Docstoc

Chapter 8 Psychoanalytic Approaches to Trauma A Forty-Year

Document Sample
Chapter 8 Psychoanalytic Approaches to Trauma A Forty-Year Powered By Docstoc
					                                             Chapter 8:

                              Psychoanalytic Approaches to Trauma:

                                    A Forty-Year Retrospective



                                           Henry Krystal



Sickness, insanity and death were the dark angels standing guard at my cradle and they have

followed me throughout my life.

--Edward Munch. (Stang 1977)

       Before the German invasion, my family lived in the Southwest area of Poland, in

Sosnowiec. My father was a bookkeeper, and I had a brother seven years older then. I was born

in 1925. When I was 41/2 years old, I was walking with my father past the elementary school,

when I said to him that I would like to go to school. This was a few days before the school year

started, so he took me in. In the office, there a few people at their desks, and my father told him

that I wanted to go to school, and that was reading already. They tested me and by an

extraordinary procedure admitted me to the second grade. However, in the winter of that year, I

developed pneumonia and puss in my right lung. Without antibiotics, this was a deadly

condition. I was operated on and a rubber tube drain was inserted into my chest. I had to stay in

the hospital for three months. This was my childhood trauma, which I survived only because my

mother stayed with me all the time. In 1999 I wrote a paper on resilience, which won the
Hayman prize of the International Psychoanalytic Association. As I write this I am reminded

coincidentally that in that paper I started by discussing the essential function of “primary”

childhood narcissism resulting from the “programming” of the child in a state of secure

attachment to the mother that he was loved and lovable, was the most important single asset in

promoting survival in Holocaust victims. My mother’s loving and caring response and her

rescuing and “guarding” me helped me to turn the trauma experience into something that I could

live with and reflect upon. Although I was a fragile and sickly boy, by 1939 I was 14 years old

and had finished the 8th grade in a coeducational school.

         A few months into the Nazi rule, my older brother was ordered to rapport to them. They

announced that the whole group was to be sent “to the East for labor.” My parents and brother

panicked and escaped to the Soviet occupied part of Poland and sent made me to stay with my

grandparents in a “shtetl” in central Poland called Bodzentin. A Shtetl was a small town with

mostly Jewish population. In this way I got separated from my brother and parents and they all

perished in the Holocaust.

       In the shtetl, where I was to stay for a long time, there were going on atrocious

persecutions by the Nazis that broke the spirit and capacity of the Jews to resist them. Besides

that I felt terribly unhappy and isolated. I was so averse to my grandfather’s constant nagging

trying to convert me to his type of religiosity, that I separated myself. I disliked the small town

Jewish rigidity, culture, and demeanor. The feeling was mutual between me and the mostly ultra

Chassidic local Jewish population, and even some of my relatives. On the other side, my whole

behavior beginning with my sporting a high- school uniform and cap were totally strange and

antipathetic to them. In my isolation, I was doing whatever I could. I kept reading anything I

could find, literally, and studying equally indiscriminately a variety of subject such as: English,
physics, mathematics etc. I did manage to do some “survival” things, like building a hiding place

in abandoned chicken coop that turned out to be a perfect hiding place. In this way I succeeded

in dodging many “actions” in which the Nazis were catching people and taking them to slave

labor. I made one close friend, without whose help I would not have survived, and we remained

close until the SS-men killed him on a death march.

       I remained in Bodzentin until the Yom Kippur in 1942 when the whole Jewish population

was eliminated. After surrounding the shtetl with the aid of their Lithuanian, Latvian and other

helpers, the Germans killed every Jewish man woman and child they found in their homes,

sometimes in their beds or hiding .The ones who, followed orders, lined up in the central market

place and were not killed in the “Action” were stuffed into freight cars and shipped to their death

in Tremblinka. I was in one of two truckloads of young people that they selected for work

assignments. I was sent to a labor camp in Starachowice. There were several camps like this in

central Poland, where we were put to work in armaments and ammunition manufacture. The

particular branch camp I landed in was on top of a hill where there was absolutely no water, and

off course, we had no change of clothes. As a result of the consequent infestation with lice -- an

epidemic of typhus broke out. This was followed by weekly selections. People who could not run

fast enough were shot, and the rest of us had to burry them in mass graves.

While I was working in a section of the plant in which we sandblasted artillery machine

grenades, I learned to be of a machine maintenance man. From that time on I listed my

occupation as “schlosser.” This means “locksmith”, but in the German usage (at least at that time

and place) it was meant to denote any metal skilled work, including tool and die making. This

accident also provided a survival opportunity later.
       In the spring of 1944, as the Soviet armies were approaching, the Nazis liquidated this

camp and send us all to Auschwitz. After their sadistic ‘welcome’ ceremony and selection, they

put the men on the ground in one barrack in the “Gypsy” (C) camp where we sat all night

squeezed one in front of the other. All night long we heard the sound of all the Gypsy families

being taken to the gas chamber and exterminated. The next they distributed us in the just emptied

barracks. In the months that followed, as we were submitted to the Auschwitz –Birkenau

“routines”, I did my best to survive one day or rather one moment at a time. We were marched

out to work, mostly on roads, while the Capos and SS-man entertained themselves with beating

and torturing us. My friend Chaim who became separated from me, managed to locate me in my

barrack finding himself in a terrible emergency. In some bizarre way he was placed in the “Straff

Commando” barrack where people were placed to be killed off in a very short time. That is

where they used to put escaping prisoners they caught. He was put to work in a swamp, and was

desperate. Fortunately, I had smuggled into the camp a diamond hidden in a giant cavity in a

molar tooth. I gave it to him, and he was able to bribe his way out of the hellhole of barrack 11.

In retrospect, about this time I was about to hit the skids toward a “musulman” death of

emotional exhaustion. This was a pattern well known to us prisoners. The clue that reminded me

of my desperate state at the time was that I recalled that at that time I used pray or plead with my

mother to help me somehow. This happening reflected both my regression to my childhood

trauma state in which my mother rescued me, and the common condition of being no longer able

to pray to God after what I had witnessed. (I discussed this issue in detail in my paper on

resilience. (In 1999.) Now, I have understood in reading a paper on addiction by N.M.Burton (in

press) in which she examined the problems from a relationist point of view that the danger that

was in giving up all hope and slipping into a dissociative paranoid/schizoid state which possibly
would have also have been the road to becoming a “Musulman”. By invoking my mother’s

image, I preserved my capacity to fight for my survival for some time.

        When, one day I landed accidentally in the plant of “Organization Tool” where they

were taking apart downed airplanes and salvaging the parts, immediately demonstrated my skills

and was picked as a “regular.” Since we had no clothes on top of the stripped prison jacket, just

working indoors already felt like a miracle. However, soon came a development that really tested

my courage.

        I discovered that I had developed Scabies. Usually this is just a nuisance; but in

Auschwitz it was a deadly condition because during selections for the gas chamber (off course,

in the naked) they were picked out skin lesions instantly. Dr. Mengele and his large medical staff

had certain ideas of whom they were going to send to their death, but skin diseases were their

favorite. I had terrible alternatives: to ignore it, and hope for a miracle, or to take the terrible

chance of reporting to the sick call. I decided to take a chance. The doctor diagnosed me

immediately and sent me to the hospital camp. Every two weeks this place was emptied, the

patients sent to their death in the gas chamber followed by the crematorium. After I was settled

down in the hospital bed, I found that I had an incredible piece of luck. The prisoner doctor

assigned to me was a man from my hometown, who had been a friend of my brother. I do not

know what he did, because there was not any proper medicine available for my infection. But

whatever way he did it, my skin cleared up, and he also gave me extra food, and he was able to

discharge me before my “time was up”.

        When I returned to my previous camp in the morning, I realized that I was being

identified by my tattoo number and taken with a group of men to a separate barrack. There must

have been more then a thousand men taken aside all of whom had arrived the day before in a
transport from Slovakia. We were taken one at a time for an interview and testing by a Herr

Bunsius, the head engineer from the Siemens factory. The tests and quizzes were designed to

identify the qualified tool and die makers. At the end of the day the prisoner camp commander

announced that 16 people were selected. (15 Slovak tool and die makers and I) In the process, he

took me aside and questioned me some more, because he was “Volksdeutsche” (ethnic German)

from the same area in Upper Silesia and he caught me in a lie about where I had trained. I

quickly admitted it to him the truth, and incredibly, he let me go on. I guess some of these things

were happening because I was back in my “home territory” less then 20 miles to my hometown.

       Finally, we were transferred to the Siemens Company “Lager” in Bobrek a branch camp

of Auschwitz. Since I was not really a qualified tool and die maker, people from my hometown

who also knew me and/or my family, who had been there for over a year, took me “under their

wings.” I remained there until we were marched out on the death march westward on January

18, 1945. In the middle of a winter night we were marching while we could hear the Soviet

artillery quite close by. While marching and freezing in our inadequate clothing, after some time

I realized that whoever could not keep up the pace was killed and left by the side of the road.

After some time, one of my two buddies weakened and was ready to give up. We took him by

his arms and walked on. It is very remarkable that even though I tried to tell this story, and even

when tried to describe it in a paper, I have not been able to regain the memory of what happened

after this point. How long we held on to each other, or when and why we stopped I do not

remember.

       Much later, just before dawn, I seem to have been walking all alone. The marchers, the

SS-men with their wagons, even the horse and buggies that were part of the convoy disappeared.

They were absolutely all gone, without leaving a trace. I recall some thoughts about hiding or
escaping at this point. I cannot really explain why I did not, except that we were already in the

German part of Upper Silesia, and I felt that I could not expect any from anyone help, nor failure

to apprehend me or rapport me. As I kept walking, I encountered an old German soldier. He was

leaning against a fence, and carrying his rifle. I do not recall any conversation between us. The

next thing I remember is walking with him in a city, with very busy military traffic, controlled by

a military policeman at the intersection. Next, I find myself in a camp where the prisoners were

“stored.” By struggling with others who were packed together on the ground, I “won” a place on

the floor to lie down. I took off my coat and wrapped the loaf of bread we were given as we were

leaving our Bobrek camp in it. When I was awakened and ordered to get on the train, my bread

was gone. This is when I experienced the worst despair because, in my rage, and disappointment

about not having escaped or hidden during the night, and after discovering this last blunder, I lost

my confidence and agency.

I ended up in the Buchenwald camp in where prisoners from all the evacuated camps in the east

were kept. This was a bedlam beyond description. Everything was out control. The struggle for

survival was down to a struggle for a spot to lie down in.

       After a week or so the Siemens company representatives sent a list, and had all us

surviving former “Bobrek” tool and die makers rounded up and shipped to Siemenstadt, (a

suburb of Berlin) to work in tool making in their enormous armaments and ammunition factories

there. We did, until one day when there was an air raid. When we came out of the shelter the

factories and the whole town was gone - bombed out. After a short time we were shipped away,

apparently with the intent to send us to a factory they still had operating somewhere. We never

made it, and after a couple of weeks in the freight train we were returned to the Berlin area to

camp Sachsenhausen, one the original concentration camps. There I remained until my 20th
birthday. On April 22, 1945 we were put on the last death-march Westward, away from the

advancing Soviet army. We were marching all day every day, and in the evening we would be

put in a small woods that the SS-men would surround. Usually they would give us at this time 3-

4 raw potatoes each– our food for the day, and we would lie down on the ground to sleep. On

March 3, on awakening, we discovered that the SS-men were gone, leaving their truck. We

looted the truck, but I was afraid that they would come back so my buddy and I took a blanket

and some clothes and ran and hid in the forest. This was an example of difficulty with registering

the idea of liberation! After some time we started to creep to the edge of the forest. We reached a

road, where we saw the German soldiers throwing away their weapons and giving themselves up

to some British soldiers. I walked up and spoke to an officer: We were liberated!

       While liberation was not easy for me, some of the people actually developed short –term

psychoses or started to eat uncontrollably and developed severe intestinal reactions. A few

months after liberation I was still “recovering” in a “Displaced person” camp when, in an

overcrowded train wagon I overheard 2 men’s conversation about the existence of an accelerated

High-school program available for Polish ex-prisoners of war sponsored by the Polish

government in exile in London. I got more information from them and I promptly applied to the

school. To my boundless amazement I was actually accepted there. And so, I put on a British

army uniform with a Polish Eagle and proceeded to work on my missed high school education. I

graduated and got my “Matura” in June ‘46.

I then moved to Frankfurt/Main where I worked at the HIAS organizing and operating a family-

tracing bureau.

       In September I started my medical studies at the Johann Wolfgang Goethe University

Medical School. I had no problem with the German language, and I rented a room from two
German women whose men were still in prisoner of war camps, and I proceeded with my

studies. I kept searching for my family, but I could find nobody. In fact, a day or two before my

liberation while marching, I realized that my legs were badly swollen all the way up to my knees.

I knew that this meant that I was soon going to die of starvation. The ironic thought came to me

that if I died in these circumstances – nobody would know, and nobody would care, in fact ---

nobody would miss me.

       When I had been in one of the Displaced Person camp I approached a British soldier and

asked him if he would mail a letter for me. He was willing to do it and so I wrote a letter to my

aunt in Detroit, Michigan. I happened to remember her address because I used to see my father

write letters to her. Fortunately, she was still at the same address, and I was her only surviving

relative – son of her favorite brother whom she had tried to bring to Detroit. I reestablished

contact with the whole family and eventually my aunt sent me the necessary certificate of

support. When I got an immigration visa from the American Consul in Frankfurt, with the help

of my aunt, I dropped my education in progress and came to Detroit in 1947, and resumed my

studies here.

         When I applied to medical school, chances were nil that I would be accepted, because

the returning veterans of WWII were waiting in line. Fortunately, during my interview, one the

people there was Dr. John Dorsey, the professor of psychiatry, who (I imagine) favored my

acceptance. Curiously, later -- his teaching and views of psychoanalysis became a major help and

inspiration in my recovery. His was a solipsistic orientation to which I refer later in this chapter

in the context of the “model affect.” I graduated from the Wayne State University medical school

in 1953, and went on with further training in psychiatry and psychoanalysis. In 1954 I married

and my wife was a schoolteacher at the time.
       While I was still in psychoanalytic training and about the time when I was developing my

private practice, there came up the matter of compensation for psychological damages caused by

the persecutions by the Nazis. I was requested by the German Consul General in Detroit to start

working as the “expert” -- examining my fellow survivors who applied, with the support of their

doctors, for pensions to compensate for their industrial (i. e. earning) capacity losses resulting

from the persecutions. This was a terrible burden for me to be reliving the whole Holocaust story

3-4 times a week with my fellow survivors.

       I really did not want to do it. However, I was the “man on the spot”, and these were my

people and so I started. I have been doing this kind of work for over forty years now. Even this

year I still got a few cases. In this way I got into studying the process and special problems of the

Holocaust survivors. Altogether, I worked with more then a thousand people.

       At the same time we had to persuade and educate the German psychiatrists and

government about the consequences of psychological trauma. The understanding and techniques

gained from the work with survivors was soon applied to treatment of Viet-Nam war veterans,

and eventually to trauma in general. In the process we were also learning about the special

problems and modification necessary in the psychotherapy of traumatized people. Consequently

I got involved in fifty years of studying, writing and teaching about this and related subjects. As

the project stated we got involved in an international project related to the care of trauma that is

so well described in Dr. Danieli’s chapter in this volume.

       Conferences on the psychological damages to“ deportees” started in Europe in 1954.

(Pross 1966). In 1948 and 1949 Friedman published papers on the emotional problems of

concentration camp survivors. He commented on the “astonishing oversight” of the German

authorities in not acknowledging the psychological consequences in the victims of persecution:
       “It seems altogether incredible today that when the first plans for the rehabilitation of

       Europe’s surviving Jews were outlined, the psychiatric aspect of the problem was

       overlooked entirely (p. 601).

       In 1956, when the Indemnification Law was passed in Germany, it seemed to refer to

restitution in cases of obvious physical disability, something like the loss of a limb. When we

(American Psychiatrists) were called in to do examinations of survivors, and send our reports to

Germany, we discovered that many German “experts” were oriented to descriptive, organic

psychiatry and did not seem to comprehend the conceptions of dynamic psychiatry. A long

struggle evolved, in which we had to convince the German examiners and authorities not only

about our findings, but even more challenging, the causal connection between the persecutions

and emotional damages. In the process, we were learning about the nature and aftereffects of

trauma. In 1961 Niederland published a paper entitled: The Problem of the Survivor. In it he

gave a number of examples of severely persecuted people, who witnessed the destruction of their

families, and then had severe problems which were obviously “persecution-connected.” Many of

these claims were turned down by the German examiners and restitution authorities, and some

were finally recognized only after appeals to superior courts. The struggle kept up for a number

of years during which well-known psychiatrists became involved in prolonged litigations,

including appeals to the Supreme Courts of the German States.

       Since we got involved in this task, I was the main psychiatric examiner for applications

for restitution in the Detroit area. In 1963 I organized a Conference at Wayne State University in

Detroit with Niederland as one of our leading participants. We held three annual conferences.

We studied the aftereffects of psychic trauma in general. In our deliberations we covered various

issues of diagnosis and psychotherapy with traumatized individuals. (Krystal, 1968) Some of the
participants in our meeting were engaged in working with adult Holocaust survivors (K. D.

Hoppe 1968, E. Tanay 1968), some with adolescent survivors (E. Sterba 1968), or survivors in

Israel, including some on Kibutzim (H. Klein 1968). R.J. Lifton reported on Hiroshima

survivors, and led a discussion on commonalities of aftereffects in the various groups. (R. J.

Lifton 1968).

       In 1968 I published a book entitled: “Massive Psychic Trauma” reporting on the

proceedings of our conferences. Some comments anticipate later observations and theories.

Bychowski (1986) reported that some of the survivors showed, besides the “direct”

symptomatology, a blocking of emotions, with simultaneous autonomic system hyperactivity

(what I later recognized as psychosomatic disturbances and regression in affects.). He made the

following comments about a patient that anticipate later descriptions of affect-lameness: “his

affective life is dulled. No matter what I do for him he says ‘thank you’ without any genuine

affection or indication of an intimate relationship”(p.81). Lifton commented: “A general pattern

of survival (In Hiroshima) was ‘psychic closing off’. In concentration-camp survivors the closing

off picture is much more chronic, in more thoroughgoing because of the long-term trauma. It is

related to what I described as the identity of the dead: if one does not feel one has the right to be

alive one is as if dead or a walking corpse. It is a symbolic psychic death.” (p.184) Reporting on

psychotherapy with survivors, K. D. Hoppe observed that the patients showed a lack of basic

trust, which was destroyed by the hopelessness, helplessness and apathy, and the “time standing

still” in the camps. After the “forced regression” in the camps the therapeutic regression was

rendered more difficult.” (p. 216)

       From his experiences with psychotherapy of survivors in Israel, Klein emphasized that

because of the loss of all early love objects, and the impossibility to accomplish mourning:
“Survivors are threatened by the possibility of an intimate relationship. They may ward it off, by

rejecting the offer of help, or by displaying the aggression against the therapist.” (p. 248).

        In a statistical review of 149 concentration camps survivors (Krystal and Niederland), the

following were found: chronic anxiety (various types) was found in 97% of the cases. Among

these were: “expectation of catastrophe, ” which later turned out to be a common posttraumatic

reaction. Sleep disturbances occurred in 71% of the cases. Disturbances of cognition, with

repetitive dreams sometimes merging into disturbances of orientation, were found in 44% ofthe

cases. Various depressive problems were noted in 80% of this population, since a significant

number of the patients had lost their spouses and children. The other conditions which showed a

high incidence were psychosomatic problems and chronic pain syndromes. In 1971, I published

a book with Niederland entitled “Psychic Traumatization”. This was an edited work with eleven

contributors, from various countries, and represented a survey of the literature to that point (both

psychiatric and sociological) and mostly reports on studies on trauma. In this volume, I reported

that in concentration camp survivors I found an: “almost universal affect lameness together with

a dread of affects. I felt that their existence in a chronic state of closing off the affective

responses, in a hopeless situation in which the ‘agitated’ anxiety reaction had ceased, and caused

them to develop a chronic disturbance of affect. They tend to overreact physiologically to

anxiety and depression. However, most of them become conscious of just somatic symptoms and

cannot name the emotion involved”. (p.19-20)

        In 1970 I read a paper to the American psychoanalytic Association (published in1985)

entitled: ”Trauma and the stimulus barrier.” This was the first of a long series of publications

reflecting my development of theories of trauma, and a number of concepts that explained the
nature of post-traumatic problems and the modifications in the techniques of psychoanalysis and

psychoanalytic psychotherapy that made possible effective treatment of these problems.

       In it I was changing the concept of the “stimulus barrier” from a passive protection as

postulated in infants (Rappaport 1953) to an active one. In this concept, it involves “the entire

defensive organization of the ego” (A. Freud 1967), in fact all of one’s self. This change made

possible the change from the view of trauma based on the economic view of metapsychology,

(causation by excessive intensity of stimuli e.g. Gediman 1971) to one in which meaning and it’s

overwhelming nature are what triggers the onset trauma. In identifying adult catastrophic trauma

I stated that the confrontation with inevitable, unmodifiable danger caused the subjective

registration of a state of total helplessness. “In the surrender to the overwhelming danger the

affect changes from anxiety (the signal of avoidable danger) to a progressive cataleptic surrender

which Stern (1951 a+ b, 1953) called the “ catatanoid reaction.” (p.135) This is a submission,

which may terminate in psychogenic death and is the mark of the onset of the traumatic state. I

reviewed and updated this subject in 1978. In 1974, I published a paper on “The Genetic view of

Affects, and Affect Regression” and in 1975 another paper appeared entitled: “Affect

Tolerance”. In these two papers I was able to explain the nature of affects manifestations we find

in posttraumatic patients as a regression in the emotions with this concept the genetic aspect of

emotions became clear. Since the regressed affect caused a problem in the handling of emotion,

next

       I studied the matter of affect tolerance. Once I understood the posttraumatic changes it

became evident that affect tolerance was an important function in normal operation and in

trauma prevention. In 1977, in a paper entitled “Aspects of Affect Theory”, I worked-out in

detail the development of affects from infancy through adolescence. In 1978 in a paper entitled
“Trauma and Affect” published in the Psychoanalytic Study of the Child, I was able to elaborate

the psychodynamics and concepts of catastrophic adult and infantile trauma (as distinguished

from childhood trauma).

         In regard to the adult phenomena, I found that most syndromes developed in the process

of trauma prevention (such as psychosomatic conditions and the addictions). For instance, in

response to a situation of absolute helplessness and surrender to it, the constriction and

progressive blocking of cognition, and progressive blocking of mental function may produce a

state of complete numbness. At this point self-mutilation may interrupt the trauma process and

prevent psychogenic death. I demonstrated that the phenomenon of psychogenic death met with

widespread denial. The surrender patterns involved are important social phenomena, namely in

mass disasters. The evidence is that a “stunned and bewildered response is a far more likely

group reaction then is panic” (Allerton 1964, 206). In aircraft accidents: “as many as half the

passengers develop what the airlines call ‘inaction due to negative panic’ and therefore fail to

evacuate the burning or the sinking craft.” (Johnson 1970 p.3 also see Krystal 1978 and 1982-

1983.)

         In 1985 I went back to the subject, and with it I reviewed psychoanalytic theory, bringing

it up to date in regard to the studies on perception, affect signals, information processing and the

vicissitudes of perceptual defenses. It was essential for the continuing study of posttraumatic

states to keep in mind that many of these patients presented themselves not with the PTSD

syndrome but with other problems, most commonly psychosomatic and /or addiction problems.

In my continuing work I also kept publishing material on psychosomatic problems and addition.

In our book, Drug Dependence (Krystal & Raskin 1970), we especially emphasized the essential
function of looking out for the history of trauma and being prepared to focus the treatment on the

traumatic history at the core of addiction.

        Back in 1974, S. Haley published a paper entitled: “ When Patients Confess Having

Committed Atrocities.” This paper opened the subject of the emotional effects of perpetrators,

which was impossible for us to study with the Nazis, because the ones we had access to were

continuing in their denial (see: Hilberg, 1961 Lanzmann, 1985, Malkin and Stein 1990, and

Browning, 1992.) This view was helpful in reconsidering the entire issue of victim-perpetrator

relationship, to which I will return later.

        In 1984 a book appeared sponsored by the American Psychiatric Association and edited

by van der Kolk. It was entitled: “Post-Traumatic Stress Disorder: Psychological and Biological

Sequelae.” Much of the experience reported in this book was derived from work with PTSD

veterans of the Viet-Nam war, and approached trauma from the broadest possible base.

        I had a chapter in this book entitled: “Psychoanalytic Views on Human Emotional

Damages”. By that time I had worked out the process and aftereffects of trauma, just as is

described below. It took a number of years, and I reported the developments in a number of

papers, however, rather then to detail the history, I will survey the whole area.

Retrospection In the last forty years, I have worked as a restitution pension examiner

performing many follow up reexaminations. This gave me chance to follow-up some people for

over 30 years time and observe the life changes in traumatized individuals. The problem of the

aging survivor of the Holocaust has presented special challenges, about which I wrote

repeatedly. (Krystal, 1985, 1991, 1995 a & b) At the same time I have also worked as a

psychotherapist and psychoanalyst. The following is a review of generalizations derived from

my many year’s observations in both areas.
        My clinical work with concentration camp survivors, other post-traumatic patients, and

psychosomatic patients, as well as those with addictions (especially during withdrawal) made me

aware of the manifestations of regressions in the nature of the affects.

The genetic view of emotions There is a gradual and orderly development of the human

capacity to experience emotions. There is evidence from developmental neuro-science and

psychophysiology correlated with clinical observations, developmental psychology and our own

longitudinal studies of the importance of the genetic aspects of emotions. All these sources have

provided evidence of the developmental progress of emotions during infancy, toddler age,

latency, and adolescence. In fact, it continues through all of our lives.

        The adult type of emotions evolves out of three affect-precursor states (or Uraffects). In

the newborn we find global reaction patterns: 1) the state of well being and contentment, 2) the

state of distress, and a third reaction pattern, that of “freezing.” This last pattern is universal in

animals but in the normal human infant it disappears at about two months of age. (Papousek &

Papousek, 1975) This is the reason why it is often overlooked. However, this third affect

precursor needs to be highlighted since it returns in trauma and it accounts for a variety of

syndromes. Especially notable, it returns in trances in traumatized children, and in the same

people as adults in every day life, and quite often in psychotherapy and psychoanalysis.

        These affect precursors fulfill their potentials through specific developmental lines: affect

differentiation, verbalization and desomatization. The maturational changes in emotions are

facilitated by primary caregivers who encourage, help, and “reward” this process. Starting with

differentiation in vocalization, the epigenetic development of emotions proceeds from the state

of well being to differentiations of all the affects that are generally pleasurable such as love,

security, contentment, joy, pride, and the like. Out of the distress state evolve the painful
feelings such as anger, guilt, jealousy, shame, anxiety, fear, and so on. Pain has a unique position

since it is not separate from the early distress affect-precursor pattern. Most of the tracts are not

yet mature and there is not yet a “body image” functional. Pain becomes separate with time.

However, in affect regression it is common to observe pain returning and becoming a part of

affects, or at times being the only symptom of, say, depression.

       The genetic development of affects hinges on the availability of empathic caring, and a

responsive holding environment. In this context, the organizers of the psyche, such as the social

smile, and the development of language operate optimally. The development of emotions in a

favorable way takes place optimally in a state of secure attachment to the mother. While

promoting affect maturation, the “good enough care-giver” shows to the child the uses of

emotions, i.e., they can serve as signals. Once differentiated and put into words, they produce

desired results more effectively and speedily. Along with the identification with patterns of the

mother this facilitates the development of familiarity and comfort with affects. The child is

shown ways to regulate emotions and to keep them within a bearable range for their greatest

utility as signals. This determines the optimal handling of emotions: “affect tolerance.” This

term refers to the reactions to having an emotion and the capacity to moderate it.

The model affect Much difficulty in understanding emotions is derived from attempts to model

affects derived from old metapsychological schemes. The idea that the nature of emotions was a

physical reaction resulted in a conviction that emotions could not be unconscious. However, as

we know, these scruples did not keep Freud from discovering the consequences of an

unconscious sense of guilt. It may help us to consider that in a living individual there cannot be

a condition of “no affect” any more than the world could exist in a state of “no weather.”
       Signal affects in an unconscious, subliminal form represent the essential “switches”

which operate all mental functions. The understanding of this form of affects does not rest on

economic conceptions. (See also critique by Gillet, 1990). In other words, the subliminal affect

signals are not in that form because of a low energy charge. The idea of “amplification” is

misleading. Perception, microgenesis, and perceptgenesis studies leave no room for doubt that

subliminal affect signals are active all the time. These subliminal, unconsciouses, I am tempted

to say “neurological,” signal affects are the automatic “switches” in all mental functions.

       The biggest “hang-up” for psychoanalysis was the use of anxiety as the model affect.

Anxiety is a very poor model for affects. Freud gave us a clue that love is the proper model

affect. He even said that a sense of guilt and hate originated from unsatisfied love: “We have

been obliged to derive every conceivable thing from this material, like economically self-

sufficient countries with their Ersatz (substitute) products.” Freud confided in Jung in 1909 that

in psychoanalysis the “cure is effected by love” and that “transference provides the most cogent

and unassailable proof that the neuroses are determined by an individual’s love life.” Dorsey,

who has pioneered this point of view in psychoanalysis, asserted: “whatever I live is deserving of

my complete love, for that is the very way I preserve my life.” Love is the representation of our

life powers. The painful emotions can be understood as love hindered, rejected, denied.

Emotions recognized, received, and acknowledged, produce the experience of wholeness and

competence. What we cannot accept lovingly and peaceably we must try to reject and alienate

and we must denote it as ‘nonself.’” (1971a: p. xvii) Our memories, wishes, representations of

ourselves and of our objects must be consciously accepted, tolerated, accommodated to, and,

hopefully, utilized to one’s advantage. Otherwise they must be handled by repression, isolation,

projection, and other (fantasy) defenses, which are experienced as externally, imposed
“symptoms.” Contrary to subjective experiences of affect that seem to be explainable by the

residues of the antiquated psychoanalytic theories, we cannot “express” them in the sense of

ridding ourselves of our affect -- emotional self continence is a self evident truth. However,

only consciously acknowledged, and experienced self continence results in a feeling of well

being. Illusionally estranged mental elements seem to continue to radiate the painful affects.

Getting stuck in such a predicament condemns one to becoming “hypnotized” by the emotions,

blocking the ability to pay attention to the message they carry. In such disasters one may devote

most of one’s energy to fight and try to block the physiological aspects of emotions, or

alternately develop an addiction to hate, pain, shame, envy. It becomes a never-ending self -

torturous life style.

        To quote Dorsey again: ”happiness is the natural expression of the appreciated wholeness

of human being ... the joy of living consists of a sensitive awareness in the unity of the human

nature.” (1965) The healing insight we have to offer is that love relates to all the other affects

like white light to all colors. Also, that the painful affects represent love outraged spurned or

rejected. When love is accepted and cherished it is recognizable as one’s life power.

        The painful self- representations and object representations are the ones that are difficult

to love. Consciously disowned hatred continues to function painfully. The dissociations, so

prevalent in wake of trauma, are the results of trying to alienate, “expel” parts of our mental

representation of the abusers. The reluctance to bear the pain attending the grieving inherent in

self- healing (as in analysis) is one example of a tendency to avoid experiencing one’s emotions

fully and consciously. Stressing that love is the most helpful model affect also represents the

healing approach to the posttraumatic tendency to experience emotions as object generated.

Focusing on love helps us to concentrate on the healing view that affects are our own evaluation
of our mental representation of our selves and our world. Only under these circumstances do we

have a chance to recognize our feelings -- to be fully conscious of the subjective nature of our

affect responses.

Affect regulation and defenses against affects Under normal circumstances the process of

affect regulation is characterized by the individual’s comfort with his or her emotions and by the

ability to use the emotions as signals for self-regulation. To the extent that emotions are

verbalized and desomatized, they are most suitable to function as signals for information

processing, and in addition, as subliminal “switches” in all the mental operations. Normal affect

regulation allows the individual to experience a feeling and evaluate the appropriateness of its

intensity and quality. Thus one is enabled to estimate its derivation from the current situation, as

distinguished from the resonance to memories of past experiences. The process of sorting out

one’s feelings n this fashion permits an individual to use the emotions to decide which of the

repertoire of possible responses is the best one, and select that course of action. This capacity

leads to realistic and mature behavior.

       The failure to recognize one’s affects as part of one’s own information processing

apparatus, tends to cause an individual to feel ruled by those emotions. Such people tend to build

up their emotions to a very high intensity based on early experiences of using them to control the

parental objects. Retaining such strategies in adult life may lead to a person behaving in an “out

of control” fashion. Affect maturation and the development of affect tolerance during the

latency period represents the most important single factor towards making possible the

maturational developments in adolescence. Such achievements require the capacity to grieve

effectively, making possible the renunciation of the infantile experience of the parents, and of

oneself. A parallel process is the integration of the various self- representations derived from the
several psychosexual developmental stages –which takes place in adolescence potentially

achieving a consciously recognized wholeness of the self.

(Erikson’s ego-identity.) Intense emotional reactions seem to threaten to overwhelm vulnerable

individuals. Defenses against emotions may be mobilized, such as denial of contents, reversal,

displacement, or turning feelings toward the self. These must be distinguished from affect

regression.

Affect Regression: Arrests and regression in affect functioning are sequelae of psychic trauma.

Traumatization can occur at any time beginning with infancy, therefore it can vary greatly in

cause, phenomenology and aftereffects. Affect regression from the mature, adult form involves

dediferentiation, deverbalization and resomatization. (In other words the reverse of the

developmental line of affects). In milder forms of affect regression the affects appear diffuse,

undifferentiated, and unmodulated. In more severe forms of affect regression -- emotions

manifest themselves mostly in their physiological component. Regression in emotions to

psychosomatics was noted and described in detail by Max Schur in 1955.

       Regressed emotions are not useful for information processing. They are only a burden

and a challenge. In this predicament, people tend to favor one of the two available behavior

patterns. Some people become stoical and suppress and/or ignore all their emotional reactions.

The price of this style of operating is that they lose the ability to recognize and use emotions and

become color blind to feelings. They live entirely on the basis of their reasoning, and their

world-view is that the intellect is the only proper way to know what matters. In the consequence

of inability to experience and be guided by one’s emotions, especially love, there is a propensity

to narcissistic superiority, indifference, and to domination and exploitation of objects. The other
common strategy is to use “external factors” to block, numb the painful affective somatic

reactions. These individuals tend to develop the spectrum of addictions.

Adult Catastrophic Trauma: Fear is the signal of impending danger. Cognitively, there is an

assumption that the danger is avoidable or manageable. When an individual is confronted with

danger that is estimated with absolute finality to be unavoidable and inescapable, one surrenders

to it. This view is in harmony with Freud’s (1926) statement that “the essence and meaning” of

the cause of psychic trauma is the subject’s estimation of his own strength...and...his admission

of helplessness ... in the ‘Erlebte Situation’”, i.e., the subjective helplessness in the face of what

one experiences as unavoidable, inescapable danger, and his surrender to it. This is the time to

reassert the basic psychoanalytic principle that the only knowable reality is one’s own psychic

reality. “The meaning of meaning”: “a mind is able to experience the meaning of anything in

nature only to the extend that it can reproduce that ‘anything’ with it’s own psychological

constructs” and “My reality testing is the particular, distinctive way I live (I create whatever I

create) it all accounts for the specific nature of the existence I ascribe to it. My observation of the

way in which I am living provides me with the only measure of reality testing of any kind”

(Dorsey, 1943 p. 48)

        Thus, we are not talking about a traumatic situation but a traumatic experience, the

psychic reality of estimating the danger as overwhelming, unavoidable, and producing an

unbearable state of mind. In this context, I have done work on resilience, which in a

retrospective study of concentration camp survivors revealed a number of traits that favored

survival, and in general characteristics and attributes which favored resistance and

resourcefulness. (Krystal, 2000)
        Once an individual surrenders to his/her subjectively evaluated inevitable fate, the affect

changes from fear to a catatonoid reaction. This is the onset of the traumatic state. The

individual gives up most or all of his or her initiatives and obeys orders. This is a powerfully

hypnotic state. The more the subject obeys orders “the deeper one goes under” and that

progression cannot be stopped until one reaches a cataleptic or “robot” state. Being able to

establish and maintain the constricted state is a life saving operation. If we have a chance to

examine an individual in this state, we find an overwhelmed, withdrawn person, often

experiencing depersonalization and derealization. The focus of attention is extremely narrow. In

concentration camps, the victims, upon being unloaded from the deadly cattle cars and going

through the dehumanization, terrorization, and loss of everyone dear, potential survivors had to

be able to instantaneously block the affective response to the fate of their families, and respond

only to what was necessary to do to secure survival on a moment-to-moment basis in a Robot-

like state. If the attempt to arrest the progression in such “automaton-like” state fails, the

deepening of the traumatic state manifests itself in a growing numbing of pain and painful

affects, followed by the loss of a sense of self reliance, initiative, and agency. There is a loss of

empowerment of any assertiveness. The right and capacity to say “no” and carry out self-defense

are progressively paralyzed. At some point the traumatic closure reaches a malignant state of a

progressive blocking of all mental functions: cognition, perception, recall, scanning, information

processing, judgment, planning, problem solving, and the rest. Finally, just a vestige of these

functions and some capacity for self-observation are retained. In this state, most normal

narcissistic functions, i.e., self-preservation, self-regard, self-defense, self-respect and self-

concern collapse and the person is “frozen.” Silently present is a massive and dangerous

diminution in self-reliance and capacity to maintain self-caring. If the trauma continues to
progress it may reach a point when all vitality is suppressed, and the individual dies of

psychogenic death, with the heart stopping in diastole. (Krystal, 1984) This process is universal

in the entire animal kingdom. (Richter, 1957, Seligman, 1975).

       For those who manage to arrest the traumatic progression in the “robot” state, and who

must live in such condition for a significant period of time, there are consequences that last the

rest of their lives. The survival in the situation of impasse, or “no exit,” occurs in a state of

psychic closing off. Survivors undergo a temporary symbolic death in order to avoid

physical or psychic death. These cataclysms result in a permanent “death imprint,”

desensitization, and identification with death and the dead. Such a disaster may become a

pattern of “dead to the world” personality type. (Murray, H. [1967]: called this a way to

“deanimate the animate,” (examples of this reaction are: Barnaby the Scrivener, Captain Ahab,

and Melville himself also The Pawnbroker, and Camus’ “The Stranger”.) The surrender

experience itself constitutes a memory that cannot be mastered or detoxified, but continues to

generate feelings of shame and a mixture of dysphoric affect precursors for the rest of one’s life.

The direct results of affect blocking can be seen in “emotional anesthesia” and affect regression.

The ability to restore the capacity for the denial of death (which we must have to function

normally) is often seriously impaired, resulting in a state of overt or latent mixture of depression,

fear, shame, guilt and pain.

       I have described the traumatic experience in order to prepare us to recognize a number of

aftereffects, as direct continuations of some component reactions of trauma. The surrender

pattern may be continued in an inability to assert oneself in any later life situation from major to

trivial ones. The situation that triggers the trauma response may also produce “primary

repression.” The percepts (ideas) not compatible with survival of the self are not registered at all,
but create a “hole in the associative networks.” They are not repressed but repudiated (This

corresponds to Freud’s use of the term Verwerfung vs. Verdrängung). Special defenses have to

be instituted against the effects of such a “black hole,” (Cohen and Kinston, 1984). Dealing with

such material in analysis may be possible through projective identification. The residuals of

cognitive constriction may manifest themselves in general dullness and docility. Very

commonly there develops a pattern of life-long startle reactions, consisting of the “jump” pattern,

not only physically but also in terms of behavior patterns such as a tendency to blunder when

scared (the “Inspector Clouseau” responses). The startle is accompanied by blocking of

cognition experienced as “freezing” in stressful situations. Having identified the symptoms of

trauma, and considering the descriptions from DSM IV, we are confronted with situations in

which we find the clinical picture of posttraumatic states with alexithymia, and related problems

but no matter how we try, we get no history of trauma. We must assume that this picture

represents the aftereffects of Infantile trauma.

Infantile versus adult trauma: The processes and aftereffects are somewhat different in

infantile, childhood, and adult types of trauma. Here, I will just discuss infantile psychic trauma

and adult catastrophic trauma. Infantile trauma is related to the nature of affect precursors, and

pre-object relatedness. If the baby’s needs cannot be fulfilled directly, and the excitation

overtakes the child’s ability to tolerate the distress, and the parent cannot comfort the child, the

excitement snowballs to a frantic condition. If the parent is not available and/or unable to restore

a state of well being, the excitement mounts until the child reaches a point of virtual

inconsolability. This situation can be identified as the point of onset of infantile trauma. In other

word’s, infantile trauma, unlike the adult type, is brought on by the intensity, and duration of

painful affects precursors. Another major difference in the progression of infantile trauma is that
the young mammal has a “built in protective device,” notably that instead of terminating in

psychogenic death, the state is psychologically ended - this safety valve maybe likened to the

original stimulus barrier. The baby will fall asleep. But this escape from misery into sleep is a

world part from the experience of a contented, loved child who goes to sleep in a cloud of

magical omnipotence, the self representation not separated from that of the mother. The infant

who goes to sleep in utter misery is at risk. If these episodes keep happening repeatedly in close

proximity, the child may start showing a failure to thrive, marasmus. All the survival functions

become impaired so that baby may die of intercurrent infection (as Spitz discovered a half a

century ago).

       The consequences of special irremediable problems in the baby or a lack of empathic

care, and a failure to progress from a successful pre-object state to a secure attachment are both

acute and chronic. They manifest themselves in psychosomatic disturbances of infancy, i.e.,

sleeping and feeding disturbances as well as a multitude of problems such as colic, eczema,

asthma, and many more. A failure of affective attunement may result in maladjustment for the

child for life. (Harmon et al, 1982)

       The survivors of infantile trauma seen as adults often act “brainwashed” into a false

belief about the perfection of their childhood accompanied by self- blame for all their problems.

As adults they present themselves with a variety of difficulties including psychosomatic or

addictive ones. Typically, they have no memory or suspicion of their infantile tragedy. Post-

infantile trauma patients suffer from a combination of alexithymia, anhedonia, aprosodia, and a

“doomsday orientation.” This is a profound, unshakable conviction and certainty of the fated

return of the infantile psychic trauma. The code word for that is “a fate worse the death.” Post-
traumatic patients believe (unconsciously but with absolute certainty) that “lightning always

strikes twice.”

       When they are successful and well, and/or when they try to exercise self- caring

functions, they tend to develop a dread of the return of the traumatic state. The abused or

traumatized children experience a desertion and betrayal by the parents who were “supposed” to

have been omnipotent and perfect. However, they must turn the aggression against themselves.

As patients they present themselves with problems of shame and guilt, which are not easy to

recognize, because these affects are not differentiated or verbalized. Hence, a potential patient’s

statement that he/she is suffering of say, depression should not be taken at its face value. The

consequences of both types of psychic trauma produce chronic insecurity as represented both by

hypervigilance and a fixation on past trauma. These posttraumatic disturbances of normal

residues of primary narcissism limit the individual’s ability to thrive and be successful in life on

the basis of optimism. They particularly lack expectations that people they encounter will like

them. In PTSD, memories and visual representations of the traumatic experiences invade present

awareness with flashbacks from the tragic past.

       In 1971, while considering the aftereffects of psychic trauma, I stated: “In our studies of

survivors of Nazi concentration camps we noted an almost universal affect lameness together

with a dread of affects and chronic anxiety. We felt that that their existence in a chronic state of

closing off the affective responses, in a hopeless situation in which the “agitated” anxiety

reaction had ceased, causing them to develop a chronic disturbance of affects. They tend to

overreact physically to anxiety and depression. However, most of them become conscious of

mostly somatic symptoms of their affects, and not their ideational component. What the

survivors show is an affect regression in which the affects come up in a dedifferentiated,
deverbalized, and resomatized way. About this time I made contact with Sifneos and Nemiah

who were working with psychosomatic patients in Boston. There followed a period of mutual

stimulation as reflected in many conferences and papers. Eventually the following concepts

were evolved, beginning with alexithymia, a term which Sifneos coined. (1973)

Alexithymia

       Alexithymia involves a diminution of the usefulness of affects for information

processing. It is recognizable by disturbances in three areas: an impairment in the patient’s

ability to name and localize emotions, and to recognize and use emotions as signals to

themselves. The affects are experienced as vague and confusing, and remain undifferentiated and

unverbalized. When questioned how they feel, or how the think they would feel in extreme

situations, they give “action” responses. Nemiah and Sifneos (1970 a & b) described alexithymia

in psychosomatic patients, and pointed out that these individuals give “action responses.” When

questioned how they would feel in a stated situation, they answered with a description of what

they would do in it, rather than being able to tell what they felt. These authors composed the first

test for alexithymia: the ”Beth Israel Alexithymia Questionnaire”. (Sifneos 1973) An improved

version is the Toronto Alexithymia Questionnaire. (Taylor at al.).

Affective Functions

       Affect functions show an impairments in the patient’s ability to name and localize

emotions, and to recognize and use emotions as signals to themselves. The affects are

experienced as vague and confusing, and remain undifferentiated and unverbalized.

       When questioned how they feel, or how the think they would feel in extreme situations,

they give “action” responses. Nemiah and Sifneos (1970 a & b) described alexithymia in

psychosomatic patients, and pointed out that these individuals give “action responses.” When
questioned how they would feel in a stated situation, they answered with a description of what

they would do in it, rather than being able to tell what they felt. At about the same time I was

describing the same phenomena in Holocaust survivors, psychosomatic and addictive

patients1985).

       Research by Taylor et. al. revealed a close correlation between alexithymia and

a lack of psychological mindedness(1984 a, 1985). These patients miss the whole “poetry of

                       life” They do not get excited about potential love objects, because they

                       experience people as duplications of each other with meaningless

differences. Cognitive function shows a sterility and monotony of ideas and

impoverishment of imagination and creativity. Operative thinking dominates at

the expense of symbolic and imaginative processes. Associations are “stimulus

bound rather than affect and memory determined.” Early in analysis the patients

appear super reality oriented, but their presentations turn out to be recitations of

details of things that happened since the last appointment, presented in a monotonous

                       tone(aprosodic) and in chronological order.

They are not able to use the psychoanalytic work to solve their problems.

       Object representations are characterized by a lack of individual attachment and

appreciation. Instead, there tends to be an exploitative quality. The capacity for self- caring,

self- comforting and self- regulation are seriously impaired, sometimes to life threatening

proportions. There is notable a “numbness”, and a lack of affective interaction with other

individuals and with the analyst. The unavailability of emotions, especially of love, does not

permit true attachments. There is a diminution of the capacity for joyous, friendly associations.

Alexithymic, anhedonic, aprosodic patients usually have multiple mental and physiological
disturbances. The point is that these lasting physiological changes influence and modify these

patients’ cognition, memory, and even states of consciousness (van der Kolk et al, 1993; Krystal

J H et al, 1994; also Amygdala studies and “divided brain,” (Hoppe, 1988, Bogen & Bogen,

1988). Related to self- care impairment is an inability to experience wish-fulfillment fantasies.

This defect is easiest to understand in the wake of infantile trauma which interrupted the normal

development of the elaboration of the transitional object from a concrete thing into a symbolic,

abstract, musical, poetic, etc. form. (Krystal, 1988) The blocking of the normal development of

the transitional process causes lifelong impairment in the capacity for “solacing.” (Horton,

1981).

         Closely related to the source of these disturbances is the success in creation of the

transitional object. The transitional process related creativity makes the object increasingly

imaginative, musical and poetic (Deri, 1984). It contributes to self-respect in childhood

(Copollilo, 1967; Ablon et al. 1993), which serves as a lasting reserve for future development of

new self-representations corresponding to the transformation and integration of the wholesome

narcissism in adolescence (Sugarman and Jaffe 1989, Benson 1980, Benson and Pryor 1973).

These conditions form the base for the capacity for wish fulfillment fantasies. The limitations in

creating dreams and inability to associate, directly limits the patient’s ability to work

psychoanalytically. The degree and severity of alexithymia can vary from person to person, or

within the same person.

In order to measure alexithymia, several well-tested instruments have been designed. Only a few

sources will be mentioned here which can be helpful and reliable: Von Rad et al. (1977, 1982),

Emde, Gaensbauer and Harmon (1976), Von Rad (1983), Ten Houten et al. (1985 a, b, c, d),
Krystal, J. H. (1988). A test that will likely become the standard is the Toronto Alexithymia

Scale. (Bagby et al. 1990, Taylor, 1984 b, 1985,1988).

Alexithymia and Psychosomatic Illness. Because of the affect regression in the state of

alexithymia, situations and experiences, which would otherwise produce useful, affect signals for

information processing, decision making, etc. tend to cause an organ response of chronic

hyperactivity. This hyperactivity goes on silently until the organ (generally a viscus) is

damaged, and a lesion is produced. The outcome is a physical illness of combinatorial etiology,

since both hereditary and environmental factors may contribute to the development of such

illness. (Krystal 1997)Psychosomatic illness can be considered as one of the most solid and

dependable “protections” against the recognition of narcissistic defects and inadequacies in

object-relations, i.e., the consequences of severe narcissistic injuries (Krystal 1998). McDougall

(1985, 1989) suggested that although the patient may present with only one illness, this picture

might be a defensive containment of a “psychosomatosis” (McDougall, 1982-1983). As

mentioned earlier, there can be no psychosomatic disease with alexithymia without affect

regression. Accordingly, if a patient has both alexithymia (which includes aprosodia) and

anhedonia, there is a high degree of certainty that the syndrome is post-traumatic. If there is

absolutely no history of trauma, then the likelihood that a history of infantile psychic trauma is

buried in the individual’s and his family’s past is very high. (Krystal 1997a, 1998)

Treatment: Analytic psychotherapy treatment of traumatized patients who show various

degrees of alexithymia and psychosomatic diseases or addictions cannot be done successfully

with the principles developed for the neuroses alone. There is need for preparatory work in the

opening phases of the analysis during which one may start demonstrating and explaining the

nature of the patient’s emotional, affective, and cognitive disturbances (Krystal 1982, 1982-83;
McDougall 1972, 1974, 1984). If psychoanalysis or any type of anxiety provoking therapy is

going to take place, the patient’s impaired affect tolerance has to be taken into consideration, and

dealt with. Actually, Raskin and I had struggled with the same problem in working with drug

dependent patients, and in our publication we emphasized in our 1970 publication that a

preparatory phase of treatment was necessary, in order to increase these patients affect tolerance,

as well as dealing with the same kinds of problems. I brought up in the work on posttraumatic

and psychosomatic patients. The most important principle in the treatment of the alexithymic

patient is that reconstruction of damaged structures has to precede the reconstruction of

repressed memories. Part of the mind where trauma persists is characterized by primal

repression, which refers to an absence of psychic structures. The analyst often feels that she is

searching for something that “is not there” (McDougall, 1988). The direct emergence of primal

repression material is risky, but may be reached and worked within a prolonged valuing,

nurturing relationship labeled “primary relatedness” by Kinston and Cohen (1986). This is the

interactional context for enhanced growth. During this period, one needs to be attuned to the

patient’s body experiences, and intermodal affect communications as in preobject relatedness

(Kumin, 1997).

Cultivating affect tolerance: In this process the patient’s thoughts of and reactions to having

emotions are attended to. One is trying to find out what the patient’s conceptions of emotions

are. Their “color blindness” about emotions needs repeated attention. Next is the matter of

reaction to “having an emotion” which may reveal deep-seated convictions about what should be

“done” with affects. Eventually, the analyst may be able to understand and demonstrate the

regressions, deficiencies, and arrests that these patients have suffered in the genetic development

of affect.
Promoting affect differentiation: This endeavor involves naming of effects, “interpreting” the

story behind the affects, and use of elucidation, confrontation, and interpretation, in order to

highlight the differences between adaptive mature responses and the patient’s infantile affective

response. The analyst can show empathy to the infantile patterns, and help verbalize emotions.

In the process of affect verbalization, differentiation and desomatization develop automatically.

Consequently, the patients also develop and keep improving their capacity for symbolic

representation and fantasy. Being able to accept a symbolic fulfillment of their needs and

wishes, instead of the concrete form they expect in the beginning, establishes an essential

component of the therapeutic effectiveness. The efforts in this direction are not purely didactic.

Rather, in the therapeutic relationship there a chance for the patient to achieve the kind of affect

development that they missed because of a lack of secure attachment in infancy, or because of

post-traumatic regression.

The“return of psychic trauma” complex: Traumatized patients have a dread expectation that

the psychic trauma state will return. Their self-caring, self-soothing and self-regulation functions

are inhibited. (Krystal, 1978b, 1979, 1982-83, 1988a; Zinberg, 1976; Edgecumbe, 1983;

Khantzian and Mack, 1983). The inhibitions are directly related to a special type of transference:

an idolatrous one. They experience all the life enhancing, care taking, regulating powers as

reserved for the primary object representation, and “walled off” within it - as in an idol.

“Taking over” one’s self-caring functions and exercising them freely is prohibited. The violation

of this prohibition is a “Promethean transgression” punishable by a fate worse then death, i.e.,

the return of the psychic trauma state.

The idolatrous transference causes the patients great difficulty in receiving, and discovering in

their analysis, the message about their own powers. They cannot register the possibility and
permissibility of overcoming their inner dissociations and blocks. The healing message to the

alexithymic patients, which is very hard for them to experience and feel, is that love is real, and

that it works. They have a difficult time imagining that idea. They cannot believe it.

They demand instant wish fulfillment. Their view on this matter is: “If you loved me, everything

would feel perfect. Since it does not, then you too are offering me “counterfeit nurturance.”

And: “This I have been getting all of my life.”

The identification with the “other side”: One of the deepest and most profoundly repressed

“secrets” is the unconscious “identification with the other side” (of the victim-perpetrator dyad).

This most-guarded defensive structure is revealed sometimes in the arduous work with the

dissociations, in an attempt to achieve conscious self-integration. While the conscious reaction

to any identification with the “other side” evokes horror and repulsion, profoundly repressed

there is a secret of a primitive unconscious form of love towards the perpetrator and victim

respectively, derived from the regressed state in an overwhelming subjugation

and sadistic assault. This constellation accounts for the importance of projective identification in

the analysis of such individuals. It serves to disavow conscious recognition of one’s authorship

of all of one’s own psychic representations, especially the one’s that are most difficult to love.

This “complex” is the strongest illustration of self-integration as the process of self-healing, and

the disinclination to it. This is actually an example of intrapsychic complex which is part of

traumatic consequences. In part, in order to be able to heal such splits and projections requires

the ability to use part of the psychotherapy which is an analog to mourning is necessary.

Completing the grieving successfully makes possible the reintegration and self-healing.

(Krystal, 1988)
Activation of denial and defenses: It is well known through many sources, especially the work

of Dorpat (1985), that when confronted with an anxiety situation (what he calls the “painful

object”), instant denial is activated, which in turn initiates a variety of defenses, including the

kind designated against keeping the memory and the affect object together. There is ample

evidence that defensive distortions of perception, cognition, and recall occur frequently when

called up by painful affect signals. The traditional psychoanalytic idea that repressed contents

are preserved intact is disproved by evidence that unconscious contents are continually reviewed

and modified. (Westerlundh and Smith, 1983; Krystal, H. and Krystal, A.D., 1993). This

discovery cautions us about the way reconstructed material must be handled. A basic principle

must be reemphasized in this context; there are two types of affect operative in the organism: one

that can be registered consciously, and another, the subliminal signal affects, which operate in

information and perception processing like automatic switches within computers (Bucci, 1985).

Defenses against trauma (“the stimulus barrier”) involve all of the individual’s mental and

emotional functions, self evidently: all ego functions. Post-traumatically, the responses to

affective signals become enormously intensified, a “hyper-alert” state, hyper-vigilance and

emergency regimes persist.

Shame, guilt, and narcissistic disregulations: At some point, when the patient has confronted

his psychic trauma and related emotional, behavioral, and cognitive strategies, it is important to

help verbalize the patient’s feelings of shame and guilt. (Schore, 1994) The (Illusionally

repressed) memory traces that generate these emotions tend to keep him/her attached to their

mental representation of their oppressors and create situations of “pain and hate addiction.”

They also impair the capacity to maintain adequate self- esteem. We must keep in mind

posttraumatic blocking of the ability to experience a mature form of love. The above-
mentioned impairment in the capacity to grieve successfully, and thereby to achieve self-

integration and the capacity for mutuality, interdependence, and intimacy requires belated

attention here. Trauma throws one into the often insoluble dilemmas of “connection or

separations,” integrity vs. disintegration, and activity vs. stasis. Such conflicts demand our

attention in these analyses to a degree that is not as central or essential for “good neurotics.”

Stereotypic interpretations simply miss the point with such patients. Unlike average good

candidates for analysis, these patients require the analyst’s help in discovering that all affects are

transformations of love. They need to consider recognizing that their rage represents their love

outraged. Their shame is their love rejected, humiliated, and poisoning their self-representation.

Many such patients come prepared for a “surgical solution” proposing that we “cut out” the bad

part of them. However we are dedicated to a psychoanalytic endeavor of accepting lovingly

every part of one’s self-representation. If possible, we like to assist in restoring and integrating

one’s alienated parts. All one’s mental contents need to be healed by a conscious endowment

with self-recognition and acquiescence.

Transference: Posttraumatic, psychosomatic alexithymic patient’s transferences of greatest

importance are not the ones that we know so well from working with “good neurotic’

analysands. These patients are quite willing to keep coming to analytic sessions forever, and

wait patiently for “the healer to cure them.” In the meantime, they continue to present the

chronologically arranged details covering the period since the last session. This format serves to

deny their authorship of their own presentations. A long-term diet of such material produces a

countertransference of boredom. The occurrence of aggressive and sexual fantasies in the

analyst is an important clue to the nature of the patient’s blocked associative powers and

“missing affects” (Taylor, 1984a & b). These patients hardly ever report dreams, and when they
do, dreams tend to be one-sentence productions to which they cannot associate. If pressed, they

may be able to “squeeze out” some additional detail of the manifest contents of the dream. It is

clear that these patients are definitely not talented for the psychoanalytic cooperative efforts. In

this context it is useful to recall that Sifneos (1972-1973) cautioned that an accurate

interpretation, which might produce good results in a “good neurotic” may produce a life-

threatening exacerbation to a psychosomatic patient.

Cohen and Kinston (1986) warned that before the contents of the “black hole”

residues of primary repression may be broached, many a patient has to go through a phase

involving danger of suicide or murder. Primary repression results in a “hold” in the associative

network of our functionally accessible mind. There is a severe splitting of grandiose self-

representations, with consequent rage and mortification. The numbing and denial involves the

dread of the discovery and revelation of one’s rage and destructiveness including toward the

original Objects, and hence necessarily in the transference. The reactive hate, and hate addiction

has to be understood in terms of superego problems in both the victim and the perpetrator.

       If psychosomatic, addictive, alexithymic patients stay in treatment until they become able

to understand and feel what the therapist is talking about, it is necessary to deal with their

inhibitions in self-care, self-soothing, and self-regulation. They need to start questioning why

they treat themselves as robots, and have no empathy for anyone. By this time it should be

possible to interpret their transference, dominated by the wish for the therapist to take over the

operation of all their vital and affective functions. The interpretations of the idolatrous

transference must wait until the patients are able to use their emotions effectively. They cannot

give up the infantile views of themselves until they are able to use the analysis for effective

grieving (Wetmore, 1963). These patients have been using substitutes for the primal object as
“placebos” making it possible for them to take care of themselves, and simultaneously deny their

self-caring. In interpreting transferences of this kind, we must remember that many aspects of

them are pre-verbal, derived from the pre-object relatedness. Many clues to their meaning

maybe presented not the patient’s words, but intonation, posture, facial expression, and the like.

Moreover, since in the traumatic state there is diminution of the sense of actuality and the

symbolizing process, what we say may not be as important as how we say it, how we sound, and

what emotion we convey. Consequently, for many patients, it is necessary to look at and see the

analyst.

        In order to succeed with such patients, the analysts cannot not expect to conduct an

analysis while sitting there like wooden statues, but they must more freely express emotions

experienced. Sometimes it is necessary to admit to such a patient that his or her perceptions of

the analyst’s reactions are accurate. One may even have to reveal countertransference reactions

and empathic failures (Maroda, 1999). Such a confirmatory admission may occur at a crisis point

of the treatment. This openness on the part of the analyst may enable the patient to trust his or

her feelings in key object relations for the first time ever.

        Anhedonia and the inhibition of playfulness, and the ability to play and enjoy it is a major

problem, but also an avenue of approach. Inhibitions in playing and joyful, pleasurable

experiences are difficult to relieve, and we have much to learn about dealing with preverbal and

presymbolic affects and traumatic residues. We need to understand pre-object relatedness and its

life-long manifestations (Kumin, 1996). We need to know more about a complex anatomical and

neurophysiological control system, which involves the orbito-frontal cortex (Schore, 1994), and

a number of other areas (Corpus Callosum, Amygdala, Hippocampus). Dealing with this kind

of patient, we can no longer ignore the proven discoveries in many neuroscience, cognitive, and
other fields showing that life-long psycho- social patterns are programmed in modifications of

brain functions, including anatomical ones. Perhaps psychoanalysis may result in functional or

even structural changes in the brain as well. (Schore, 1994; Hoppe, 1988; Bogen and Bogen,

1988). The studies on “divided brains” on patients with divided Corpus Callosum showing

severe alexithymia-like symptom have recently assumed new importance with the findings that

“interhemispheric integration is essential for memory consolidation. Dreaming, REM sleep, and

cortical consolidation become the integrating processes that mediate autobiographic narrative.

Blockage of these integrative processes may be seen at the core of unresolved trauma and may be

revealed as one form of autobiographic incoherence” and “This highly complex form of

collaborative communication (in secure attachment of the infant) allows the dyad to move into

highly resonant states. And also enables the child’s mind to develop its own capacity for

integration. Such capacity may be at the heart of self-regulation (Siegel, 1999 p. 334)

Conclusions: This has been a review of the interaction between the functions of emotions in

general, and the special challenges for psychoanalysis in the context of affect regression. The

nature of one’s self-representation and the psychosocial responses to significant objects are

markedly influenced by the quality and availability of emotions. Analysis cannot be effective

unless the patient has adult-type affects available, and participates in the analysis emotionally.

Without this capacity, it is not even clear to such individuals what is truly animate. The

alexithymic answer to fantasy is that it has to be connected to immediate wish fulfillment. They

say: “otherwise what is the point of it?” This reaction is a direct effect of trauma, notably the

repudiation of wishes and fantasies, giving up parts of self- and object-representations and

replacing them with nothing. Analysis of these patients requires that they reintegrate the

(Illusionally) alienated parts of themselves, including the memory traces of the most terrible
experiences. To have a therapeutic effect, these have to become consciously recognized parts of

their self-representation. This is the reason why in working with such people we must keep the

recognition of psychic reality being the only knowable reality as the first and foremost orienting

principle. We must also enter the arena of infantile conflict, in order to help an extension of the

scope of self- representation. Interpretations in this sphere enable the patient to conceive the

message of empowerment for exercising their self-care potential, including play, fantasy, and

solacing competence. The history of psychoanalysis has been a factor in the development of

insights in a certain order, according to the kinds of patients that were worked with. It had been

possible to work with talented patients without spending a great deal of time and efforts on

examining the relationship of their emotions to psychosomatic diseases, addictive mechanisms,

issues of self-care and self-esteem regulation. However, the “expanding scope of

psychoanalysis” has occasioned work with patients with whom it is imperative to pay attention to

these issues. Observations from analytic work with post-traumatic, alexithymic, psychosomatic,

and addictive patients have a great deal to offer to everyday analytic treatment, for no patients

are free from some of these “unpopular” problems. In addition, we must consider that many

reactions, which present themselves in the whole spectrum of diagnostic categories, and the

infinite variety of psychodynamic processes which often developed in successful trauma

prevention. In this last sentence resides the progress of the last eighty years.

       When psychoanalytic theory first postulated that the cause of the neuroses was trauma,

the understanding of the nature of trauma was at its infancy, and not based on a broad

perspective and long term studies of the sequels of traumatization.
References:

   Ablon, S. A., Brown, D., Khantzian, E. J., Mack, J. (Eds.) Human feelings: Explorations in

   affect development and meaning. Hillsdale, NJ, Analytic Press, 1993.

   Ainsworth, M. D. S., Blehar, M. C., Walters, E., Wall, S. Patterns of attachment, a

   psychological study of the strange situation. Hillsdale, NJ, Lawrence Eribaum Assoc., 1978.

   Bagby, R. M., Taylor, G. J., Parker, T. D. A., Loiselle, C. Cross-validation of the factor

   structure of the Toronto Alexithymia Scale. Psychosom. Rev 34: 47-51, 1990.

   Benson, R. M. Narcissistic guardians: Developmental aspects of transitional objects,

   imaginary companions, and career fantasies. Adolescent Psychiatry 8: 25-264, 1980.

   Benson, R. M., Pryor, D. B. When friends fall out, Developmental interference with the

   function of some imaginary companions. J Am Psychoan. Assoc 210: 457-473,1974.

   Bogen, J. E. Bogen, G.M. Creativity and the corpus calosum. In Hemispheric

   specialization, Psychiatric Clinics of North America; 11: 293-302.

   Bowbly, T. The making and breaking of affectional bonds. Br J Psychiatry 130:201-

   210,1977.

   Brown, D. Affective development, psychopathology, and adaptation. In Human feelings:

   Explorations in affect development and meaning. Edited by Ablon, S. A., Brown, D.,

   Khantzian, E. J., Mack, J. Hillsdale, NJ, Analytic Press, 1993.

   Browning, C.R. Ordinary Men. Reserve Police Battalion 101 and the Final Solution In

   Poland.

   NY HarperCollins, 1992

   Bucci, W. Dual coding: A cognitive model for psychoanalytic research. J Am Psychoan.

   Assoc Vol. 33:571-608, 1988.
Bychowski, G. (1986). In: Krystal H. (ed) Massive Psychic Trauma pp 75- 86. NY IUP

Cohen, J. and Kinston, W. Repression theory: a new look at the cornerstone. Intern. Jour. of

Psychoanalysis, 65: 411- 422.

Copolillo, H. P. Maturational aspects of the transitional phenomenon. Int J Psychoan,

48:237-246,1967.

Demos, E. V. Facial expressions of infants and toddlers: A descriptive analysis. In Emotion

and Early Interaction. Edited by Field, T., HIllsdale, N. J., Lawrence Erlbaum Assoc., 1982.

Deri, S. K. Symbolization and Creativity. New York, International Universities Press, 1984.

Dorpat, T. L. Denial and defense in the therapeutic situation. Northvale, NJ, Jason Aronson,

1985.

Dorsey J.M. Some considerations of psychic reality. Internat. Jour. Psychoan. 24: 147-151,

1943

Dorsey, J. M. Allness or Illness. Wayne State.U.Press 1965.

Dorsey, J.M. Psychology of Emotion: Self Discipline by Conscious Emotional Continence.

           Wayne State U. Press 1973.

Edgecumbe, E. On learning to talk to oneself. Bulletin of the British Psychoanalytic

Society, 5: 1-     13, 1983.

Eissler, K. R. Die Ermordung von vievielen seiner Kinder muss ein Mensch ertragen

koennen, um eine Normale Konstitution zu haben? Psyche, 17:241-291 1963.

Emde, R. N. The prerepresentational emotional self and its affective care. The

Psychoanalytic Study of the Child, 38:165-192,1983.

Emde, R. N., Gaensbauer, T. J., Hamron, B.J. Emotional expressions in infancy. New York,

International Universities Press, 1976.
Engel, W. Reflections on the Psychiatric Consequences of Persecutions. Amer. Journal

Psychotherapy 16,:191-203, 1961

Freud, A. Comments on Trauma in Psychic Trauma ed. S. Furst . NY Basic Books . 1967.

Freud, S. Sketches for a preliminary communication (1893-1895). In The standard edition of

the complete psychological works of Sigmund Freud, Vol 2. Translated and edited by Strachey, J. London, H

Freud, S. Inhibition, symptoms, and anxiety (1926). In The standard edition of the complete

           psychological works of Sigmund Freud, Vol 20. Translated and edited by

Strachey J. London. Hogarth Press, 1959, pp 77-175.

Friedman, P. The Effects of Imprisonment. Acta Med. Orientalia 7:163-167, 1948.Some

Aspects of Concentration Camp Psychology. American Jour. Psychiatry 105:601-605, 1949

Gadini, R. Transitional objects and the process of individuation. Journal of the American

Academy of Child Psychiatry, 4: 347-364, 1970.

Gadini, R. The concept of the transitional object. Journal of the American Academy of

Child Psychiatry, 14: 731-736, 1975.

Gadini, R. Early care and the roots of internalization. Int. Rev Psychoan. 14: 321-333, 1987.

Gediman, H. K. The concept of the stimulus barrier. Its review and reformulation as an

adaptive ego function. Int. Jour. Psychoan. 52: 243-255, 1971

Gillet, R. The problem of unconscious affect: signal anxiety versus double prediction theory.

Psychoanalysis and Contemp. Thought, 13: 551-600, 1990.

Giora, Z. Dream styles and the psychology of dreaming. Psychoanalysis and Contemporary

Thought, 4: 291-381, 1981.

Giora, Z. The unconscious and its narratives. Budapest, Turin Publishing House, 1991.
Greenspan, S. I. Psychopathology and adaptation in infancy and early childhood. New

York, International Universities Press, 1981.

Hadley, J. L. The instincts revisited. Psychoanalytic Inquiry, 12: 396-418, 1992.

Harlow, H. F. The nature of love. Am. J Psychology, 13: 673-685, 1958.

Harmon, R. J., Wagonfeld, S., Emde, R. N. Anaclitic depression: A follow up from infancy

to puberty. The Psychoanalytic Study of the Child, 37: 67-94, 1982.

Haley, S. A. When the patient reports atrocities. 1974 Archives of General Psychiatry 30:

191-196.

Hilberg, R The Destruction of the European Jews. Chicago, Quadrangle Books

Hofer, M. A. Toward a developmental basis for disease predisposition, the effect of early

maternal separation on the brain, behavior and cardiovascular system. In Brain, behavior and

bodily disease. Edited by Warner, H., Holdes, M. A., Stunkard, A. J. New York,       Raven

Press, 1981.

Hofer, M. A. Some thoughts on “the transduction of experience” from a developmental

perspective. Psychosomatic Medicine, 44: 19-28, 1982.

Hofer, M. A. On the relationship between attachment and separation processes in infancy.

In Emotion: Theory, research and experience: Emotions in early development, Vol II. Edited

           by Pluchik, R. New York, Academic Press, 1983.

Hoppe, K.D. Psychotherapy with Concentration Camp Survivors. In Krystal, H. Massive

Psychic Trauma. N.Y. I.U.P. Chapter 8: 204-219 1968

Horton, P. L. Solace. The missing dimension in psychiatry. Chicago, University of Chicago

Press, 1981.

Izard, C. E. The face of emotions. New York, Basic Books, 1971.
lzard, C. E. Human emotions. New York, Plenum Press, 1977.

Jones, J.   Emotions as a Process An inquiry into the centrality of affects in psychological

life. Hillsdale, NJ Analytic Press ,1992

Kernberg, O. F. Borderline conditions and pathological narcissism. New York, Jason

Aronson, 1975.

Kernberg, O. F. Object relations and clinical psychonalysis. New York, Jason Aronson,

1975.

Khantzian, E., Mack, J. E. Self-preservation and the case of the self. The Psychoanalytic

Study of the Child, 38: 290-232, 1983.

Kinston, W., Cohen, J. Primal repression: Clinical and theoretical aspects of the mind: The

realm of psychic states. Int. J. Psychonal, 67: 337-555, 1986.

Klein, H. Problems of Psychotherapeutic Treatment of Israeli Holocaust Survivors. In H.

Krystal (ed.)      Massive Psychic Trauma, NY IUP Chapter 8: 233-247. 1968

Krystal, J. H. Assessing alexithymia. In Integration and self-healing. Edited by Krystal, H.

Hillsdale, NJ, Analytic Press, 1988, pp 286-31.

Krystal, J. H., Bennett, A., Bremner, J. D., Southwick, S. M., Charney, D. S. Towards a

cognitive neuroscience of dissociation and altered memory function in post- traumatic

disorders. In Neurobiological and clinical consequences of stress: From normal adaptation to

PTSD. Edited       by Friedman, M. J., Charney, D. S., Deutsch, A. Y., New York, River

Press, 1994.

Krystal, H. Trauma: Consideration of its intensity and chronicity. In Psychic traumatization.

Edited by Krystal, H., Niederland, W. G. Boston, Little & Brown, 1971.
Krystal, H. The genetic development of affects and affect repression. The Annual of

Psychoanalysis, 2: 98-126, 1974.

Krystal, H. Affect tolerance. The Annual of Psychoanalysis, 3: 179-210, 1975.

Krystal, H. Trauma and Affect. The Psychoanalytic Study of the Child, 33: 81-118, 1978a.

Krystal, H. Self-representation and the capacity of self-care. The Annual of Psychoanalysis

6: 209-247, 1978b.

Krystal, H. Severe Psychic Trauma and Psychogenic Death. Psychiatric Problems in Medical

Practice. Eds. C.U. Balis, L. Wurmser, E. McDaniel, & R.G. Green, Boston, Butterwor Chap.

4: 79- 97 1978c

Krystal, H. Alexithymia and psychotherapy. American Journal of Psychotherapy, 33:

1728,1979.

Krystal, H. The hedonic element in affectivity. The Annual of Psychoanalysis, 9: 93-

114,1981.

Integration and Self-healing In Posttraumatic States. Journal of Geriatric Psych. 14: 165-189

1981b.

Krystal, H. Psychotherapy with alexithymic patients. In Psychosomatic Medicine:

Theoretical, clinical and transcultural aspect. Edited by Krakowski, A. J., Kimball, C.P.

New York, Plenum, 1982,            pp 737-744.

Krystal, H. Alexithymia and the effectiveness of psychoanalytic treatment. International

Journal of Psychoanalytic Psychotherapy, 9: 353-388, 1982-1983.

Krystal, H. Trauma and stimulus barrier. Psychoanalytic Inquiry, 5: 131-161, 1985.

Krystal, H. Integration and Self-Healing. Hillsdale, NJ, Analytic Press, 1988a.
Krystal, H. On some roots of creativity. In Hemispheric specialization. Edited by Hoppe,

K. D. Philadelphia, Saunders, 1988b, pp 475-491.

Krystal, H. Integration and Self–healing in Posttraumatic States, a Ten Year Retrospective.

American Imago 48:93-118, 1991

Krystal, H. Late Life Effects of Trauma. Jour. Geriatric Psychiatry 26: 1995 a

Krystal, H. Trauma and Aging: a Thirty Five Year Follow up. In Trauma: Explorations in

Memory. Ed: C. Caruth, Baltimore: Johns Hopkins U. Press pp. 65-100 1995 b

Krystal, H. Beyond DSM-IIIR: Therapeutic considerations in post traumatic stress disorders.

In International Handbook of Traumatic Stress Syndromes. Edited by Wilson, J. P., Rafael,

B. New York, Plenum Press, 1993, pp 841-853.

Krystal, H. Desomatization and the Consequences of Infantile Trauma. Psychoanalytic

Inquiry Vol. 17: 126- 149. 1997 a.

Krystal, H. The Trauma of One’s Vulnerability and Death. In Omnipotent Fantasies and the

Vulnerable Self. C.S. Ellman and J. Reppen eds. Northvale: Jason Aronson Ch. 5: 139- 186.

1997 b.

Krystal, H. (Resilience) Psychische Widerstaendigkeit: Anpassung und Restitution bei

Holocaust-Ueberlebenden. Psyche 9/10 pp. 839- 859, 2000

Krystal, H. Affect Regulation and Narcissism. In Disorders of Narcisism. E.F. Ronningstam,

ed APA Press Chapter 13: 299-326, 1998

Krystal, H. and Krystal, A. D. Psychoanalysis and neuroscience in relationship to dreams

and creativity. In Creativity and affect. Edited by Shaw, M. P., Runko, M. A. Norwood, NJ,

Ablex Publishing, 1993, pp 185-212.
Krystal, H. and Niederland, Wm. G. Psychic Traumatization. Aftereffects in Individuals and

Communities Boston, Little Brown & Co. International Psychiatry Clinics vol.8 No. 1, 1971

Krystal, H. and Raskin, H. A. Addiction and pain. Mimeographed, 1963.

Krystal, H. and Raskin, H. A. Drug Dependence. Detroit, Wayne State University Press,

1970.

Kumin, I. Pre-object relatedness. Early attachment and the psychoanalytic situation. NY,

Guilford Press, 1990.

Lanzman, C. Shoah. NY Pantheon Books, 1985

Lifton, R. J. Death in life: Survivors of Hiroshima. NY, Random House, 1967.

Lifton. R. J. Observation on Hiroshima Survivors. In H. Krystal (ed) Massive Psychic

Trauma. NY IUP Chapter 7: 168-201, 1968

Lifton, R. J. The Broken Connection. NY, Simon and Schuster. 1979

Main, M. Analysis of peculiar form of reunion behavior seen in some day-care children: Its

history and sequelae in children who are home reared. In Social development in childhood:

Daycare programs and research. Edited by Webb, R. Baltimore, MD, Johns Hopkins

University Press, 1977.

Malkin, P.Z. and Stein, H. Eichman in my Hands. NY Warner Books.1985

Marty, P. and de M’Uzan, M. La pensée operatoire. Revue Psychoanalitique, 27(Suppl.):

345-356, 1963.

Maroda, K. J. Seduction, surrender, and transformation. Hillsdale, NJ, Analytic Press,

1999.

Marty, P., de M’Uzan, M., David, C. L’investigation psychosomatique. Paris, Presses

Universitaires Paris, 1963.
McDougall, J. The anti-analysand in analysis. In Ten years of psychoanalysis in France,

New York, International Universities Press, 1972.

McDougall, J. The psychosoma and psychoanalytic process. lnt. Rev. Psycho-anal, 1: 437-

454,1974.

McDougall, J. Alexithymia: A psychoanalytic viewpoint. Psychotherapy and

Psychosomatics, 38: 81-90,1982.

McDougall, J. Alexithymia, psychosomatosis, and psychosis. International Journal of

Psychoan. and Psychotherapy, 9: 379-388, 1982-1983.

McDougall, J. Theaters of the mind. New York, Basic Books, 1989.

McDougall, J. Theaters of the body: A psychoanalytic approach to psychosomatic illness.

New York,          Norton, 1989.

Meehl, P. E. Hedonic capacity: Some conjectures. The Bulletin of the Menninger Clinic,

49: 295-307, 1975.

Maloy, J. R. Violent attachments. Northvale, NJ, Jason Aronson, 1992.

Modell, A. A narcissistic defense against affects and the illusion of self-sufficiency. Int. J.

Psychoan. 56: 275-282, 1975.

Nemiah, J. C. and Sifneos, P. E. Affect and fantasy in patients with psychosomatic disorders.

In: Modern trends in psychosomatic medicine-2. Edited by Hill, O. W. London,

Butterworth, 1970a, pp 26-34.

Nemiah, J. C. and Sifneos, P. E. The psychological management and treatment of patients

with peptic ulcer. Advances in Psychosomatic Medicine, 6: 169-173, 1970b.

Niederland, W. G. The problem of the survivor. Journal of the Hillside Hospital, 10: 233-

247,1961.
Niederland, W. G. Clinical observations of the “survivor syndrome.” lnt. J.Psychoan. 49:

313-315, 1968a

Niederland, W. G. An interpretation of psychological stresses and defenses in concentration

camp life and the late after-effects. In Massive psychic trauma. Edited by Krystal, H. New

York, International Universities Press, 1968b, pp 60-86

Niederland, W. G. Survivor Syndrome. Further observations and dimensions. J.Am.

Psychoan. Assoc 29: 413-426, 1961

Ogden, T.H. Matrix of the Mind. Northway N.J. Jason Aronson, 1986

Papousek, H. and Papousek, M. Cognitive aspects of preverbal social interactions between

human infants and adults, in Parental Interaction. (Ciba Symposium) NY Associated

Publishers, 1975

Parkes, C. M. and Stevenson-Hinde J. (Eds.) The place of attachment in human behavior.

New York, Basic Books, 1989.

Pine, F: On the Expansion of the affect array. The Bulletin of the Menninger 43:79-95, 1979

Pollock G.H. The psychosomatic specificity concept: Its evaluation and reevaluation. The

Annals of Psychoanalysis 5: 141-168, 1977

Pribram, K.H. Languages of the Brain. Englewood Cliffs, NJ Prentice-Hall,1971

Rado, S. The Emotions, Adaptational Psychodynamics: Motivation and Control. Edited by

Klein, H. New York, Science House, 1969, pp 21-30.

Rappaport, D. On the Psychoanalytic Theory of Affect in Collected Papers ed. M. M. Gill

NY Basic Books. 1953 pp. 476- 512

Reiser, M.F. Memory and the Brain. New York, Basic Books, 1990
Schore, A. N. Affect Regulation and the Origin of the Self: Neurobiology of Emotional

Development. Hillsdale, NJ Lawrence Erlbaum Assoc. 1994

Seligman, M.E.P. Helplessness. On Depression, Development and Death. San Francisco,

Freeman 1975

Siegel, D.J. The Developing Mind NY The Guilford Press. 1999

Sifneos, P. Clinical Observations on Some Patients Suffering from a variety of

Psychosomatic Diseases. Acta Medica Psychosomatica. Proceedings of the 7th European

Conference on Psychosomatic Research. Rome, September 11-16 1967 pp 452-458.

Sifneos, P. Is Dynamic Psychotherapy Contraindicated for a Large Number of Patients with Psychosomatic D

Sifneos, P. The Prevalence of “Alexithymic” Characteristics in Psychosomatic Patients.

Psychotherapy And Psychosomatics 22: 255-262, 1973

Solo, A.E. New Research on Affect Regulation Development: Universal and Theoretical

Considerations. Psychoanalytic Inquiry 7: 331-347, 1987

Solyom, A.E., Homes, T.M. & Hoffman, P. Infant Clinical Assessment Procedure. It’s

Implications for Diagnosis and Treatment in the Second and Third Years. Infant Mental

Health Jour. 4:104-115, 1983

Spitz, R.A. Anaclitic Depression. The Psychoanalytic Study of the Child 2:313-342 1946

Stang R. Edward Munch: The Man and his Art. NY Abbeville Press 1977

Sterba, E. The Effect of Persecutions on Adolescents. In Krystal, H (ed.) Massive Psychic

Trauma N.Y. IUP 1968 chapter 4: 51-60

Stern, D.N. The Interpersonal World of the Infant. NY Basic Books, 1985

Stern, M.M. Pavor Nocturnus. Int. J. Psychoan. 32: 302-309 1951a

Stern, M.M. Anxiety, Trauma, and Shock Psychoan. Quart. 20:179-203 1951b
Stern, M.M. Trauma and Symptom Formation. Int. J. Psychoan. 20: 202-218, 1953

Sugarman, A. Jaffe, L.S. A developmental Line of Transitional Phenomena

In: The Facilitating Enviroment: Clinical Implications of Winnicott’s Theories. From, G. &

Smith B.L. (eds) NY IUP 1989 pp 88- 96

Tanay, E. Initiation of Psychotherapy with Survivors of Nazi Persecutions. In Krystal. H (Ed)

Massive Psychic Trauma. Chapter 8: 219-232 NY IUP 1986

Taylor, G. J. The Boring Patient Canadian Jour. Psychiatry 29: 217-222, 1984a

Taylor, G. J. Alexithymia: Concept, Measurement, and Implications for Treatment. Am.

Jour. Psychiatry   141: 725-732 1984b

Taylor, G. J. Verbal Measures of Alexithymia. What do they Measure. Psychotherapy and

Psychosomatics 43: 32-37, 1985

Taylor, G.J. Psychosomatic Medicine and Contemporary Psychoanalysis. Madison, Ct, I. U. Press,   1987

Ten Houten, W.D. Hoppe, K.D. Bogen, J.E. Walter, D.O. Alexithymia and the Split Brain

Lexical-level Content Analysis. Psychoth. & Psychosom. 43:202-208,1985 a Alexithymia

and the Split Brain. II. Sential- Level Content Analysis. Psychotherapy and

Psychosomatics 44: 1-5 1985 b Alexithymia and he Split Brain: III. Global Level Content

Analysis. Psychother. And Psychosom. 44:89-94, 1985 c          Alexithymia and the Split

Brain: IV. Gotshalk- Gleser Content analysis. Psychother. And Psychosom. 44: 113-121,

1985 d

Tompkins, S.S. Affect, Imagery, Consciousness. The Positive Affects Vol. I NY Springer,

1962

Tompkins, S.S. Affect, Imagery, consciousness. Positive Affects Vol. II NY Springer 1963

Tompkins, S.S. Primary Motives of Man. Humanitas 3:321-345,1968
   van der Kolk, B.A. Biological Considerations about Emotions, Trauma, Memory and the

   Brain. In Human Feelings Ablon et al. (eds.) Hillsdale, NJ 1993 pp 221-256.

   van der Kolk, B.A. Post-traumatic Stress Disorders, Psychological and Biological Sequelae.

   Washington, D.C. America Psychiatric Press. Inc. 1984.

   Von Rad, M. Alexithymie: Empirische Untersuchungen zur Diagnostic und Therapie

   Psychosomatisch Kranker. Berlin, Springer-Verlag, 1983.

   Von Rad, M. Lalucat, L. and Lolas F. Differences in Verbal Behavior in psychosomatic and

   Psychoneurotic Patients. Psychother. Psychosom. 28:83-97 1977

   Von Rad, M. and Lolas, F. Empirical Evidence of alexithymia. Psychother. Psychosom.

   38:91-192,1982

   Westerlundh, B. and Smith, G. Percepgenesis and the Psychodynamics of Perception.

   Psychoanalysis and Contemp. Thought. 6: 597-640, 1983

   Wetmore, R.G. The Role of Grief in Psychoanalysis. Int. Jour. Psychoanal. 44: 97-103 1963

Zinberg, N.E. Addiction and Ego Function. The Psychoan. Study Child. 30:567-588, 1975

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:24
posted:2/14/2012
language:English
pages:54
wangping12 wangping12 http://
About