[Pharmacokinetic risk factors of beta-blockers overdose in the elderly: Case report and pharmacology approach]. / Facteurs de risque pharmacocinétiques de surdosage en bêta-bloquants chez les patients âgés : cas clinique et rationnel pharmacologique.

Beta-blockers are widely prescribed in elderly patients and may induce severe adverse drug reactions. We report a case of bisoprolol-induced bradycardia in an elderly patient with impaired renal function and use of cytochrome P450 inhibitors. A literature review has been performed in order to analyze pharmacokinetic risk factors of beta-blockers overdosing in geriatrics. Various mechanisms can result in decreased elimination of beta-blockers. These mechanisms vary according to the beta-blocker agent and may be combined in some individuals, especially elderly patients. This can lead to unexpected overexposure. Knowledge about drug interactions and pharmacokinetic elimination pathways is important for preventing overexposure and adverse drug reactions when using beta-blockers.

Interpretation and containment.

The author explores two aspects of the analyst's effort to imagine the inner world of his patient and the way that they are manifest in the clinical moment. The first of these is the analyst's recognition and interpretation of his patient's elaborated fantasies. This current of the analyst's imagination is most often evoked by the patient's communication of whole-object transferences, which occurs largely in his verbal associations. The second is the analyst's reception and transformation of his patient's primitive emotional experience, a process that Bion has called containment. This second imaginative current is most often evoked by the patient's communication of part-object transferences, which occurs largely in affect and action. Interpretation and containment both go on at once in clinical work, although one or the other is usually dominant. Attention to the interplay of interpretation and containment in the clinical moment enables us to identify the articulation of whole- and part-object transferences and to integrate ego-psychological and Kleinian frames of reference in clinical work. In addition, the concept of mutual containment opens Kleinian theory to the possibility of a two-person psychology in which the roles of analyst and patient are more symmetrical than they are usually conceived to be within this frame of reference. The author presents two clinical examples to demonstrate the interplay of interpretation and containment. In the first, these processes operate smoothly. In the second, the process of containment is strained but ultimately successful.

Transferences of deception.

Three characteristic transference configurations are identified that frequently emerge in the analyses of patients for whom deception and inauthenticity are central themes. These configurations are labeled (1) imposturous, (2) psychopathic-paranoid, and (3) psychopathic-unreal. Patients who develop these transferences have actively split the object world along two distinct axes. The first split has occurred along the lines of pleasure and unpleasure. The second divides objects along the lines of the experience of reality, with some objects felt to be charged with exaggerated, painful meaning, and others felt to be devoid of meaning and affect. This split, which arises as a way of managing painful object relations, is then woven into fantasy and defense at many developmental levels. Material from the analyses of two patients is presented to demonstrate the interplay of the three transference configurations, the fantasies that underlie them, and the clinical importance of analyzing the second split.

Emptiness as defense in severe regressive states.

This paper examines the empty states experienced by severely ill borderline patients. At times of stressful regression, these patients use complaints of emptiness to describe profound disturbances of affect, cognition, object relations, and bodily experience. Empty states may be seen as complex defensive configurations which protect a borderline level of psychic structure from the impact of aggressively charged object relations, and ward off further regression to states of fragmentation or fusion. Severely ill borderline patients consolidate an empty screen by means of a characteristic repertoire of primitive defenses consisting of various forms of projective identification, including bitriangulation and projective identification of psychic agencies, somatization, acting out, and specific alterations in cognition. The author describes the highly deviant organizations of the object world seen in empty states, and the complex and disturbing countertransferences which these states evoke.