Stress Processes in Pregnancy and Preterm Birth

ABSTRACT— Preterm birth (PTB) is of epidemic proportions in the United States, particularly among African Americans. Its consequences range from risk of infant mortality to lifelong disease and disability. Stress is a contributor to preterm labor and delivery. This article summarizes research on stress as a risk factor for PTB. As is evident in considering the complex mechanisms, psychological science has much to contribute to addressing this important health issue.     

Visual configural processing in adults born at extremely low birth weight

Being born at extremely low birth weight (ELBW; ≤1,000 g) is associated with enduring visual impairments. We tested for long‐term, higher order visual processing problems in the oldest known prospectively followed cohort of ELBW survivors. Configural processing (spacing among features of an object) was examined in 62 adults born at ELBW (M_age = 31.9 years) and 82 adults born at normal birth weight (NBW; ≥2,500 g: M_age = 32.5 years). Pairs of human faces, monkey faces, or houses were presented in a delayed match‐to‐sample task, where non‐matching stimuli differed only in the spacing of their features. Discrimination accuracy for each stimulus type was compared between birth weight groups, adjusting for neurosensory impairment, visual acuity, binocular fusion ability, IQ, and sex. Both groups were better able to discriminate human faces than monkey faces (p < .001). However, the ELBW group discriminated between human faces (p < .001), between monkey faces (p < .001), and to some degree, between houses (p < .06), more poorly than NBW control participants, suggesting a general deficit in perceptual processing. Human face discrimination was related to performance IQ (PIQ) across groups, but especially among ELBW survivors. Coding (a PIQ subtest) also predicted human face discrimination in ELBW survivors, consistent with previously reported links between visuo‐perceptive difficulties and regional slowing of cortical activity in individuals born preterm. Correlations with Coding suggested ELBW survivors may have used a feature‐matching approach to processing human faces. Future studies could examine brain‐based anatomical and functional evidence for altered face processing, as well as the social and memory consequences of face‐processing deficits in ELBW survivors.     

On Hope and Hard Choices

In Handle with Care (2009), novelist Jodi Picoult presents a heartbreaking case involving the question of wrongful birth. This essay examines Ronald M. Green's writings in the field of bioethics to see what wisdom they might bring to this case. I argue that Green's contributions to bioethics exemplify some of the best of ethical argumentation: attention to facts, discernment of morally relevant differences, enunciation and justification of principles, originality, and compassion. I then draw from his work three foci that illuminate aspects of the dilemma presented by Picoult: the importance of parental love, the possibility that the dilemma might be reframed away from wrongful birth, and the need to shift our focus to questions of justice. While appreciating Green's contributions to bioethics, I also indicate several places of nuanced disagreement.     

论医学模式转变对助产土在产程守护中角色转变的影响

伴随着医学模式的转变,助产士在产程守护中的角色由单一守护者的角色向全面、多重角色转变,助产士的工作内容与职责也相应发生变化。现代医学模式下助产士的角色转变对医疗效果有良好的改进,体现了“以人为本”的医疗文化理念,同时也对助产士的要求更为全面。     

关于低出生体重儿诊疗最优化原则的思考

出生体重及低出生体重发生率是衡量社会发展和妇幼保健状况的重要指标。低出生体重不仅直接增加新生儿和婴儿的患病率和死亡率,而且与儿童的远期预后如生长发育落后、智力低下、脑瘫及成年期胰岛素抵抗密切相关。通过运用诊疗最优化的原则,对低出生体重儿进行预防,及早干预治疗,可提高其生命质量。     

COGNITIVE AND SOCIOEMOTIONAL FUNCTIONING AT 4½ YEARS IN CHILDREN BORN TO MOTHERS WHO HAVE RECEIVED TREATMENT FOR SUBSTANCE‐ABUSE PROBLEMS WHILE PREGNANT

Cognitive and socioemotional functioning at 4½ years of age were examined in children born to mothers with substance‐abuse problems (n = 22) recruited from residential treatment institutions while pregnant, and then compared to children born to mothers with mental health problems (n = 18) and children from a low‐risk group (n = 26). No significant group differences in cognitive functioning were found, but the children born to mothers with substance‐abuse problems showed more caregiver‐reported socioemotional problems than did the low‐risk children, like the children born to mothers with mental health problems. Birth weight had an effect on internalizing problems at 4½ years and mediated the relation between group and socioemotional problems, although not when controlling for caregiver education, single parenthood, and anxiety and depression. At 4½ years, 7 children born to mothers with substance‐abuse problems were placed in foster care. These children had lower birth weight and higher caregiver‐rated internalizing problems. In addition to emphasizing the importance of the quality of the prenatal environment, this study suggests that families with previous substance abuse are in need of long‐term follow‐up to address socioemotional problems and enhance further positive child cognitive development. The foster‐placed children may be in particular need of long‐term follow‐up.     

Sigmund Freud and Otto Rank: debates and confrontations about anxiety and birth

The publication of Otto Rank's The Trauma of Birth (1924) gave rise to an intense debate within the secret Committee and confronted Freud with one of his most beloved disciples. After analyzing the letters that the Professor exchanged with his closest collaborators and reviewing the works he published during this period, it is clear that anxiety was a crucial element among the topics in dispute. His reflections linked to the signal anxiety concept allowed Freud to refute Rank's thesis that defined birth trauma as the paradigmatic key to understanding neurosis, and, in turn, was a way of confirming the validity of the concepts of Oedipus complex, repression and castration in the conceptualization of anxiety. The reasons for the modifications of anxiety theory in the mid-1920s cannot be reduced, as Freud would affirm officially in his work of 1926, to the detection of internal contradictions in his theory or to the desire to establish a metapsychological version of the problem, for they gain their essential impulse from the debate with Rank.     

Precipitation anxiety

Therapy with autistic and psychotic children led the author to introduce the concept of precipitation anxiety. Freud's first theory of the instincts was expressed in the dynamics of conflict, but his subsequent development of life and death instincts is better understood in terms of a gradient of energy between two extremities of the same axis. Object relations result from a caesura (Bion) which creates a gradient of psychic energy experienced initially as a precipice which, if left unregulated, generates intolerable anxiety. Satisfactory emotional encounters with the mind of the object bring about the necessary adjustments to the slope of the gradient. Autistic mechanisms may block off precipitation anxiety, but they also prevent mental growth. Both the dynamics of conflict and the dynamics of the gradient are vital for psychic development, but the very existence of the former is contingent on successful negotiation of the energy gradient (working through). After illustrating his thesis with clinical material drawn from a group therapeutic setting, the author discusses points of convergence and divergence with two other fundamental notions: the aesthetic conflict (Meltzer) and premature psychic birth (Tustin). The proposed model furthers our understanding of the therapeutic process and stresses the importance of the containing object in the transference situation.     

Resonance and Ambiguity—about Metaphorical Thinking

This presentation is based on the theory, presented by the author, of the development of the mind and its psychoanalytic treatment as a stage-specific continuum, applicable in principle to all levels of disturbed and arrested mental development. This paper focuses on the nature of attainment and mediation of understanding with psychotic, borderline and neurotic patients, and the significance of successful conveyance of understanding as related to the general goal of psychoanalysis, to achievement of a structural change in the analysand's representational world and, finally, to the question of the main curative factor in psychoanalytic treatment. After discussing all these questions, the author ends up giving the conveyance of stage-specific and individual understanding a central place in all of them. The goals of understanding and psychoanalysis in general seem to be more-or-less identical. Starting and continuing new structuring internalizations in the patient's world of experience is primarily motivated by conveyance of the analyst's stage-specific and individual understanding, and thereby leading to alleviation or elimination of consequences of the developmental arrest. It seems thus warranted to conclude that conveyance of the stage-specific and individual understanding seems to be the central curative element in the psychoanalytic interaction.