In this paper, we explored the super-ego of patients with coronary artery disease. Research results have confirmed the initial hypothesis that a significant number of patients with coronary artery disease has rigorous super-ego. Among patients with coronary artery disease (N=50), and control group (N=50), we have found significant differences in the quality of super-ego and ego attitude towards the demands of the super-ego. The results of this research contribute to understanding the impact of psychological factors in coronary artery disease

Bilić, Vedran

Marčinko, Darko

Miličić, Davor

English

University of Zagreb Medical School Repository

Coll. Antropol. 35 (2011) Suppl. 1: 127–131Short communicationSuper-ego in Patients with Coronary ArteryDiseaseVedran Bili}1, Darko Mar~inko2,3 and Davor Mili~i}3,41 University of Zagreb, Zagreb University Hospital Center, Department of Psychological Medicine, Zagreb, Croatia2 University of Zagreb, Zagreb University Hospital Center, Department of Psychiatry, Zagreb, Croatia3 University of Zagreb, School of Medicine, Zagreb, Croatia4 University of Zagreb, Zagreb University Hospital Center, Department of Cardiology, Zagreb, CroatiaA B S T R A C TIn this paper, we explored the super-ego of patients with coronary artery disease. Research results have confirmed theinitial hypothesis that a significant number of patients with coronary artery disease has rigorous super-ego. Among pa-tients with coronary artery disease (N=50), and control group (N=50), we have found significant differences in the qual-ity of super-ego and ego attitude towards the demands of the super-ego. The results of this research contribute to under-standing the impact of psychological factors in coronary artery disease.Key words: coronary artery disease, super-ego, psychological factorIntroductionIn this paper we investigate the quality and charac-teristics of the coronary patients super-ego. Super-egohas a large impact on the feelings, plays an importantrole in the regulation of self esteem, and in psychodyna-mics of depression1.In estimating the super-ego we considered various el-ements and manifestations of super-ego:quality of the super-ego, object sources of the super--ego, (where they were obvious), amplitude of outsourc-ing super-ego attitudes (return of identifications to ob-jects), fragmentation of super-ego, the attained level insuper-ego structuration, the extent to which conflicts areexternal or internalized, the regulation of self-esteem,the functions of super-ego, the influence of the primaryprocess in the functioning of super-ego, the regression ofsuper-ego, instinctive sources of super-ego, how own ag-gressiveness increases super-ego activity, to what extentare the instinctive desires sublimated.Database (Medline Search, Kluwer Journals, psycho-analytic Electronic Publishing Archive CD Jourlit/Book-rev) searching have not found studies that have specifi-cally dealt with the super-ego of patients with coronaryartery disease, although a series of papers is publishedwhich explore the psychological characteristics of coro-nary patients.For example, in the seventies of the twentieth cen-tury, cardiologists Friedman and Rosenmann2,3 describedthe characteristics of coronary patients and called themthe character A, and then they developed and used ameasuring instrument, a test of character A, which is oneof the best tests of stress. Bonaguidi and colleagues4 usedCattell’s inventory to investigate relationship betweenpersonality traits and behavioural responses in patientswith acute myocardial infarction. They have found morepronounced super-ego in patients who had suffered acutemyocardial infarction.The research was part of a project 'Quality of life of so-matic patients'. It was conducted in New Zagreb Hospitalat the Cardiac surgeon Department of the KB Dubravaand at the Department of Psychological Medicine, of theZagreb University Hospital Center, University of Zagreb.This study aimed to estimate the quality and propertiesof super-ego and investigate the influence of the qualityof super-ego as the likely psychological factors in coro-nary artery disease.127Received for publication April 12, 2010Our hypothesis was that a significant number of pa-tients with coronary artery disease has rigorous super--ego. We suppose that there are significant differencesbetween sample of coronary patients and control groupin the quality of super-ego, which shall become evidenton the Kleinian Psychoanalytic Diagnostic Scale (revisedversion) (in further text the KPDS) sub-scale 11th 'degreeof persecutory anxiety that comes from the super-ego'(persecuting super-ego) which shows the quality of super--ego. Also, we suppose that there are significant differ-ences between sample of coronary patients and controlgroup in ego attitude towards the demands of the super--ego which shall become evident on the KPDS sub-scale14th 'kind of relationship with feelings of guilt' whichshows ego attitude towards the demands of the super-ego.Patients and MethodsThe study included one hundred patients sufferingfrom heart disease. All patients were hospitalized forheart surgery. Examiner who conducted the interviewdid not know before the interviews whether the respon-dent was suffering from coronary heart disease or othercardiac diseases. The main feature, on the basis that weincluded subjects in the sample was the presence of coro-nary artery disease. The main feature, on the basis thatwe included subjects in the control group was the ab-sence of coronary artery disease and the presence ofother cardiac diseases. Other cardiac disease was in mostcases a heart valve disease. Sample (Group 1) consistedof 50 patients suffering from coronary artery disease.The control group (Group 2) consisted of 50 patients suf-fering from other heart diseases.In the study, we used the following methods:Random sample methodSample and control groups were selected randomlyamong patients who met criteria for cardio surgical treat-ment and were hospitalized for scheduled heart surgeryat the Department of heart Surgery, Dubrava UniversityHospital in Zagreb.Method of equivalent groupsThe groups were demographically matched by me-thod of equivalent groups for age, sex, education, maritalstatus and number of children per family. For the study,subjects were selected whose intellectual status was al-lowing adequate cooperation in the investigation, and wehave excluded the patients with established psychiatricillness.Review of medical recordsReview of available medical records (access to special-ist reports, discharge letters, medical histories) of all pa-tients enrolled in the study allowed us a detailed intro-duction to their somatic diseases and sorting patientsinto two groups: a) suffering from coronary artery dis-ease and b) suffering from other heart diseases.As the methods and tools of psychological assessmentof patients, we used a psychiatric interview, psychody-namic interview5,6, psychodynamic estimate of super-egoand the KPDS. Mandatory prerequisite for psychodyna-mic and psychiatric interview was the patient’s free andvoluntary consent to an interview. Psychiatric and psy-chodynamic interviews are conducted simultaneously,and the assessment of patients by the KPDS the sameday thereafter. During and after the interview we haveobserved and monitored the transference and counter--transference response, which has enabled us scoring theKPDS questionnaire.Psychodynamic assessment of super-egoIn this research, the main purpose of psychodynamicinterviews was to evaluate the super-ego. In psychody-namic estimate of super-ego, we took into account vari-ous elements and manifestations super-ego7–14.The Kleinian Psychoanalytic Diagnostic Scale(KPDS) (revised version)After psychiatric interview, unstructured psychody-namic interview and psychodynamic assessment of su-per-ego evaluation of psychological structure profile andthe structure of object relations of the individual s con-ducted on the KPDS scale based on what the intervieweesaid and what the examiner could detect in the relation-ship. In our study the use of the KPDS has enabled ussystematize the abundance of data obtained using psy-chodynamic interviews (with special emphasis on psy-chodynamic assessment of super-ego) and to facilitatesubsequent statistical elaboration of the data, which weconsider important methodological contribution in thiskind of research.The KPDS is a standardized psycho-diagnostic instru-ment based on psychoanalytical theory of object rela-tions15. The scale was constructed to allow the inclusionof psychodynamic and the corresponding object relationsdimensions in clinical trials.Statistical methodsThe obtained numerical results were, in collaborationwith the statistician, analyzed using standardized andaccepted methods in the SPSS16 statistical package on apersonal computer. We used the Student t test and c2--test. To test score for the KPDS and sub-scales elevenand fourteen we used the Student t-test for independentsamples, and to test the difference between the twogroups in qualitative demographic variables we used thec2-test.ResultsThe statistical analysis of demographic characteris-tics of Group 1 and Group 2 used the c2-test. The resultsof qualitative variables are shown in absolute and rela-tive frequencies. Differences between groups 1 and 2 forqualitative variables (sex, marital status, number of chil-V. Bili} et al.: Super-ego in Patients with Coronary Artery Disease, Coll. Antropol. 35 (2011) Suppl. 1: 127–131128dren in the family, education) were tested by c2-test forindependent variables.Table 1 shows the demographic characteristics ofGroup 1 and Group 2 and the results of statistical analy-sis thereof. For validation of statistical analysis (to sat-isfy the conditions for the interpretation of c2-test) inproperties 'Number of children in the family' were mer-ged categories 'Four children', 'Five children', 'Six chil-dren', 'Seven children' and 'Eleven children', and in prop-erties 'Education' were merged categories 'Illiterate' and'Unfinished primary school', as well as 'Associate degree'and 'University degree'.Table 2 presents the results of statistical analysis ofage for groups 1 and 2.Quantitative demographic variable age was tested byStudent t-test for independent samples and the c2-test.The results are shown by the arithmetic mean and stan-dard deviation. Results of statistical analysis of demo-graphic characteristics showed that Group 1 and Group 2were equivalent by gender, age, marital status, numberof children in the family and educational attainment.Also, we performed a global evaluation of the person-ality of patients through the KPDS. The results of sub--scales 11th 'degree of persecutory anxiety that comesfrom the super-ego' (persecuting super-ego) and 14th'kind of relationship with feelings of guilt', referring tothe super-ego, we have observed separately, too, giventhe specific needs of this research. Sub-scale 11th showsthe quality of super-ego, and the sub-scale 14th ego atti-tude towards the demands of the super-ego.The statistical analysis of results and results of theKPDS (quantitative variables) are shown using the ari-thmetic mean, standard deviation and the meridian.The differences between Group 1 and Group 2 (sincethe distributions followed Gaussian distribution) weretested by Student t-test for independent samples.Table 3 shows the overall results of Group 1 andGroup 2 on sub-scales 11th, 14th, 11th + 14th, KPDS anddifferences in overall results between the groups.Table 4 shows the statistical differences found be-tween Group 1 and Group 2 on the 11th sub-scale. Group1 has 56.7% more points than Group 2.Table 5 shows the statistical differences found be-tween Group 1 and Group 2 on the 14th sub-scale. Group1 has 79.7% more points than Group 2.Table 6 shows the statistical differences found bysummation sub-scale 11th and sub-scale 14th betweenV. Bili} et al.: Super-ego in Patients with Coronary Artery Disease, Coll. Antropol. 35 (2011) Suppl. 1: 127–131129TABLE 1DEMOGRAPHIC CHARACTERISTICS OF GROUP 1 AND GROUP 2AND THE RESULTS OF STATISTICAL ANALYSIS THERE OF(A)Group 1 Group 2 In total % PMale 40 (80%) 32 (64%) 72Female 10 (20%) 18 (36%) 28 0.075Marital statusMarried 42 (84%) 44 (88%) 86Single 3 (6%) 3Separated 1 (2%) 1 (2%) 2Widowers/widows 4 (8%) 5 (10%) 9 0.368(B)Number of children in the familyChildless 5 (10%) 2 (4%) 7One child 9 (18%) 9 (18%) 18Two children 22 (44%) 24 (48%) 46Three children 7 (14%) 6 (12%) 13Four children 5 (10%) 5 (10%) 10Five children 1 (2%) 1 (2%) 2Six children 1 (2%) 1 (2%) 2Seven children 1 (2%) 1Eleven children 1 (2%) 1 0.791**EducationIlliterate 1 (2%) 5 (10%) 6Unfinishedprimary school4 (8%) 6 (12%) 10Primary school 4 (8%) 9 (18%) 13Secondary schoolqualifications33 (66%) 25 (50%) 58Associate degree 3 (6%) 4 (8%) 7University degree 5 (10%) 1 (2%) 6 0.113TABLE 2RESULTS OF STATISTICAL ANALYSIS OF AGEFOR GROUPS 1 AND 2Group 1 Group 2 PAge (years) 60±8.1 57.3±11.2 0.167TABLE 3OVERALL RESULTS OF GROUP 1 AND GROUP 2 ON SUB-SCALES11TH, 14TH, 11TH + 14TH, KPDS AND DIFFERENCES IN OVERALLRESULTS BETWEEN THE GROUPSIn totalSub-scale11thSub-scale14thSub-scale 11th +Sub-scale 14thKPDSGroup 1 94 106 200 1479Group 2 60 59 119 1101Difference 34 47 81 378TABLE 4SHOWS THE STATISTICAL DIFFERENCES FOUND BETWEENGROUP 1 AND GROUP 2 ON THE 11TH SUB-SCALE. GROUP 1HAS 56.7% MORE POINTS THAN GROUP 2Arithmeticmean ±StandarddeviationMedianSub-scale 11thTotal pointsGroup 1 1.9 ± 0.4 2 94Group 2 1.2 ± 0.4 1 60T=8.09 df=98 p<0.001Group 1 and Group 2. The sum of the sub-scale 11th andsub-scale 14th of Group 1 was 68.1% greater than the sumof Group 2.Table 7 shows the statistical difference in overall re-sults of the KPDS of Group 1 and Group 2. Total scorethe KPDS of Group 1 was 34.3% higher than Group 2.Statistical analysis of the KPDS results showed sig-nificant difference between Group 1 and Group 2 onsub-scale 11th, and sub-scale 14th, the sum of the sub--scale 11th and sub-scale 14th, as well as the total numberof points the KPDS and in a way that Group 1 has signifi-cantly higher scores than Group 2.DiscussionIn this study, we explored the quality of super-ego aswell as psychosocial determinants of mental qualities,character and behaviour of coronary patients.Higher total score on the KPDS indicates more re-gressive psychic structure and object relations.Higher score on the KPDS sub-scale 11th 'degree ofpersecutory anxiety that comes from the super-ego' (per-secuting super-ego) is related to more regressive super--ego functioning.Higher score on the KPDS sub-scale 14th 'kind of rela-tionship with feelings of guilt’s, is related to problemswhich ego has in meeting demands of strict and punish-ing super-ego.From these results it is evident that significant num-ber of patients suffering from coronary disease has astrict super-ego, which is substantially different fromsuper-ego in control group. The results also show thatthe ego of coronary patients is largely occupied in meet-ing the requirements of strict super-ego, which draws itsenergy and limits functioning free of conflict. Such dif-ferences found expression for example in attitudes to-wards work, ambition, levels of life and professionalstress and family support. The requirements of strictsuper-ego exhaust ego and limit it in an optimal adapta-tion to reality. Strict super-ego affects workaholic life-style, prevents stress relaxation and change of lifestyle.It also has adverse impact on family relationships. Strictsuper-ego contributes to sense of failure because of theunconscious paranoid anxiety or depressive guilt.The results obtained are consistent with other re-ports, which do not specifically deal with the super-ego ofcoronary patients. Nasilowska-Barud17 in the study ofanxiety in men who had suffered myocardial infarctionfound that about 60% of patients have a high level of in-ternal tension, which was in connection with the conflictof the super-ego and the instincts. Nirkko18 and col-leagues found differences between the super-ego of pa-tients who died of myocardial infarction and patientswho survived. Bonaguidi19 and colleagues in patientswho had suffered an acute myocardial infarction havefound a significantly more rigid super-ego than in heal-thy control group.Results of the study confirm the initial hypothesisabout the presence of a strict super-ego in the group suf-fering from coronary disease.ConclusionA significant number of patients with coronary arterydisease has rigorous super-ego. Super-ego of patientswith coronary disease is more rigorous than the super--ego of patients in the control group. Super-ego is in-volved in the complex interaction of psychological factorswith other risk factors of coronary heart disease.R E F E R E N C E S1. BILI] V, super-ego u oboljelih od koronarne bolesti. PhD Thesis(University of Zagreb, Zagreb, 2006). — 2. FRIEDMAN M, ROSENMANRH, Type-A behavior and your heart (Knopf, New York, 1974). — 3. RO-SENMAN RH, Type-A behavior pattern: A personal overview. In: STRU-BE MJ (Ed) Type-A behavior (Sage, Newbury Park, 1991). — 4. BONA-GUIDI F, MICHELASSI C, TRIVELLA MG. CARPEGGIANI C, PRU-V. Bili} et al.: Super-ego in Patients with Coronary Artery Disease, Coll. Antropol. 35 (2011) Suppl. 1: 127–131130TABLE 5STATISTICAL DIFFERENCES FOUND BETWEEN GROUP 1 ANDGROUP 2 ON THE 14TH SUB-SCALE. GROUP 1 HAS 79.7% MOREPOINTS THAN GROUP 2Arithmeticmean ±StandarddeviationMedianSub-scale 14thTotal pointsGroup 1 2.1 ± 0.5 2 106Group 2 1.2 ± 0.4 1 59T=10.23 df=98 p<0.001TABLE 6STATISTICAL DIFFERENCES FOUND BY SUMMATIONSUB-SCALE 11TH AND SUB-SCALE 14TH BETWEEN GROUP 1AND GROUP 2Arithmeticmean ±StandarddeviationMedianSub-scale 11th +Sub-scale 14thTotal pointsGroup 1 4.0 ± 0.7 4 200Group 2 2.4 ± 0.7 2 119T=10.93 df=98 p<0.001TABLE 7SHOWS THE STATISTICAL DIFFERENCE IN OVERALL RESULTSOF KPDS OF GROUP 1 AND GROUP 2Arithmeticmean ±StandarddeviationMedianKPDSTotal pointsGroup 1 29.6 ± 5.6 30.0 1479Group 2 22.0 ± 4.8 22.0 1101T=7.28 df=98 p<0.001NETI CA, CESANAG, Psychological Reports, 78 (1996) 691. — 5. KLAINE, Psihoterapijski intervju. In: Simpozij o neurologiji i psihijatriji (Lek,Ljubljana, 1969). — 6. GRUDEN V, Psihoterapijski intervju. In: Psiho-terapija (Osnove psihoterapije) (Medicinska naklada, Zagreb, 1992). — 7.SANDLER J, Psychoanal Study Child, 15 (1960) 128. — 8. 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Bili}University of Zagreb, Zagreb University Hospital Center, Department of Psychological Medicine, [alata 4, 10000 Zagreb,Croatiae-mail: vedran.bilic2@zg.t-com.hrSUPER-EGO OBOLJELIH OD BOLESTI KORONARNIH ARTERIJA SRCAS A @ E T A KU ovom radu istra`ivali smo super-ego oboljelih od bolesti koronarnih arterija srca. Rezultati ovog istra`ivanja supotvrdili po~etnu hipotezu da zna~ajan broj bolesnika oboljelih od koronarne bolesti ima strogi super-ego. Izme|u bo-lesnika oboljelih od koronarne bolesti (N=50) i kontrolne skupine (N=50), na{li smo zna~ajne razlike u kvaliteti supe-rega i u stavu ega prema zahtjevima superega. Rezultati ovog istra`ivanja doprinose razumijevanju utjecaja psiho-lo{kih ~imbenika u koronarnoj bolesti.V. Bili} et al.: Super-ego in Patients with Coronary Artery Disease, Coll. Antropol. 35 (2011) Suppl. 1: 127–131131

Super-ego in patients with coronary artery disease [Super-ego oboljelih od bolesti koronarnih arterija srca]

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