separate concepts in psychoanalysis. The concept of mental pain lies at the core of psychoanalysis; it was introduced by Freud and was further elaborated by a number of investigators, mostly by Bion. Mental pain refers to a pain that the patient reports as being impossible to describe in words, and lacking any associations, whereas psychic suffering can be both named and described by the patient. Mental pain is derived from non-tolerance on the part of the psychic apparatus when it is harmed by very painful emotions. In contrast to psychic suffering, mental pain resists elaboration and transformation by dream-work. How to address and transform the patient's mental pain is a major challenge facing the analyst in his clinical work because mental pain may halt or slow the progression of the analytical process. To overcome this hindrance, the work of the analyst is focused on helping patients to modify their mental pain into psychic suffering, that is, to reactivate in the patient the chain of transformations that generates thought. The analyst is also challanged with the mental pain of the patients because he has himself to tolerate the mental patient induced by counter transference. Suggestions for the analyst on how to deal with the mental pain of the patient during psychoanalytic therapy are proposed.     

Conceptualizing adult development

On the premise that human development is a lifelong process, and with awareness of certain limitations of the stage model, the authors conceptualize a new model based on developmental process. This model is offered as a basic model for the development of mental functions and structures in both childhood and adulthood.     

Conceptualizing and measuring global interpersonal mistrust-trust

Global interpersonal mistrust is conceptualized as a general mistrust of the motives of others in situations related to one's well-being: a general tendency to view others as mean, selfish, malevolent, or unreliable people who are, thus, not to be depended on to treat one well. The authors developed an 18-item unidimensional self-report inventory measuring interpersonal mistrust as a negative cognitive orientation toward others. The measure comprises items describing perceptions of specific hypothetical interpersonal situations rather than items asking respondents to describe their own general behavior. The measure was reliable and evidenced construct validity in a heterogeneous sample of Australians.     

Conceptualizing and Measuring Global Interpersonal Mistrust-Trust

Abstract

Global interpersonal mistrust is conceptualized as a general mistrust of the motives of others in situations related to one's well-being: a general tendency to view others as mean, selfish, malevolent, or unreliable people who are, thus, not to be depended on to treat one well. The authors developed an 18-item unidimensional self-report inventory measuring interpersonal mistrust as a negative cognitive orientation toward others. The measure comprises items describing perceptions of specific hypothetical interpersonal situations rather than items asking respondents to describe their own general behavior. The measure was reliable and evidenced construct validity in a heterogeneous sample of Australians.     

Space and Language in Conceptualizing Identity

In this paper, we discuss the conceptualization of space as a dimension relevant to personal identity and the central role that is attributed to language with respect to its constitution. It is argued that the identification with a certain geographical space and the use of (a) certain language(s) or linguistic variety can be regarded as crucial for the self-definition of individuals and also groups. We pursue a threefold goal: (1) to highlight the contribution of geographical research to our understanding of the self as a phenomenon situated in space; (2) to discern merits, but also problems related to the recent strong emphasis of the role of language with respect to identity constitution, especially in constructivist and poststructuralist approaches; and (3) on the basis of these findings, to draw conclusions concerning the given and constructed elements of identity, with a particular focus on space and language. In addition to a survey of relevant theoretical positions, empirical examples are presented with the aim to illustrate how geographically marked identity is constituted.

     

Self-conscious emotions in patients suffering from chronic musculoskeletal pain: A brief report

Objective: The role of self-conscious emotions (SCEs) including shame, guilt, humiliation and embarrassment are of increasing interest within health. Yet, little is known about SCEs in the experience of chronic pain. This study explored prevalence and experience of SCEs in chronic pain patients compared to controls and assessed the relationship between SCEs and disability in pain patients.

Design and measures: Questionnaire assessment comparing musculoskeletal pain patients (n = 64) and pain-free control participants (n = 63). Pain was assessed using the McGill Pain Questionnaire; disability, using the Roland–Morris Disability Questionnaire; and six SCEs derived from three measures (i) Test of Self-Conscious Affect-3 yielding subscales of shame, guilt, externalisation and detachment (ii) The Brief Fear of Negative Evaluation Scale and (iii) The Pain Self-Perception Scale assessing mental defeat.

Results: Significantly greater levels of shame, guilt, fear of negative evaluation and mental defeat were observed in chronic pain patients compared to controls. In the pain group, SCE variables significantly predicted affective pain intensity; only mental defeat was significantly related to disability.

Conclusion: Findings highlight the prevalence of negative SCEs and their importance in assessment and management of chronic pain. The role of mood in this relationship is yet to be explored.     

Our suffering and the suffering of our time

Theoretical Medicine and Bioethics -     

Sex differences in trauma symptoms,body image and intensity of pain in a Polish sample of patients suffering from chronic pain

The main goal of the current study was to investigate sex differences in the relationship between the level of trauma symptoms appearing in posttraumatic stress disorder (PTSD) and intensity of pain in a sample of 300 Polish patients suffering from chronic pain, specifically rheumatoid arthritis and lower back pain. We also focused on participants’ body image with body esteem as a mediator. To assess the intensity of pain among participants, we used the Numerical Rating Scale. The level of trauma symptoms was assessed with the PTSD Factorial Version Inventory. To measure body image among participants, we used the Body Esteem Scale. The results of our study suggest that trauma symptoms and body image dimensions were significant predictors of pain intensity among men suffering from chronic pain. Moreover, trauma symptoms and age were significant predictors of pain intensity among women suffering from chronic pain. Finally, we demonstrated that sex differentiates the reaction to chronic pain.