Psychiatric History 精神病史 Clare first came into psychiatric treatment about four years prior to her last hospitalization and her coming into therapy with me. At the time she was a nursing student. The precipitating circumstances of her acute decompensation at that time involved her boyfriend, a rather unstable and probably schizophrenic young man whom Clare had known since childhood and dated episodically through the years. About this time she finally gave in to his wish to sleep with her, and she had intercourse with him on several occasions. She felt that she was being imposed upon, taken advantage of, and was infuriated and resentful at having to submit to the sexual play, but felt totally unable to express these feelings for fear of his rejecting her. The sexual activity was unsatisfactory and unrewarding both for her and for him, so that after this brief period of sexual involvement they more or less separated again. This had been the quality of her relationship to him for several years since they began dating in high school. 克莱尔第一次接受精神治疗大约是在她最后一次住院接受我的治疗的四年前。当时她是一名护理专业的学生。当时，她的急性失代偿症的恶化，与她的男朋友有关。他是一个相当不稳定、可能患有精神分裂症的年轻人，克莱尔从小就认识他，多年来断断续续地与他约会。大约在这个时候，她终于屈服于他想和她上床的愿望，她和他有过几次交媾。她觉得自己被强迫了，被人利用了，对不得不屈服于性游戏而感到愤怒和怨恨，但又完全无法表达这些感情，因为她害怕他会拒绝她。这种性行为对她和他都是不令人满意和没有回报的，所以在这短暂的性接触之后，他们或多或少又分开了。自从他们在高中开始约会以来，这一直是她和他关系的特点。 At this point Clare began to become increasingly depressed and withdrawn. Her appetite became quite poor and her periods irregular. Over the next six months she lost about thirty-five pounds and had only one menstrual period. During this time she began her student rotation on the psychiatric service. Her problem came to the immediate attention of her supervisor. She was quite depressed and was having difficulty in concentrating on her work, remembering simply nursing duties and performing routine tasks that she had mastered before. It was suggested that she take a leave of absence before undertaking the psychiatric rotation—so she left for a six weeks' break which she spent at her parent's home. At home she avoided contact with people as much as possible and spent most of her time alone, in her bedroom, reading and writing her thoughts in her diary. Her depression and extreme withdrawal did not abate. 就在这时，克莱尔开始变得越来越沮丧和孤僻。她食欲不振，月经不规律。在接下来的六个月里，她瘦了35磅，只有一次月经。在此期间，她开始了她的学生轮转精神科服务。她的问题立刻引起了主管的注意。她很沮丧，很难集中精力工作，只记得护理的职责和她以前掌握的日常任务。有人建议她在进行精神病学的轮转之前先休假一段时间，所以她在父母家休息了六周。在家里，她尽量避免与人接触，大部分时间都是一个人呆在卧室里，阅读和写日记。她的抑郁和极度的孤僻并没有减轻。 She came back to the hospital and started her rotation. She was able to perform her duties admirably—despite the fact that she continued to be depressed. Her academic performance, as always, was excellent. She remained distant from her fellow students, however, and kept herself isolated and withdrawn. She would only talk to one or two of the girls and assiduously avoided the rest. She spent most of her time reading books about mental illness. She confided to one of her "talking" friends that she could see herself in the patients in the hospital. She was obsessively perfectionistic in her work and instituted a number of compulsive routines. Some of her behavior was rather bizarre. She decided to rearrange her room, so she piled all the rugs, drapes, furniture, and other belongings neatly in the closet and left only the bed, a chair, and the dresser in the room. These she would compulsively rearrange several times each day. 她回到医院开始了她的轮转。她很好地履行了自己的职责——尽管她仍然很沮丧。她的学业成绩一如既往地优秀。然而，她与她的同学们保持着距离，使自己孤立和孤僻。她只和一两个姑娘说话，其余的人都尽量避开。她把大部分时间花在阅读有关精神疾病的书籍上。她向一位“话”友透露，她能在医院的病人身上看到自己。她对自己的工作过分追求完美，并制定了一些强迫性的例行公事。她的一些行为相当怪异。她决定重新整理她的房间，所以她把所有的地毯、窗帘、家具和其他物品整齐地堆放在壁橱里，只留下床、一把椅子和梳妆台。她每天都会强迫自己重新整理几次。 Despite these obsessional defenses the depression worsened. She became increasingly apathetic and withdrawn. She confided to one girl who had become a sort of confidant that she felt increasingly that she could not face each new day. Occasionally she would describe the details of dissections she had read about to the other nurses in a morbid fashion that tended to frighten the other girls. She would also talk about death and how morticians would prepare the corpse for burial. 尽管有这些强迫性的防御，抑郁症还是恶化了。她变得越来越冷漠和孤僻。她把这件事告诉了一个已经成为她知己的女孩，她越来越觉得自己无法面对每一天。偶尔，她会用一种病态的方式向其他护士描述她读到的解剖的细节，这种方式往往会吓到其他的女孩。她还会谈论死亡，以及殡仪业者如何为葬礼准备尸体。 After several months of a gradual and increasingly morbid picture, Clare began to feel impulses to cut herself. She began by scratching at her thighs with a pin. She had an unquenchable desire to see her own blood. Shewould scratch herself until she bled. During this time she was still functioning well as a student and kept her inner feelings very much to herself. Finally she confided to her friend some of her wishes to cut herself. Soon after she began cutting herself with razor blades. This was discovered one day when she had cut both of her thighs in several places, so that the blood was visibly soaking through her uniform while she was working on the ward. This bizarrely evolving picture and the encroachment of suicidal ideas made psychiatric referral imperative. Clare's self-laceration in her groin points to the important link between her self-hate and her own femininity. Her destructive impulses were directed against her own feminine self—that part of her that was rooted in the maternal introject. 几个月来，克莱尔的病情逐渐恶化，她开始有割伤自己的冲动。她开始用别针划大腿。她有一种看自己血的强烈愿望。她会抓伤自己直到流血。在这段时间里，她仍然是一个很好的学生，把自己的内心感受藏在心里。最后，她把自己想自杀的一些想法告诉了她的朋友。不久之后，她开始用刀片割伤自己。有一天，当她在病房工作的时候，这事被发现了，她把自己的两条大腿都被割破了好几处，血明显地浸透了她的制服。这种奇怪的演化图景和自杀想法的侵入使得精神病学的转诊势在必行。克莱尔腹股沟上的自残表明了她的自我憎恨和她自己的女性气质之间的重要联系。她的破坏性冲动是针对她自己的女性自我的——她的这部分根植于母亲内摄[她无意识地憎恨她内摄的母亲形象]。