LAS RACES PSICOLGICAS DE LA VIOLENCIA 1, 2 O animal possui uma agresividade, mas não há actos de violência propiamente definidos. E sua agressividade está limitada a um pré-requisito para o sustento, a defesa de su País e dentro da espécie, em conjunto com uma ordem de relacionamento para o apareamento. Violencia propiamente dicha, no hay si no es en el hombre. Jos Luis Lpez Aranguren Descargar o artculo O fenômeno da violência ha afligido a humanidade em toda sua história, convertida en una crnica de atrocidades e manifestações brutais que estão sendo sucedidas no transcurso de toda a vida. Qualquer perodo que analizramos é baado en sangue, saturado de guerras, crmenes, torturas y dems actos crueles orientados a infligir sufrimiento. Ltimamente, estes problemas se han visto fortemente agravados ao disponer a humanidade de mtodos de exterminio a bomba atmica capaces de aniquilar toda a forma de vida, no que se refere ao tema da violência do mar objeto de uma atenção especial e proliferar estudos sobre o tema Desde diferentes perspectivas. É possível que este recente inters por el tema mar porque é que existe uma maior sensibilidade frente ao mesmo, e por este motivo se intente esconder muitas das formas de violência e solo se ejetos por oculto Esto supondra um certo progresso da humanidade . O trmino da violência é usado para referirnos à prova de problemas da corrupção de tipo destrutivo, um abuso da força do poder para o malware ou subyugar aos dems. Odio es el trmino que designa os componentes afectivos como como o tipo de relacionamento do objeto que se estabelece. La complejidade do processo da violência e do polimorfismo de sus manifestações exige a pesquisa de mar multidisciplinar, investigado entre diferentes vrtices. A violência é capaz de enfocar como um indivíduo, por exemplo, a personalidade criminal como um fenomeno social, por exemplo, as subculturas da violência e as associações mafiosas e do ngulo político, por exemplo, a violência revolucionária, o terrorismo, a violência de las Instituições, la estatal, etc. A pesar de que todas estas formas de violência não estão comparadas. Estancos sino que mantem uma cierta interrelação e influência recproca, ya que como sealan J. Puget (1988) y Y. Gampel (1997) a violência social Inscreva-se na realidade psiquica, neste mercado necessario restante e exposto e cirúrgico aos psicologos da violência humana. Resumidamente, podramos considerar os pontos de vista em relação à teorização sobre as gestas da violência. Me refiero a las tesis instintivistas e as tesis ambientalistas. As quais se sustentan, no solo in base a argumentos cientficos, sino que se apoiam em gran medida em previas tomas de posicin ideolgica. Se trata de uma antiga controvérsia sobre a natureza humana, sobre su pretendida bondad o, por el contrario, su malignidad, e você pode se ilustrar com os critérios antagnicos de Thomas Hobbes e Jean-Jacques Rousseau. Enquanto isso para o primeiro estado do mundo do homem era o Bellum omnium contra omnes (Guerra de todos os todos) por um egocentrismo innato, para o segundo, o homem nace inocente e slo se corrompe e vuelve agresivo devido a a nefasta influencia da Sociedade. En el fondo, lo que impera é a gran resistência e reconocer que é o interior do ser humano, há recursos destructivos. Na atualidade, os representantes de ms aliviam as tesis instintivistas como Konrad Lorenz e Robert Ardrey, filho objeto de duras crticas por parte de Ashley Montagu, Geoffrey Gorer, Scott, Boulding, etc. acusados, injustamente, de querer perpetuar a concepção del Pecado original, e de esta moda de eximir ao homem de uma única responsabilidade por su agresividad. A su vez se lê o reprovador do defensor uma visin pesimista da humanidade, com o risco de conduzir a uma atitude de omissão das necessidades de transformações sociais e da creencia na imposibilidade de extirpar o mal. É como se considere que o reconhecimento da presença de elementos destrutores na natureza humana leva-se a uma conclusão que não seja modificável, negando as capacidades madurativas do homem para poder contender os impulsos primitivos e a possibilidade do cambio psquico. Tampoco tem en cuenta estes autores que, como postula Konrad Lorenz, junto aos instintos agresivos existem ritos vinculantes e de apaciguamento que impiden que a agresão intraespecífica revela um desenlace mortal, al menos en los animales. Em realidade, a agravação de um conjunto de funções: defesa do território onde se encontra a alimentação, orden jerrquico ao serviço da seleção natural, defesa da progênie, etc. mas dificilmente levado a la muerte, ms tudo todo lo contrario, la Agresin sera bsica para a supervivencia da espécie. O problema importante que se plantea é o homem, o ltimo peldao da escala evolutivo, o perdurar, os instintos agresivos ou as novas modalidades podem ser adquiridos ao processo de hominização. A violência no homem O psicoanlisis ha sido considerado, pode de forma excesivamente simplista, como uma concepção instintivista é uma afirmação que merece uma análise ms riguroso. En primer lugar, no is too coherente hablar de instintos em el hombre. En efecto, designamos como instintos uma forma de comportamento heredado, genrico, que se desencadena por meio de estímulos, internos, físicos, físicos, físicos, físicos, sociais, sociais, sociais, sociais, sociais, sociais. Evolucin del ser vivo. A pesar de todo, tambin existe a possibilidade de uma susceptibilidade especial a um certo aprendizagem nos animais ms evolucionados, sobre todo em lo que se tem denominado os perodos crticos, el imprinting, e que correspondem aos inicios de la vida e en en todos As circunstâncias externas de conformando o acuando os instintos. Para o homem Freud utiliza o trmino trieb que es ms traduzido por pulsin. Tal como se imprime, e que denomina um processo dinmico consistente em um impulso que faz o que é o organismo para a frente (Laplanche y Pontalis, 1971), si bem na pulsação para o elemento impulsionável, de embate o empuje , Ms que el de fijacin a un determinado fin. En realidad, trata-se de necessidades de potencialidades inatas, e de um grau elevado de plasticidad, que se desenvolve na ação de fatores de diferente ndole. Como escreve Freud (1912), El psicoanlisis nos ha llevado a prescindir de laestrills anttesis estabelecidas entre fatores externos e internos, entre o destino do indivíduo e su constitucin. Estudo do nível de plasticidad da medida das armas humanas, neste caso das agresivas, o que é a distância enorme do animal da agresividade. El bilogo Adolf Portmann (citado por D. Freeman, 1970) quando a pessoa está com os outros, como a pessoa que está com os demais, com a crueldade e a dificuldade, bem como a grande diversão de pessoas. Niveles animales. Como si hubiesen animales que hicieran um susconneres lo que se hacen os homens los unos a los otros. Precisamente aquino zologo ha de trazar uma clara linfa divisória: estas coisas malvolas, horribles, sem filho uma supervivencia animal transportada na transicina imperceptível do animal ao homem esta maldade pertencente a este lado da divisão de linha, é puramente humana. E estes estragos que causam a violência son debidos a la relativa independencia que o homem tem de sus pulsões, por assim dizer, por exemplo, no caso das pulsações agresivas, desvantagens para vnculos Sadomasoquistas. En esta misma direccin Hartmann e outros (1949) afirman que en el hombre las pulsiones estn mediatizadas por las funciones yoicas, y citan a Murphy que remarca como na espécie humana a inteligencia substituye o instinto. Psicoanlisis e violencia O reconhecimento da agresão como pulsão autônoma foi descoberto lento da teoria psicoanaltica. Respecto a este hecho Freud, en 1930, se sorprenda de su recarregar a idéia da existência de uma pulsação destrutora especifica no homem: Não comprendo como pudim passar por alto a localização da agresão sem ertica e da destruição, omitiendo asignarle A posicin que le corresponde na interpretação da vida. Y se preguntaba: Por qu hemos necesitado tanto tempo para decidir a reconocer a existência de uma pulsação agresiva. Em realidade, a importância da agresão como uma defesa contra o avanço do tratamento, foi contemplada desde os inícios do psicoanlisis. Um aspecto que atraiu a atenção de Freud foi o sadismo, como ficou de boca em boca para os ensaios de ensaios para uma sexualidade (1905), se bem em um momento para considerar como uma das pulsações parciais que formam parte da pulsação sexual. No deja de ser interessante, sem embargo, que é o mesmo, trabalhe e adiante, admitáve os impulsos para a crueldade, com o nacen de fontes de fato independentes da sexualidade e a relação com as pulsações de domínio. Se trata de uma afirmação que reaparece espórralmente em su obra, como em Pulsões e destino de pulsação (1915). Estima-se em uma obra de estúdio. Conheça um profundo estudo do odio e de su relacin com as frustrações do mundo. Externo, com os estímulos de desagrado que você recebe e que incita um intentar agredir e destruir os objetos que são filhos Das situações de malestar. Con estas formulações Freud se anticipa Algumas opções para os trabalhos da Escola de Yale sobre a frustração. Adems, Freud escrevem El odio es, como relacin de objeto, ms antiguo que o amor brota da repulsa primordial que o eu narcisista opone ao inicio da vida ao mundo exterior, que prodiga de estmulos. De esta forma, fica definida pela afinidade do odio com as pulsações de conservação, esto é, reconocem os defensivos da agresão. De todas as formas não foram ao ano 1920, en Ms all del principio del placer. Que as pulsões agresivas não estão a cargo de um estatus autônomo e sereno reconhecido por sua própria especificidade e independência. Segn Ernest Jones, al principio, a hipoteca da existência da agresiva como derivada e representante principal de uma pulsação autodestrutiva foi expressada com pouco convencimento por parte do mesmo Freud, como uma especulacin que trascenda a experiência psicoanaltica. Se trata de tratamentos de senhas, de sistemas de proteção de energia, de energia e de mecanismos de proteção do organismo, defraudamos e desvie para o mundo exterior, onde se manifeste como agresividad. Slo con el transcurso del tiempo Freud se aferr a esta conceptualizacin and the developed in the campo clnico. A pesar de todo, não encontrou uma grande aceptacin entre gran parte de psicoanalistas estas novas formulações tericas, a antítese entre as pulsações de vida e as pulsações de morte e a ltima instância representando a polaridade entre os processos anablicos e catablicos, e a luta Entre o amor e o odio como você está convidado. Empdocles: por Amistad convergen en Uno todas as coisas enquanto que, outras vezes, por odio de Discordia cada una diverge de todas A proposta de uma pulsação de morte, tal como foi postulada por Freud, Desencadear um intenso debate que persiste um homem de entre quem foi acolhido favoravelmente, e inclusive a evolução e aplicação da clnica como hicieron os psicoanalistas afins a la escola kleiniana, e os que, por o contrario, se opusieron a estes novos planteamientos tericos y Los rechazaron. En lo que s que hubo un acordo geral foi em uma necessidade de conceder a maior parte do tempo atencioso nos componentes corporativos e destrutivos da personalidade. Está interessado em saber o que é Freud, para o final de sua vida, tena algumas dudas sobre si a formulação de pulsações de morte como manifestacin primária de uma tendência autodestrutiva poda ser modificada. Strachey (1961) e as notas introdutórias ao Malestar na cultura lembrou uma carta de Freud del ao 1937, dirigida pela princesa Marie Bonaparte, na sugestão de que a agresividade está primariamente dirigida para o mundo exterior. El giro da pulsação agresiva para o interior, por descontado, a contrapartida do giro da libido para fora, quando passa dos objetos. Se podra imaginar um esquema segn el cual, originariamente, em todas as pulsações de vida são dirigidas para o investimento e toda a agresividad para fora, e que se estivessem cambiando no curso da vida. Posteriormente, Melanie Klein postul que tambin originariamente a libido estava orientada com os objetos externos, sim, por outro lado, mantém-se o fiel na consideração da agresão como uma externalização de pulsações autodestructivas. Esta divergencia entre psicoanalistas tem um paralelismo a nível sociológico, como se ha. Entre os partidários de negar uma agresividad inata no homem, e por quanto considerar a violência como o resultado de um processo de aprendizagem social, como Ashley Montagu, Geoffrey Gorer, etc. ha existido in vivo intros por descubrir sociedades com ausência de agresividad .......................................................... No obstante, este é o ponto essencial, se trata de estudos muito isolados, você pode limitar-se a avaliar a conduta externa, olvidando examinar a realidade psiquica. Em cambio, na investigação das fantasias diurnas e dos processos, a agresividade dos indivíduos sempre pode ponerse de manifiesto, ms o menos vehementemente. A observação simples dos jogos infantiles aporta dados esclarecedores sobre de sus impulsos violentos. Melanie Klein (1927) selar a analoga existente entre os jogos de nios pequenos em anlisis e alguns crmenes horribles que haban sucedido en nos tiempos. Expondr a continuação de uma vida útil que considero muito ilustrativa sobre a hostilidade latente e não se manifesta na latitude aparente. O paciente A. era um chico jovem com uma personalidade muito passiva, e que iniciou um tratamento psicoanaltico falando a fracaso escolar e uma intensa apata. Era filho nico, con um ambiente familiar muito infantilizador. O padre era um ativo fabricante, muito emprendedor e resolutivo que, além disso, estava com muita freqüência ausente do lar devido a um sus negócios, durante os ratos em que convivem com o filho era muito exigente e chave. La madre, muito sobreprotectora, tentativa de consolar na sua própria soledad a travs de trato como o filho, como si fora su pareja. A. era un filho dcil y obediente, que jams cre problemas e viva muito recluido no mundo, prcticamente sin amistades. O que é o que é mais importante para a criação de um grupo de empresas. Despus de probar diferentes tratamentos mdicos, su familia decidido por uma consulta, enviada por um dos mdicos que habam atendido ao chico. Al cabo de poucos anos de experiência, e durante a separação de uma semana de semana, teve um sueo muy violento que contrastaba com o seu comportamento fortemente inibido e apagado durante as sessões. A. so que: Estaba tumbado na praia, descansando cerca do mar. En la playa haban tambin otras personas desconocidas, y un a mo, mdico, com a esposa. De repente, de menor porte da superfície do sali un ser enorme y extrao. Era como um buzo de antiguos, dentro de uma escadaria, a cabeça em um casco de metal com uma janela de vidro frente aos olhos. Del casco sala un tubo que serva para receber oxgeno. Tambin poda ser como extraterrestre gigante. Aquel ser se dirigi amenazante haca la playa, causando um pavor extremo a todo el mundo, que huy, y yo tambin. Então pusemos uma perseguir a mis tos para embestirles. Meespert an espantado y temblando. Poco a poco, um par de parceria, pudins ir entendiendo su sueo. El ser gigante y extrao representatividade uma parte do paciente que não poda reconocer como própria, e a depositar em um ser alejado e estrambtico, como um extraterrestre. Era, adems, uma parte que é muito infantil, o que é mais fácil de usar. Se diriga contra o analista, representante dos pais, que durante o fim da semana e a sua própria parceira, e é o que é mais simbolizado pela parceria dos mdico unidos e atacados. Al cabo de alguns dos tantos outros, que vena um ser como uma continuação do anterior. Era durante a ditadura franca: Iba a la Universidad e eu encontraba com que o campus universitário estava tomado pela polícia que carregava brutalmente com porras, disparos de pelotas e fundos de humores contra os estudantes, os quais são os edifícios Universitários y se defenderam lanzando piedras y adoquines contra a polica. Eu me asustaba muito y me quedaba paralizado, sin poder mover-me para um lado para outro. No poda irme, ni meterme in the revuelta o tomar partido por algumas das partes contendientes. En este sueo podemos observar o conflito entre um supery muy cruel, representado por policiais, e uma agresividad defensiva ao serviço da supervisão representada pela rebeldia dos estudantes que intentam proteger as tendências na autoconservação, a afirmação e o desenvolvimento pessoal. Ele citou este caso por questões principais. En primer lugar, porque si bem as circunstâncias familiares estão intimamente envolvidas com a patologia de A. pode-se ver com claridade em o primer sueo a dura agresividad que le domina e que, adems, parece uma agresividad muy primigenia, que quase podramos catalogar de Fetal, por las caractersticas morfolgicas del buzo. En segundo lugar porque, tal como se observa em segundo lugar, é um caso em que nos observamos um grave conflito interno que cheguei a paralizar o paciente, sem poder de carga de situação. En este sueo se constata a presença de pulsões agresivas de muy diversa ndole. Por um lado, os objetos tiranos e destrutivos superiados, por outro, a agresividad autopreservativa de los estudiantes. Se trata do mesmo de gnero de pulsões O as diferenças qualitativas de estas de formas de agresividade dependem de outros fatores, como as personagens em que se tem concertado as pulsações agresivas y de vida. Un problema central que se plantea al abordar os fenmenos agresivos en general, o ms concretamente da violência, é cmo entenda a multiplicidade de formas em que se expressa, não nicamente em trminos de intensidade, sino tambin por sus diferentes peculiaridades e funções: autopreservativas , De domínio e bsqueda de poder, de realizacin perversa sadomasoquista, destructiva, etc. Esta heterogeneidad de pulsiones agresivas, que são a partir da literatura da destruição ou aniquilação do objeto, do próprio eu. A la expressin del anhelo de proteção do automóvel do objeto estimado, ha motivado que a nível superior dos enfoques tericos para dar uma explicação coerente a estas questões. Como, autores como Stone, Markowitz, Fenichel y Gillespie, entre outros, recusam a necessidade de admitir uma agresividad primária ou pulsional e bem como o agregado de diferentes actos com diversos orgãos, unidos pela natureza de seu impacto sobre os objetos , Por favor, por ms por sus efeitos. Outros autores em troca, e em uma lnea que continua com as sugestões de Freud, piensan que esta heterogeneidad responde aos níveis da qualidade nas comidas das mãos, das vidas e das mortes, teste quiz de forma mais simples. Provavelmente ms inexacta, prescindiendo de especulaciones de compleja verificacin, entre las pulsiones libidinales e agresivas. A mi modo de ver, esta segunda hiptesis é muito ms prxima a la clnica y pode explicarmos de forma muito ms plausível a diversidade de manifestações em que se expressa a agresividad. Participe de este ponto de vista tratar de exponer a sua própria concepção. Apresente a existência de diferentes classes de pulsações, Freud selar a necessidade de ter em conta a religião e os conflitos ou pugnas entre as mesmas na indústria laboral. En el fondo, todo acontecer vital venidero é presidido por su actitud conjunta io antagnica. Solamente por a accin concorrente ou mutuamente opuesta das pulsões primarias Eros y Pulsin de muerte, nunca por uma outra vez isolada, podemos explicar a multiplicidade dos fenmenos da vida (1937). Tambin seal Freud que en realidade, estas pulsiones quase nunca são apresentadas em forma pura sino que habitualmente estn fusionadas o misturas de forma diferente. Herbert Rosenfeld desenvolveu estas ideias e introduzindo o conceito de fusão patológica para descrever os processos em que são os impulsos liberadores de seres humanos submissos ou subordinados aos impulsos destrutadores, em que se encontram na fusão normal, os impulsos destrutadores, os que estão sendo subordinados e ao serviço de los Libidinales. Ele destacou-se que as pulsações no homem se caracterizam por su plasticidad, pelo fato de ser influentes por fatores de meio ambiente, sobre todo por as situações que afetam a primeira infancia. Desde o momento do nascimento, entre em contato com um processo incessante, entre o recinhecimento e o mundo externo, a travs dos mecanismos de introdução e criação, que é o bsico para o desenvolvimento e a organização da personalidade. A mente infantil se encontra em um lugar de fundo, de acordo com a internalização, ou menos distorsionada dos objetos externos, e, por isso, está distorcida. As situações de comodidade, bem-estar e destino, por o contrário, as de deslocamento e maldade, afetando a imagem do mundo que se vai construindo. Grotstein cree que as experiências suscitadas pelos estados de deslocamento são experientes como a invasin del self por un no-m. Melanie Klein (1934) escreve que é inevitável que a agresividad innata resultou incrementada por praças externas desfavoráveis e de forma inversa, que diminui por obra de amor e comprensão que recebe o nio, e estes fatores continuam atuando durante todo o desenvolvimento pessoal. As privaciones das necessidades emocionais e fsicas do infante não são sentidas como a ausência do objeto, como a presença de um objeto malo (a mãe) que inflinge dolor. Adems, en casos de maltrato infantil o problema se pode complicar devido à possibilidade de as identificações com o agresor. A identificação é uma forma primitiva de funcionamento mental e de vnculo objetal. Probável, um dos fatores ms influentes para que se constituyan subculturas da violência (Wolfgang y Ferracuti, 1971), é decir, territórios ou pases determinados onde a violência se manifestação de forma endmica, é o que é a causa de mecanismos identificadores familiares. Além disso, na forma de bandas violentas as identificações juegan a papel importante. Por um lado, por um lado, a identificação dos diferentes membros com o capito, que depositáve e suporta as capacidades de pensar, decidir e dirigir, e por outro as identificações recortadas entre estes membros, o nível de coerção grupal. O impacto de todos os fatores em toda a série, o que é mais difícil de aprender. Se trata de processos muito completos, em que é necessário implantar uma multiplicidade de eventos que estimulan que se fortalezcan o se atenhem os persecutorios e destruidores, por el contrario, sean los libidinales los que se afiancen. Como seala Ludwig von Bertalanffy, esta possivel destruição é debida a que el homem no vive, nicamente, em un nivel biolgico, sino que cria um universo simbólico no pensamento, a emocin, o lenguaje e a conduta. Y es en este universo simblico onde a violência, entre outras manifestações, adquiere unas caractersticas singulares privativas do ser humano, que desafortunadamente pode expresar um nível de sofisticação e de crueldad muito alejado de reações instintivas próprias de animais. Inclusão em grandes agrupamentos humanas com cierta freqüência ha existido uma idealização da violência, como tem expressado alguns poetas futuristas entre os que sobresale Filippo Tommaso Marinetti, que se torna um afiliado ao fascismo, e quem afirma que a guerra é a devuelve a las razas A virilidade perdida nas masturbações refinadas de velhas civilizações. La guerra, para Marinetti, significaba o herosmo, o amor ao perigo, o ensalamento da força e, como seala Fredric Wertham, o que é mais importante e irracional: a violência esensor como un argumento. Niveles de la conducta violenta Como você está ciente, as pulsações agresivas estn fusionadas com as libidias, o que é a empresa que é a empresa que está em condições de manter entre as diferentes categorias de pulsações e por as peculiaridades da aliança Relacin que mantengan entre s. Outro aspecto a tener em conta é o de pulsões e dirigidas para o auto para o mundo objetal. De acordo com estes pontos de vista, podramos descrever diferentes níveis bsicos u organizações mentais em que se expressam a forma em que se realizou a fusão ou a defusin pulsional. A referência a níveis u organizaciones não existe, alude a configuraciones mentales estables, de tipo caracterolgico, sino tambin a cuasas constelações mentais que se estruturan em momentos concretos e limitados, devido à presença de diferentes fatores, e que explicam a irracionalidade de alguns estados afectivos Y determinadas conductas. Existen situações de conflito pessoais e sociais que favorecem a mudança de comportamentos embrionários violentos. Me refiero principalmente a estallidos de guerras o revoluciones, onde o supery colectivo sufre uma radical transformadora e a proibição de matar se convierte na obrigação de exterminar a los enemigos. Esta transmissão de valores é propiciada por desenfrenagem de uma violência extrema e polimorfa, na que incluso participou pessoas que em perodos de tranquilidade social se haban comportado plcidamente. Isto não significa que todo o mundo se sume a cometer estas exibiciones violentas. Arthur Hyatt Williams, que antes de ser psicoanalista haba sido mdico militar, justo na guerra de Birmania durante a segunda guerra mundial e eu comunicamos informações interessantes observações que efectuam de diferentes combatientes. La guerra na jungla birmana tenia caractersticas próprias. Era uma luta de guerrilhas, na que os combatientes de um e outro estavam escondidos nas profundidades da selva e se atacaban por sorpresa, por lo que cada combatiente se daba perfecta conta dos inimigos que habam matado com sus disparos. Por la noche, a reunir a guerrilha, se comentou a luta e enquanto que alguns soldados se mostraban por causa dos japoneses e os que estão falando sobre a vida, pensando no que diz respeito ao fato, , De tipo manaco, las muertes que haban realizado. É direto, que, enquanto que alguns matá-los em defesa própria e dos valores que sustentam, e são responsáveis sententes de seus atos, habam outros soldados que vivem como um acontecimiento propício para exercitar uma violência de forma aberta, sem trabas e con a Vantagem de que não estava solo justificada, sino que até poda ser premiada. Se definish, de esta moda, das formas diferentes de agresin, da carcter autopreservative e da violência destrutiva, tal como se pona de manifiesto no segundo nível de A .. Em mi opinin, estas diferenças reposan en profundas estruturas mentais, y adems Plantean graves problemas sociales, por lo que ms avançar intentar efectuar uma descrição detalhada de pontos de vista sobre estes temas. De momento slo quisiera sealar que en la agresin autopreservativa los impulsos agresivos estn sometidos a las pulsiones libidinales que são o incitação ao processo de sublimação. Por este motivo, os impulsos primitivos se reorientan a la bsqueda de novos finos e objetos de moda que a agresin se pone, por um lado, ao serviço da maduracça, afirmando o reconhecimento do mundo pessoal, por outro lado, intentando consolidar y afianzar Unos valores e interesses sociales. Enquanto esta forma de agresividad responde a uma finalidad de ndole defensiva frente a as amenazas externas, a violência destrutiva, que pode adquirir mltiples modos de expressão e resposta a diferentes motivações, tem como finalidad infligir dao o subyugar al objeto. Esta violência própria do homem, e a sua vida é a história pessoal, está no domínio do narcisismo, com desespero e falta de preocupação pelo objeto. Um modo de preparação para a exposição, e apesar de não estar em busca de tipos de perfis, você pode se adaptar a um tipo de violência a outro, podemos agrupar a violência destructiva em quatro grandes apartados que respondem a uma continuação : Reaccin frente a um perigo interno, organizador mental sadomasoquista, defusin pulsional e sobretodo, por su gran trascendencia social e as problemáticas que plantea, a motivada por influencias situacionales. Reaccin frente a um perigo interno Contrariamente a as opiniões comnmente admitidas, Freud (1916) postul que la relacin culpadelito se poda invertir en muchos casos. No era el delito el que generaba sentimientos de culpa, sino que existan previamente unos sentimientos de culpa de origen desconocido para o sujeito vinculado à la situacin edpica que incitaba um cometer el delito, bsicamente por does por um lado, para poder concretar la Culpa y, por el otro, para a bsqueda de castigo expiatorio. Antes se ha mencionado como las ansiedades frente a las pulsiones de muerte, actuando en el interior de la mente, pueden llegar a no ser tolerables, por lo que el yo las intenta desviar hacia el exterior en forma de agresin. A pesar de las dudas que suscita la aceptacin de una pulsin de muerte, lo que parece indudable es que la accin intimidatoria de un supery muy arcaico adquiere una dramtica importancia en el origen de ansiedades extremadamente persecutorias y generadoras de culpa insoportable. La desviacin hacia el exterior de las pulsiones destructivas, no solo es debido al propsito de evitar las amenazas internas, sino que tambin se proyecta en el exterior al perseguidor interno para conseguir librarse del mismo, y de esta manera poder controlarlo y atacar para aniquilarlo. Un episodio paranoide, del cual fui testigo, va en esta misma lnea. En una ocasin un individuo que haba asesinado precisamente al polica que le vigilaba, por sus antecedentes y las sospechas que despertaba, me dijo con un tono muy convencido y de forma sigilosa: durante mucho tiempo, y paseando por la calle vi que me segua la misma persona. Como es lgico, empec a sospechar que tramaba algo, asesinarme clavndome un cuchillo por la espalda, o algo as, de forma que decid librarme de este hombre. Sbitamente me tir encima de l y le hund mi navaja en su pecho. Cuando la proyeccin encuentra obstculos imposibles de superar, como ocurre en situaciones de aislamiento, la amenaza interna puede adquirir caractersticas verdaderamente terrorficas como, por ejemplo, el temor de volverse loco presente en los presos recluidos en celdas de aislamiento. En entrevistas realizada en la crcel, diferentes presos me han confiado el profundo pnico que les inspira el que les encierren en estas celdas: su miedo a la locura. Y esto es quiz ms frecuente e intenso en presos con una personalidad conflictiva y un historial delictivo grave. Cuando se les priva de la continua actuacin a la que les lleva su ansiedad y quedan en una situacin de incomunicacin, les invade el miedo a la enajenacin mental. Es como si hubiesen de huir perpetuamente de ellos mismos, descargando su ansiedad por las vas motrices. Es tambin la ansiedad lo que les estimula a la ingesta de drogas, como forma de adormecer la mente y vivir en un mundo ms insensible, opaco y con sensaciones ms sosegadas. Por este motivo, la privacin brusca de la droga puede desencadenar en un individuo adicto una reaccin extremadamente violenta. Una breve vieta clnica puede ilustrar la importancia de la presin superyoica en el desencadenamiento de una brusca crisis violenta. P. era un chico joven que inici una psicoterapia por sus problemas de conducta. Adems de fracaso escolar, cometa pequeos hurtos bolgrafos, caramelos, objetos de escritorio, etc. en las tiendas de su vecindad, eligiendo sobre todo aquellas de las que su familia era cliente, como si desease ser descubierto, y que sus padres se enteraran de sus actividades y le castigasen. Tambin, a menudo se peleaba con sus compaeros y casi siempre se llevaba la peor parte al elegir a los ms forzudos. P. tenia unos acentuados y vagos sentimientos de culpa, que llevaban aparejada una necesidad de castigo. El padre de P. era un hombre de gran fortuna, que controlaba cuidadosamente y con cierta tacaera. Era muy viejo, enfermo y un poco invlido, y se pasaba la mayor parte del da metido en cama. P. era el mayor de una familia con pocos hermanos. Era el favorito de la madre, una mujer aun joven y muy angustiada, con quien mantena una relacin simbitica. Un da, mientras la familia coma junta, el padre atendi una llamada por telfono de un tendero que se quej de que P. haba vuelto a robar en su tienda. El padre, disgustado y con un tono dolorido, recrimin al hijo dicindole: Tu, lo que quieres, es matarme a disgustos. La respuesta de P. irritado, fue lanzar con clera un cuchillo que tenia en la mano contra el padre, como si se lo quisiese clavar. El padre, afortunadamente, se pudo apartar y as evitar ser herido. El anlisis de este suceso puso en evidencia que la incriminacin del padre de que el hijo le matara, determin que la figura paterna ocupase el lugar de un supery acusatorio. Muchas veces el hijo se haba sentido culpable por la vejez y enfermedad del padre, como si l fuera el culpable debido a los ataques verbales o de pensamiento que le haba infligido, as como por el hecho de tener a la madre tan copada. Ante la recriminacin del padre, P. sinti una culpa insoportable ya que pona al descubierto sus celos y encarnaba la realizacin del deseo de disponer para l slo de toda la dedicacin y el afecto de la madre. El ataque contra el padre, en realidad, representaba un ataque a su supery que le criticaba severamente por abrigar en su interior estos deseos prohibidos y que le humillaban. Toda la escena se constituy como una herida narcisista que desencaden una furiosa crisis destructiva. No se trataba de una simple rplica a quien ha lanzado un agravio, sino de una reaccin ms profunda, una respuesta al dolor que puede significar la prdida de la autoestima producida por la ofensa al propio narcisismo. Los acontecimientos que afectan el equilibrio narcisista, fcilmente pueden desencadenar reacciones violentas. En muchos conflictos sociales graves, los problemas de tipo narcisista juegan un importante papel ya que, a pesar de que puedan responder a otras motivaciones econmicas, polticas, etc., los factores psicolgicos en conexin con los aspectos narcisistas de la personalidad, que estn en la base de ciertas efervescencias pasionales, adquieren una enorme importancia. Freud (1917) describi un fenmeno que nombr con el ttulo de el narcisismo de las pequeas diferencias, y que ampli ms tarde (1930) y que hace referencia a los sentimientos de intensa hostilidad que pueden quedar reprimidos y por tanto inconscientes y que se oponen a los sentimientos de confraternidad que seran propios de grupos o individuos vecinos con una cierta convivencia. El destino de estos sentimientos de enemistad puede ser diverso, aunque las consecuencias son similares. Pueden crear situaciones extremadamente conflictivas, como el racismo, el maltrato a la mujer, la lucha entre comunidades con distinta religin o tipo de creencias, etc. Los graves problemas que pueden surgir responden, bsicamente, al temor a la prdida de la propia identidad, a confundirse con el extrao, con quien, por otra parte, se siente cierta afinidad y el odio es una forma de tomar distancia, un intento de autoafirmarse. Por este motivo retrata una actitud propia de individuos con un sentimiento de identidad poco consolidado, y escasamente delimitado. Tambin es posible que los impulsos agresivos sean desviados hacia nuevos objetivos con tal de mantener la cohesin social. Es de sobras conocido que en momentos de crisis social buscar un enemigo o emprender una accin blica es una actitud que ha sido utilizada por bastantes pases para intentar mantener la paz interna. Entre nosotros, durante la poca de la dictadura franquista, cuando las protestas sociales iban en aumento, a menudo se hacan reclamaciones sobre Gibraltar para desviar la agresividad hacia un pas extranjero. En trminos similares, Franco Fornari ha considerado que la guerra representa una institucin social con una funcin defensiva frente las ansiedades paranoides y depresivas que existen, con mayor o menor intensidad, en todo el mundo, y que si bien aparentemente se presenta como una defensa contra peligros externos es, en realidad, una defensa contra peligrosas fantasas internas inconscientes. Estrechamente vinculados con el problema del narcisismo de las pequeas diferencias existen los casos en que la agresin se ejerce contra las personas que pueden representar aspectos rechazados de uno mismo. Z. era una chica joven con grandes necesidades emocionales que intentaba negar, debido a las mltiples frustraciones que haba sufrido desde su tierna infancia. Para sentirse segura, se haba construido una imagen de s misma como de alguien que se bastase por s sola. En la relacin transferencial haba un constante uso de la identificacin proyectiva. La negacin de la dependencia se manifestaba ostentosamente. Actuaba intentando despertar curiosidad, hablaba de forma ambigua incluso dando a entender que haba muchos hechos que no explicaba a menudo llegaba con retraso, hacindose esperar, y las primeras vacaciones las adelant un par de das. En las relaciones de pareja era muy seductora, intentando cautivar al hombre, y cuando consegua que su pareja dependiese de ella, se desenamoraba, ya que su pareja pasaba a representar los aspectos dependientes que odiaba. Entonces, empezaba a maltratarlo hasta que al fin lo abandonaba. El uso patolgico de la identificacin proyectiva tambin tiene una dimensin social que explica la perpetuacin de ciertos regmenes violentos, fundamentalmente en pases poco desarrollados. Citara, a modo de ejemplo, los tpicos golpes de Estado destinados a derribar un tirano y que, en caso de tener xito, es frecuente que a pesar de las promesas de libertad solo implique la sustitucin del antiguo dspota por otro de idntica condicin, que instaura una nueva dictadura. Friedrich Schiller, en la tragedia La conjuracin de Fiesco dramatiza admirablemente este riesgo. Para evitar que Fiesco se pueda convertir en un nuevo dictador, el conjurado Verrina, el amigo de Fiesco, lo asesina una vez que ste ha vencido al antiguo dictador Andrea Doria. Las relaciones entre el poder y el ejercicio de la violencia son algo que ha sido reiteradamente sealado, as como tambin el hecho de que mantener alguna forma de poder se presta a su abuso y a que se estimulen los aspectos regresivos de tipo destructivo de la personalidad, en gran parte por la inmunidad que otorga. Los estudios de Philip Zimbardo, a los que me referir ms adelante, corroboran experimentalmente estas opiniones. En un artculo anterior (Bassols, 1980) intent perfilar diferentes formas de poder, huyendo de criterios polticos y de legitimidad, centrndome nicamente en los aspectos psicopatolgicos, es decir, en los estados mentales en que se apoyan. Distingua entre las formas sanas o al servicio de la maduracin, basadas en unas capacidades y conocimientos y, por tanto, que solo afectaban a aspectos parciales de la relacin y que tendan a anularse progresivamente propias de la posicin depresiva, y las formas en que predominaba la explotacin violenta y el ejercicio del dominio sobre los otros, propias de la posicin esquizo-paranoide. Organizacin mental sadomasoquista He puesto sadomasoquista porque son dos componentes de una misma personalidad en que la presencia de uno implica a su vez la presencia del otro, lo que no impide que exista un predominio de uno u otro, y que el restante est en estado larvado o inconsciente. Aqu, por la orientacin de este trabajo, me ocupar nicamente de los elementos sdicos. Al sadismo en la actualidad se le ha dado un significado ms amplio que el de una perversin sexual. Entendemos por sadismo el abuso de poder que conduce a infligir dao fsico o moral, como malos tratos o humillaciones a otros seres, para obtener una satisfaccin, sentido de dominio, de superioridad, sexual o de sexualidad inconsciente, etc. Lo que define estos estados mentales es la fusin patolgica de las pulsiones, la primaca de las pulsiones destructivas, que establecen una alianza perversa con las pulsiones libidinales, las cuales quedan subordinadas a las agresivas y proporcionan el elemento de fruicin al perpetrarse actuaciones violentas. Al quedar los aspectos libidinales del self atados o en complicidad con los destructivos, las capacidades de vida y de crecimiento mental quedan paralizadas. Para Donald Meltzer, en los estados mentales donde reina el sadismo, se quiere crear un mundo que es el negativo del de la naturaleza, un mundo de no-vida, donde no existen las grandes angustias de los que estn vivos y constreidos por sus lmites. Se tratara, por tanto, de defensas manacas: No es la sensualidad lo que se codicia, sino la triunfante abolicin de la angustia depresiva, y aun de la persecutoria, aunque de la depresiva sobre todo (Meltzer, 1974). Estas defensas manacas que se utilizan ofrecen gran fascinacin. La proliferacin de espectculos de personajes reales o irreales perversos, los temas crueles y la asistencia multitudinaria de pblico que reciben avala este atractivo (el boxeo en muchos pases, adems de otras fiestas sangrantes). Muchas veces queda restringido nicamente a la mera contemplacin, aunque en ocasiones y ciertas personas pueden inducir al paso a actitudes sdicas. Hyatt Williams ha llamado la atencin sobre muchos crmenes que han estado precedidos por periodos en los que se ha cultivado el uso de armas violentas y otros utensilios ofensivos o belicosos, acompaados por fantasas diurnas de carcter violento y la tendencia a frecuentar espectculos brutales como si el futuro delincuente buscara estmulos externos para cometer sus delitos. Esto, adems, como es de fcil observacin, tambin est vigente a un nivel colectivo de ciertos Estados el cultivo primordial de armamento previo a una aventura blica. La organizacin mental sdica es de ndole narcisista, con absoluto desprecio y falta de preocupacin por la vctima, sin sentimientos de culpa o de compasin por el dao que se le ocasiona, incluso puede ser motivo de burla, todo lo cual hace que nada impida la ejecucin de la violencia. Para el autor de una violencia sdica lo nico que es imprescindible es que la vctima padezca un sufrimiento, que es lo que le provoca excitacin. Un problema muy preocupante es que los comportamientos sdicos pueden estar activos en pocas precoces de la vida, en nios y nias al inicio de la pubertad e incluso antes. En muchas clases escolares de nios de estas edades se presentan actitudes de desprecio y asedio moral hacia alguno de los escolares, de forma crnica y prolongada durante mucho tiempo. De pronto, un grupo dirigente deja de comunicarse con un escolar, no le contestan, prescinden de l en los juegos, hacen como si no existiera o se burlan y hablan groseramente de l manifestndole una abierta hostilidad. Un conjunto de actitudes que han sido definidas como mobbying (acoso laboral) o bullying (acoso escolar), y que con la aparicin del Facebook ha tenido una mayor difusin al facilitar las comunicaciones entre escolares. Las causas pueden ser mltiples y los motivos desencadenantes a veces son nimios. En ocasiones se puede elegir la vctima por tratarse de un nio apocado y tmido, pero tambin puede ocurrir con estudiantes brillantes y emprendedores, debido a la envidia que pueden despertar. Tambin puede ser motivo de bullying el hecho de introducir un nuevo compaero en un grupo de clase ya formado, o que el asediado pase por momentos difciles, enfermedades familiares, familia desestructurada, etc. En el bullying . el grupo violento en general est formado por nios mediocres, en ocasiones muy forzudos. La vctima, ante una situacin de este tipo, puede sufrir trastornos mentales graves, depresin, prdida de todo inters y de la autoestima. Por ltimo, existen los compaeros de clase que generalmente consienten la situacin por miedo de que si ayudan a la vctima van a ser tambin motivo de asedio. En el fondo, es una situacin muy parecida a la de muchas poblaciones adultas. Una caracterstica frecuente en las personalidades sdicas son los vivos sentimientos de resentimiento por las muchas injusticias que creen haber sufrido. Se trata de injusticias la mayor parte reales, aunque tambin otras son imaginarias, pero todas tienen como principal funcin disculpar al delincuente por sus actividades violentas. Bastantes presos en la crcel se dedican a escribir sus biografas, memorias, poemas, proyectos de reforma del rgimen penitenciario, etc. Un hecho que he podido constatar en la abundante produccin literaria que me han entregado delincuentes con un cargado historial sdico, es que nunca aparecen sentimientos de culpa sino, por el contrario, una amplia exposicin de agravios, con gran rencor y odio. Muchos de los tatuajes que habitualmente se hacen practicar los presos aparte del popular amor de madre son tambin una ostentosa exhibicin de impulsos violentos. Por esta razn, un sdico puede estar buscando vengarse de forma indiscriminada de una sociedad que ha sentido muy hostil, lo haya sido o no. Hace muchos aos, cuando colaboraba con una institucin dedicada a la reinsercin social de delincuentes, tuve ocasin de estudiar a un joven atracador que nombrar D. Era un chico de gran corpulencia y que trataba a sus vctimas de forma despectiva y sdica, con continuas amenazas y burlas. D. era el supuesto cabecilla de una pequea banda, compuesta por cuatro o cinco miembros, que cometan sus asaltos en un barrio residencial y preferentemente los sbados por la noche. Debido al hecho de actuar siempre en un rea limitada, fue fcilmente detenido gracias a la vigilancia que mont la polica. Lo que sorprendi es que una vez detenido se mostrase aterrado y se pusiera a llorar como un nio. La imagen que se tenia de l cambi radicalmente. En lugar de un chico sdico, que disfrutaba causando pnico a los viandantes, a las parejas elegantes, que eran sus vctimas predilectas, a las que insultaba y amenazaba exhibiendo un peine metlico que haba afilado y que acercaba a los rostros de los atracados a los que alguna vez incluso haba causado algn ligero araazo en la cara, se mostraba como un chico inseguro y tmido. Despus, se supo que trabajaba de camarero en un restaurante donde era muy obediente, con una conducta muy correcta y respetuosa. Era el hijo pequeo de una familia de dos hermanos. El padre y el hermano mayor eran personas agresivas, independientes y que ejercan un oficio muy duro y se burlaban de D. al que despreciaban debido a que lo vean muy dependiente de la madre. La madre tambin haba sido camarera de joven en un restaurante, y era una persona muy dominante que haba deseado que su segundo hijo hubiese sido una nia. Este deseo haba afectado a la relacin con D. que aunque de forma penumbrosa, se haba sentido poco aceptado en su sexo. D. haba sido un nio solitario y con pocos amigos, que en los inicios de la adolescencia iba slo al cine los domingos donde haba sufrido dos agresiones homosexuales y que al fracasar en los estudios la madre le haba colocado de camarero. D. viva sometido a la madre, idealizada y a la vez persecutoria, y luchaba internamente entre el deseo de continuar bajo su dependencia y el deseo de afirmar su personalidad y su virilidad. El conflicto interno se resolvi en la adolescencia adoptando una doble vida, como la del Dr. Jekyll y Mr. Hyde. Durante la semana predominaban las identificaciones con los deseos maternos, cumpliendo sus obligaciones pasivamente y con docilidad en el restaurante, y durante los fines de semana se opona activamente a adoptar esta actitud y deseaba mostrar una masculinidad violenta y sdica. En realidad, el dinero producto de los atracos se reparta entre los otros compaeros de la banda, sin que l participase del reparto, ya que l tenia un sueldo adems de las propinas propias de su trabajo. Ms que ser el lder del grupo, era alguien utilizado por los compaeros que lo estimulaban a ocupar el lugar de mayor riesgo debido a su corpulencia. Para D. esto era una situacin muy satisfactoria, ya que lo que verdaderamente le apeteca era sentir las vctimas atemorizadas y contemplar la cara de terror que ponan, hecho que le proporcionaba una gran sensacin de poder. De esta manera, por medio de las identificaciones proyectivas, poda depositar en las personas asaltadas su parte de nio dbil e indefenso. Hyatt Williams insiste en que cuando los elementos crueles no pueden ser mitigados por los aspectos libidinales del self . tiene lugar una disociacin que provoca que el individuo se comporte como si tuviese dos diferentes personalidades: una brutal y violenta, y otra amable y con capacidad para sentir amor, como en la mencionada disociacin: Dr. Jekyll y Mr. Hyde. Hay ocasiones en que las dos actitudes pueden manifestarse hacia la misma persona, si bien en otros casos existen elecciones claramente diferenciadas para cada una de las actitudes. Un ejemplo tpico es el del miembro de una pareja que maltrata a su conyugue, mientras es complaciente y afable con su amante, o el marido que es impotente con la esposa y en cambio puede ser sexualmente activo con prostitutas. Tambin en el terreno de los negocios o del trabajo podemos observar estas disociaciones con cierta frecuencia. Personas muy correctas en el mundo familiar yo social, y capaces de hacer graves deshonestidades cuando se trata de asuntos econmicos. Esta posibilidad de que un individuo exhiba una distinta personalidad segn determinadas circunstancias, explica el elemento sorpresa, casi de incredulidad, con la que las amistades o conocidos de alguien acusado por un crimen puede recibir las noticias del hecho. Herbert Rosenfeld (1990) describe el caso de una de sus pacientes, mdico generalista y en ejercicio adems como psiquiatra, casada y que pareca feliz en el matrimonio, con buenas relaciones con el hijo y los padres, que tenia en su personalidad una parte criminal y destructiva de la cual su psicoanalista slo se enter, igual que el propio marido, por la noticia que dieron los peridicos de su detencin por la polica por dedicarse al trfico de drogas. Lo que resultaba ms sorprendente es que daba la impresin que mostraba una gran preocupacin e inters para ayudar a sus pacientes. En muchos casos la culpa es negada e incluso pueden idealizarse perversamente las partes criminales de la personalidad, con lo cual los problemas existentes pueden hacerse ms graves ya que el sujeto puede adherirse fanticamente a creencias irracionales destructivas o sdicas, lo que favorece que se dedique a actividades altamente antisociales y malignas como el terrorismo, la tortura, etc. Mientras, por otro lado, contina con sus ocupaciones habituales, intentando anular la culpa y teniendo una vida aparentemente normal. De todas formas, es difcil que las consecuencias de su conducta perversa no se inscriban, aunque sea de forma inadvertida, en el fracaso del proceso de integracin y de maduracin personal, deteriorando al sujeto psquica o somticamente. Precisamente en la obra teatral La doble historia del Doctor Valmy . Antonio Buero Vallejo aborda con gran sutileza el tema de un torturador, miembro de la polica poltica, con buenas relaciones familiares, pero que de resultas de sus actividades de torturador deja castrado a un preso poltico. A pesar de no lamentar ni arrepentirse de su accin de forma consciente, y sin relacionarlo, el torturador lo expa con la aparicin de una impotencia sexual de origen psquico. He conservado el ttulo que utiliza Philip Zimbardo para referirse a este tema, a pesar de que mis puntos de vista sobre estos fenmenos difieren sensiblemente de las suyos. Los graves problemas ticos que ha atravesado la sociedad estos ltimos aos, los terribles horrores de los genocidios, los asesinatos de colectividades enteras, las torturas en lugares de reclusin, crmenes contra la humanidad, vejaciones de toda clase con una absoluta falta de respeto por la vida humana y por su dignidad, han estado efectuados por gobiernos, principalmente los tirnicos, con la colaboracin o el silencio de gran parte de la sociedad. Lgicamente, estos graves hechos han atrado el inters de mltiples disciplinas que se han interesado en investigar sus motivaciones profundas. En este apartado intentar analizar los estudios psicolgicos que me parece gozan de mayor garanta y nos permiten una aproximacin al salvajismo imperante de una violencia desenfrenada. Stanley Milgram (1963), preocupado por la pasividad del pueblo alemn y su obediencia a los crmenes de Hitler, realiz un experimento muy interesante en la Universidad de Yale para detectar hasta qu punto las personas pueden sentirse obedientes a las autoridades. Mediante anuncios, Milgram consigui que cuarenta varones se prestaran a colaborar en un estudio sobre la memoria y el aprendizaje, aunque con este ttulo disimulaba el verdadero objetivo del experimento: el estudio de las actitudes obedientes ( Behavioral study of obedience ). Las personas que se ofrecieron para participar representaban a la poblacin normal de New Haven (EE. UU.), desde simples jornaleros a personas con ttulo universitario, a los que se les pag por su colaboracin. El experimento consista en investigar la influencia del castigo en el aprendizaje. Para esto, Milgram dividi el personal en maestros y en aprendices mediante un sorteo apaado de forma tal que los sujetos que participaban quedaron seleccionados como maestros, mientras que unos cmplices del experimentador hicieron de vctimas o aprendices. Una vez hecha la seleccin, maestro y alumno pasaban a una sala contigua, donde el alumno era sujetado con correas a una especie de silla elctrica, donde recibira descargas elctricas cada vez que cometiese un error de aprendizaje. Las descargas elctricas iban subiendo de intensidad ante los errores del alumno, y eran aparentemente cada vez ms dolorosas. En realidad, las descargas de electricidad eran fingidas y los aprendices hacan teatro quejndose horriblemente del dolor. Lo que interesaba en el fondo era ver cmo los maestros obedecan al aplicar un mtodo torturante, obedeciendo las rdenes del experimentador que instaba a continuar aplicando el suplicio ante les presuntas equivocaciones de los aprendices. Entre los maestros se observaron grandes inquietudes, temblores, sudores, morderse los labios, todos sntomas de su gran inquietud. En catorce casos hubo, entre los que hacan de maestro, risas y carcajadas extraas fuera de lugar, como si intentasen descargar su tensin interna. Un caso tuvo que ser interrumpido por nerviosismo extremo del maestro. Un hecho inesperado fue que ninguno de los casos se tuvo que detener antes de llegar al nivel de shock de 300 voltios, cuando las victimas parecan sufrir intensamente, empezaban a patear la pared y no respondan al maestro. Solo cinco de los 40 maestros se negaron a obedecer rdenes y prolongar el experimento aumentando la dosis de las supuestas descargas. Cuatro aplicaron otra descarga, dos interrumpieron al nivel de los 330 voltios, uno a los 345, otro a los 360 y, finalmente, uno a los 375 voltios de descarga. Es completamente sorprendente ver el alto nivel de obediencia, ya que solo catorce personas (el 35) se rebelaron y se negaron a continuar, y aun, en ciertos casos, de forma muy tarda. Es notable observar la gran tensin en muchos de los obedientes que manifestaban gran inquietud, temblores, etc. y que, sin embargo, continuaban aplicando descargas. Al momento de finalizar el estudio respiraron relajados, sintindose aliviados, cuando hubiesen podido interrumpir el experimento renunciando a la escasa ganancia econmica que perciban. Da la impresin de que a nivel externo se dramatizaba el conflicto interno entre los aspectos violentos del self . puestos mediante la identificacin proyectiva en el experimentador, y sus partes sanas que se oponan a continuar las torturas a los aprendices. Lo que resulta muy negativo es que en la mayora de casos triunf la parte sdica. Como dijo Erich Fromm, este experimento es muy interesante, no solo como estudio de la obediencia y conformidad, sino tambin de la crueldad y destructividad. De igual manera, son importantes los estudios de Philip Zimbardo (1973) quien efectu unas interesantes y demostrativas experiencias que a mi parecer complementan las de Milgram. Sus estudios proporcionan datos tangibles, a pesar de que creo deberan ser objeto de una reinterpretacin, sobre la influencia de la ubicacin o emplazamiento en la escala de la jerarqua social, como inductora quedando siempre un sector de libertad de las elecciones identificativas que efecta el sujeto. En sntesis, el experimento de Zimbardo y otros consisti en un estudio en el que se intentaba valorar en qu medida un entorno institucional poda influir sobre las disposiciones internas de las personas que habitaban en este entorno. El tema que escogieron para realizar esta investigacin fue el carcelario, estudiando el comportamiento de unos supuestos presos y guardianes, y cmo el ambiente determinaba unos cambios disposicionales. Todos los participantes fueron seleccionados a travs de un anuncio en el que se pedan estudiantes voluntarios para participar en una investigacin psicolgica sobre la crcel, cobrando un sueldo de quince dlares diarios. Se dividieron a los voluntarios, mediante el azar, en dos grupos: uno de carceleros y otro de reclusos. Dejo al margen un conjunto de detalles del escenario que ya desde el primer momento pretendan degradar y despersonalizar a los presos, como el hecho de tener que ir con muy poca ropa y, adems, de tipo femenina. Al cabo de unos pocos das, algunos de los participantes que ejercan de guardianes, aproximadamente la tercera parte, se haban identificado con su papel y trataban de forma humillante y desptica a los presos. De este modo, corroboraron lo que escribi Lord Acton en 1887 al afirmar que el poder corrompe, y el poder absoluto corrompe absolutamente. Mientras tanto, los prisioneros se convertan en personas aterrorizadas y sumisas, motivo por el cual se tuvo que suspender el experimento antes del tiempo previsto. Es importante sealar que los guardianes que mantuvieron una actitud correcta frente a los presos no hicieron, sin embargo, nada para protegerlos del grupo ms sdico, como si las mortificaciones y malos tratos que all se infligan no tuviesen nada que ver con ellos. Se convirtieron en una mayora silenciosa. En un estudio sobre las crceles efectuado conjuntamente con el Dr. Josep Oriol Esteve, tambin encontramos que la identificacin de los funcionarios con sus funciones represivas y administradora de castigos, estaban mucho ms asumidas que el destino de vctima por parte de los presos. El mismo fenmeno se ha descrito en el holocausto alemn, en que algunos de los nombrados policas judos se comportaron de forma brutal, parecida a las fuerzas de las SS. Todo un indicativo de los aspectos violentos latentes en muchas personas, y que se manifiestan cuando tienen ocasin de ejercerlos sin riesgo y con total impunidad. Hellman . el que podra catalogarse como el guardin ms duro y sdico en el experimento de Zimbardo, que humillaba y degradaba constantemente a los presos, se excus diciendo que: si te pones un uniforme color caqui, te dan una porra y te dicen que tu trabajo es mantener a raya a unos prisioneros, no eres la misma persona que si llevaras ropa de calle, y por lo tanto tienes que actuar en consecuencia. El resultado de estas pruebas deja un triste sabor. En las exploraciones psicolgicas previas que se hicieron a los sujetos elegidos, se les consider como personas normales. Sin embargo, al entrar a formar parte de la experiencia la mayor parte de los individuos sufri unos cambios de actitud y se revelaron como seres enormemente inmaduros, faltos de un self slido y fuerte que les permitiera desobedecer unas rdenes crueles, e incapaces de poder tomar decisiones de forma autnoma. Este mismo self dbil haca que supliesen sus ineptitudes identificndose con el uniforme y con situaciones externas, sin poder utilizar sus recursos mentales personales para formarse un criterio propio y poder dirigir su conducta. Aunque sera preferible tener un mayor conocimiento de los sujetos de estas experiencias, y pese a que su vida anterior al parecer haba transcurrido normalmente, al someterlos a unas situaciones lmite, una parte, puede que cerca de la mitad, se descompensaron y manifestaron sntomas autnticamente patolgicos. En estos casos sobresale la pasividad ante el entorno, la dificultad para mantener unos criterios personales que les permitiera una libertad de eleccin. Adems, exista una escasez de relaciones afectivas con los compaeros con quienes compartan la misma situacin, y falta de empata ante el sufrimiento de los dems. La pasividad estaba en la base de sus identificaciones mimticas, de un supery pegado a las normas que se les haca aplicar por los que detentaban la autoridad. Todo ello hace pensar en los posibles dficits familiares sufridos por los afectados desde la ms tierna infancia y que habran dificultado la construccin de una identidad slida, lo cual puede tener importantes consecuencias. Mi impresin personal es que en el momento actual los cuidados a nivel psicolgico de los nios ms pequeos y la satisfaccin de sus necesidades mentales es, en general, deficiente y ayuda poco a la integracin de su personalidad, como reflejan los casos de estos estudios. En estos experimentos, tanto la crueldad que se manifest en ciertos momentos, como los diferentes comportamientos exhibidos, nos recuerdan, por la actitud adoptada con cierto parecido, a aquellas personas que colaboraron activamente en los crmenes de Estado ms despiadados y desalmados de estos ltimos tiempos, como han sido el nazismo y otros genocidios como los de Ruanda, los Balcanes, etc. Al plantear estas cuestiones de carcter sociopoltico, creo que una ligera revisin del Caso Eichmann, el mayor criminal del siglo XX que se encarg de llevar a seis millones de seres humanos a campos de concentracin para ser reducidos a cenizas, puede aportar una visin ms amplia. Para ello me guiar por el libro de Hannah Arendt (1999) que estuvo presente durante todo el juicio y escribi un amplio relato del mismo, y de sus propias reflexiones. Intentar profundizar en la mente de Adolf Eichmann crea importantes dificultades por las contradicciones y divergencia de su personalidad. Seis psiquiatras examinaron a Eichmann en Jerusaln, y lo encontraron sano mentalmente. Incluso uno lleg a decir que era ms sano que l mismo, y otro consider ejemplar el trato de Eichmann con su familia. No dejan de ser curiosos estos dictmenes si se observan las actitudes ms ntimas de este hombre. Probablemente las opiniones expresadas y las observaciones efectuadas se referan nicamente a la forma en que Eichmann se presentaba, como un ser adulto normal. Sin embargo, a travs de ciertas observaciones es fcil darse cuenta de su intento de ocultar el enorme vaco de se personalidad, la falta de un pensamiento propio, y su pasividad y falta de emotividad. Ya de joven pretendi ingresar en una logia masnica, pero su amigo Ernst Kaltenbrunner le propuso hacerse de la SS, lo que Eichmann acept. Es decir, una eleccin tan comprometida se hizo de forma superficial, sin saber demasiado lo que significaba ya que conoca poco el nazismo. Lo habitual en Eichmann era dejarse guiar por otros y obedecer rdenes, incapaz de responsabilizarse de sus actos. Su defensa en el juicio fue no sentirse culpable ya que slo haba obedecido las rdenes que reciba, y aadi que no odiaba a los judos cosa que parece cierta ya que tuvo una novia juda. Adems, antes de que se eligiese la Solucin Final, haba hecho el proyecto de mandar a los judos a Madagascar. Pues por qu acept llevar a los judos a una muerte horrible La impresin es que su falta de capacidades emocionales y de juicio las supla mediante unas identificaciones mimticas masivas con las figuras dominantes, y que lo que se le ordenaba se tenia que cumplir sin plantearse ningn juicio moral. Eichmann se poda sentir culpable si un tren se retrasaba, sin embargo no tenia ningn remordimiento por los asesinatos que ayudaba a cometer. Cuando la derrota de Alemania, Eichmann estuvo muy preocupado porque no tendra un jefe que le dirigiera, y estara sin recibir rdenes y sin reglamentos que cumplir. Parece que se trataba de una personalidad como las que describi Helen Deutsch y que denomin personalidades como s, precisamente por su falta de autenticidad. Parecen seres adultos, pero con un gran vaco emocional, son personajes como de teatro, desempean un papel, pero se conducen como tteres, faltos de un vivo mundo interno y una absoluta falta de criterios morales. El problema es que en muchas persona existen rasgos como s que pueden pasar a un primer plano ante una situacin lmite como evidenciaron las experiencias de Milgram y de Zimbardo, con un resultado catastrfico. Como dice Hanna Arendt, lo ms grave en el caso de Eichmann, era precisamente que hubo muchos hombres como l y que estos hombres no fueron pervertidos ni sdicos, sino que fueron y siguen siendo, terrible y terrorficamente normales. He intentado hacer una breve revisin de los puntos que creo ms fundamentales de la agresividad humana, de sus funciones estructurantes y de los efectos destructivos de la violencia. Tambin he elegido los aspectos que creo que tienen un mayor relieve social. Creo que el estudio y la profundizacin en estos temas desde las diferentes disciplinas es una de las tareas ms perentorias, si deseamos vivir en una sociedad menos conflictiva. 1. Este artculo es una nueva versin ampliada de un anterior trabajo titulado Les arrels psicolgiques de la violncia (Bassols, 2001), publicado en la Revista Catalana de Psicoanlisi . Vol. XVIII, nms. 1-2, pp. 5-21. 2. Traducido del cataln por Ramon Bassols y Sacha G. Cuppa. Aranguren, J. L. L. (1992), Problemas ticos de la utilizacin de la violencia, Revista Internacional de Sociologa . nm. 2. Ardrey, R. (1969), Gnesis en frica . Hispano Europea. Arendt, H. (1999), Eichmann en Jerusaln. Un estudio sobre la banalidad del mal . Barcelona, Lumen. Bassols, R. (1980), Reflexions sobre el poder des duna perspectiva psicoanaltica, Quaderns de Psicologia . nm. 2. (1988), Aspectos dinmicos de la delincuencia y adicin a drogas en la delincuencia, Ponencia al Simposio Nacional Sociedad Rorschach . Madrid. (1999), Sobre fanatismo y violencia, Temas de Psicoanlisis (en papel), vol. IV. (2001), Les arrels psicolgiques de la violncia, Revista Catalana de Psicoanlisi . Vol. XVIII, nms. 1-2, pp. 5-21. Buero Vallejo, A. (1976), La doble historia del Doctor Valmy . Selecciones Austral, Espasa-Calpe, S. A. Empdocles. (1944), Poema, en Los Presocrticos . Fondo Cultura Econmico, Mxico. Fornari, F. (1972), Psicoanlisis de la guerra . Siglo XXI. Freeman, D. (1970), La agresin humana en perspectiva antropolgica, en Historia natural de la agresin . compilado por Carthy, J. D. y Ebling, F. J. Mxico, Siglo XXI. Freud, S. (1968), Obras Completas . Biblioteca Nueva, Madrid. (1912), Sobre los tipos de adquisicin de la neurosis . (1915), Los instintos y sus destinos . (1916), Varios tipos de carcter descubiertos en la labor psicoanaltica . (1917), El tab de la virginidad . (1920), Ms all del principio del placer . (1930), Malestar en la cultura . (1932), Nuevas aportaciones al psicoanlisis . (1937), Esquema del psicoanlisis . Gampel, Y. (1997), The role of social violence in psychic reality, en The perverse transference 038 others matters . Ed. por Jorge L. Ahumada y Otros, Jason Aronson. Hartmann, H. Kris, E. Loewenstein, R. M. (1949), Notes on the theory of agresin, Psychoanalytic Study of the Child . nm. 3-4, pp. 9-36. Hyatt-Williams, A. (1964), The psychopathology and treatment of sexual murderers, en The pathology and treatment of sexual deviation . Ed. por Ismond Rosen, Oxford University Press. (1978), The criminal character, 8 Congreso Internacional de Criminologa . Lisboa. Jones, E. (1959), Vida y obra de Sigmund Freud . Editorial Nova. Joseph, B. (1993), La desesperacin engendra la violencia, la violencia engendra la desesperacin, Psicoanlisis . Vol. XV, nm. 1. Klein, M. (1989), Obras Completas . Paids. (1927), Tendencias criminales en nios normales . (1934), Sobre la criminalidad . Laplanche, J. y J. B. Pontalis. (1971), Diccionario de psicoanlisis . Trabalho. Lorenz, K. (1971), Sobre la agresin: el pretendido mal . Siglo XXI. Meltzer, D. (1974), Los estados sexuales de la mente . Kargieman. Montagu, A. y Otros (1970), Hombre y agresin . Kairos. Puget, J. (1988), Social violence and psychoanalysis in Argentina: the unthinkable and the unthought, Free Associations . nm. 1, pp. 84-140. Rof Carballo, J. (1967), Violencia y ternura . Ed. Prensa Espaola. Rosenfeld, H. (1971), A clinical approach to the psychoanalytic theory of the life and death instincts: an investigation into the aggresive aspects of narcissism, International Journal of Psychoanalysis . Vol. 52, pp. 169-178. (1990), Impasse e interpretacin . Madrid, Tecnipublicaciones. Schiller, C. F. (1882), La conjuracin de Fiesco . Biblioteca Arte y Letras. Strachey, J. (1979), Nota introductoria al Malestar en la cultura de Freud, Amorrortu. Wolfgang, M. y Ferracuti, F. (1971), La subcultura de la violencia . Mxico, Fondo Cultura Econmico. Zimbardo, P. J. y Otros (1986), La psicologa del encarcelamiento: privacin, poder y patologa, Revista de Psicologa Social . 1, pp. 95-105. Ramon Bassols Pars Psiquiatra. Psicoanalista de la Sociedad Espaola de Psicoanlisis (SEP-IPA). Presidente de la SEP (1994 8211 1998).Editoraposs Note: The narration and closed captions in this video are in English. For subtitles in 13 other languages, see this video on the website of the World Health Organization . Idelalisib and Rituximab in Relapsed Chronic Lymphocytic Leukemia Richard R. Furman, M. D. Jeff P. Sharman, M. D. Steven E. Coutre, M. D. Bruce D. Cheson, M. D. John M. Pagel, M. D. Ph. D. Peter Hillmen, M. B. Ch. B. Ph. D. Jacqueline C. Barrientos, M. D. Andrew D. Zelenetz, M. D. Ph. D. Thomas J. Kipps, M. D. Ph. D. Ian Flinn, M. D. Ph. D. Paolo Ghia, M. D. Ph. D. Herbert Eradat, M. D. Thomas Ervin, M. D. Nicole Lamanna, M. D. Bertrand Coiffier, M. D. Ph. D. Andrew R. Pettitt, Ph. D. F. R.C. Path. Shuo Ma, M. D. Ph. D. Stephan Stilgenbauer, M. D. Paula Cramer, M. D. Maria Aiello, M. A. Dave M. Johnson, B. S. Langdon L. Miller, M. D. Daniel Li, Ph. D. Thomas M. Jahn, M. D. Ph. D. Roger D. Dansey, M. D. Michael Hallek, M. D. and Susan M. OBrien, M. D. N Engl J Med 2014 370:997-1007 March 13, 2014 DOI: 10.1056NEJMoa1315226 Comments open through March 19, 2014 Background Patients with relapsed chronic lymphocytic leukemia (CLL) who have clinically significant coexisting medical conditions are less able to undergo standard chemotherapy. Effective therapies with acceptable side-effect profiles are needed for this patient population. In this multicenter, randomized, double-blind, placebo-controlled, phase 3 study, we assessed the efficacy and safety of idelalisib, an oral inhibitor of the delta isoform of phosphatidylinositol 3-kinase, in combination with rituximab versus rituximab plus placebo. We randomly assigned 220 patients with decreased renal function, previous therapy-induced myelosuppression, or major coexisting illnesses to receive rituximab and either idelalisib (at a dose of 150 mg) or placebo twice daily. The primary end point was progression-free survival. At the first prespecified interim analysis, the study was stopped early on the recommendation of the data and safety monitoring board owing to overwhelming efficacy. The median progression-free survival was 5.5 months in the placebo group and was not reached in the idelalisib group (hazard ratio for progression or death in the idelalisib group, 0.15 Plt0.001). Patients receiving idelalisib versus those receiving placebo had improved rates of overall response (81 vs. 13 odds ratio, 29.92 Plt0.001) and overall survival at 12 months (92 vs. 80 hazard ratio for death, 0.28 P0.02). Serious adverse events occurred in 40 of the patients receiving idelalisib and rituximab and in 35 of those receiving placebo and rituximab. Conclusions The combination of idelalisib and rituximab, as compared with placebo and rituximab, significantly improved progression-free survival, response rate, and overall survival among patients with relapsed CLL who were less able to undergo chemotherapy. (Funded by Gilead ClinicalTrials. gov number, NCT01539512 .) Media in This Article Figure 1 Progression-free and Overall Survival. At the time the study was stopped, the median duration of progression-free survival among 110 patients receiving idelalisib and rituximab had not yet been reached among the 110 patients receiving placebo and rituximab, the median duration of progression-free survival was 5.5 months (hazard ratio for progression or death in the idelalisib group, 0.15 95 confidence interval CI, 0.08 to 0.28 Plt0.001) (Panel A). The median duration of overall survival in the two study groups had also not been reached the overall survival rate was 92 in the idelalisib group versus 80 in the placebo group at 12 months (hazard ratio for death, 0.28 95 CI, 0.09 to 0.86 P0.02) (Panel B). Figure 2 Forest Plot of Progression-free Survival in Prespecified Subgroups. Hazard ratios of less than 1.00 for disease progression or death indicate better results in the idelalisib group. Article Activity Chronic lymphocytic leukemia (CLL) is the most prevalent leukemia among adults. Standard treatments include combinations of purine analogues, alkylating agents, and monoclonal antibodies. In younger patients without major coexisting illnesses, these regimens can provide high response rates of durable length but have substantial toxic effects. As a result, these treatments often have unacceptable side effects in older patients and those with coexisting illnesses. 1 Patients with relapsed CLL often have limited options because of the development of resistance to, or persisting toxic effects of, previous therapies. This is particularly true for elderly patients and those with coexisting illnesses. 2 For these patients, the guidelines of the National Comprehensive Cancer Network recognize rituximab (Rituxan, GenentechBiogen Idec) as a treatment option. 3 Rituximab is commonly used in such patients, although it has not been approved as monotherapy. Rates of response to rituximab vary, and the duration of progression-free survival is generally short. 4-7 The B-cellreceptor signaling pathway plays a key role in the pathogenesis of CLL. 8-11 Signaling through the B-cell receptor is mediated in part by the activation of the delta isoform of phosphatidylinositol 3-kinase (PI3K). The delta isoform is one of four catalytic isoforms (p110 , , , and ) that differ in their tissue expression, with PI3K being highly expressed in lymphoid cells 12 and the most critical isoform involved in the malignant phenotype in CLL. 13 It activates the serinethreonine kinases AKT and mammalian target of rapamycin (mTOR) and exerts pleiotropic effects on cell metabolism, migration, proliferation, survival, and differentiation. 14,15 Additional surface receptors that may play important roles in CLL pathophysiology (e. g. CXCR4, 16 CD40, 17 and CD49d 18 ) also transduce their signals in part through PI3K. Idelalisib (formerly called GS-1101 and CAL-101) is a potent, oral, selective small-molecule inhibitor of PI3K. 15 In phase 1 studies, idelalisib (both as a single agent and in combination with other agents, including rituximab 19,20 ) had clinically significant activity with an acceptable toxicity profile in patients with relapsed or refractory CLL. On the basis of these encouraging results, we conducted Study 116 a phase 3, randomized, double-blind, placebo-controlled trial of combination therapy with idelalisib and rituximab in patients with relapsed CLL. Study Design and Conduct The trial was designed by the sponsor, Gilead, with input from all the authors. Gilead implemented the study and provided data analysis. The trial was conducted, according to the principles of Good Clinical Practice, at 90 centers in the United States and Europe after approval by the relevant regulatory authorities and the institutional review board at each study site. All patients provided written informed consent. All the authors had full access to the study data and were involved in the interpretation of the data and in the preparation, revision, and final approval of the manuscript. All the authors made the decision to submit the manuscript for publication and vouch for the accuracy and completeness of the data and adherence to the study protocol (available with the full text of this article at NEJM. org). Study Treatment All patients were assigned to receive rituximab intravenously (at a dose of 375 mg per square meter of body-surface area), followed by 500 mg per square meter every 2 weeks for 4 doses and then every 4 weeks for 3 doses, for a total of 8 infusions. Patients were stratified according to the presence of 17p deletion (a deletion of the 17p13 chromosomal region in the gene encoding tumor-suppressor p53 TP53 ) or other TP53 mutations or the lack of somatic hypermutation in the gene encoding the immunoglobulin heavy-chain variable region ( IGHV ), all of which are associated with an inferior outcome. The patients were then randomly assigned to receive rituximab with either oral idelalisib (at a dose of 150 mg) (idelalisib group) or placebo (placebo group) twice a day. Patients in the placebo group who had disease progression while enrolled in Study 116 could enroll in Study 117 to receive idelalisib. Patients in the idelalisib group who had disease progression could receive an increased dose of the drug (300 mg twice daily). Eligibility Eligible patients had CLL that had progressed within 24 months after their last treatment and were not able to receive cytotoxic agents for one or more of the following reasons: severe neutropenia or thrombocytopenia caused by cumulative myelotoxicity from previous therapies, an estimated creatinine clearance of less than 60 ml per minute, or a score on the Cumulative Illness Rating Scale (CIRS) 21 of more than 6 for coexisting illnesses not related to CLL. 2 (The CIRS score ranges from 0 to 56, with higher scores indicating an increased number or greater severity of coexisting illnesses.) Previous treatment must have included either a CD20 antibodybased regimen or at least two previous cytotoxic regimens. Assessments We scheduled clinic visits, which included laboratory testing, every 2 weeks for the first 12 weeks, then every 4 weeks for 12 weeks, and then every 6 weeks for 24 weeks, followed by visits every 12 weeks. The treatment response was assessed on the basis of serial computed tomography or magnetic resonance imaging of the neck, chest, abdomen, and pelvis (performed every 8 weeks for 6 months and every 12 weeks thereafter) and laboratory hematologic measurements. We used the criteria of the International Workshop on Chronic Lymphocytic Leukemia (IWCLL) 22 to determine rates of response and progression, including Richters transformation (in which CLL is transformed into an aggressive lymphoma). These criteria were recently modified to exclude lymphocytosis as an isolated criterion for disease progression in patients treated with agents inhibiting the B-cell receptor. 23,24 Independent review by a committee whose members were unaware of study-group assignments determined rates of response and disease progression for each patient and the dates of occurrence. Centralized reference diagnostic procedures were performed at Ulm University (Ulm, Germany) or Cancer Genetics (Rutherford, NJ) with the use of fluorescence in situ hybridization for genomic aberrations, DNA sequencing for IGHV mutation status, and WAVE DNA fragment analysis and confirmatory Sanger sequencing for TP53 analyses, as described previously. 25-27 Adverse events were graded with the use of the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE), version 4.03. End Points The primary end point of the trial was progression-free survival. Secondary end points were rates of overall and complete response, lymph-node response, and overall survival. Statistical Analysis We calculated progression-free survival, which was defined as the interval from randomization to disease progression or death from any cause (whichever came first), using the KaplanMeier method and compared rates using a stratified log-rank test. We used a Cox model with adjustment for stratification to calculate hazard ratios. The rate of overall response was defined as the proportion of patients who had a complete or partial response on the basis of the IWCLL modified criteria. 25 The lymph-node response rate was defined as the proportion of patients who had a decrease of 50 or more in lymphadenopathy. Overall survival was defined as the interval from randomization to death from any cause. All efficacy analyses were based on the intention-to-treat principle unless otherwise stated. For binary-response end points, we used the CochranMantelHaenszel chi-square test, adjusted for stratification, to assess between-group differences. A sequential testing procedure was applied to adjust for the overall type I error rate in other words, if the primary end point was significant, the secondary end points of rates of overall response, lymph-node response, and overall survival would be tested sequentially. The sample size provided a power of more than 85 to detect a 75 improvement in the median progression-free survival. Two interim analyses were prespecified after approximately 50 and 75 of the anticipated 119 events had occurred, at alpha levels of 0.001 and 0.005, respectively. The 220 patients who were included in the study were enrolled between May 2012 and August 2013. The data cutoff for this analysis was August 30, 2013. A total of 78 of the patients were 65 years of age or older, 40 had at least moderate renal dysfunction (creatinine clearance, lt60 ml per minute), 35 had poor bone marrow function (grade 3 or higher anemia, thrombocytopenia, or neutropenia), and 85 had a CIRS score of more than 6. The median CIRS score in each study group was 8 ( Table 1 Table 1 Characteristics of the Patients at Baseline and Study Status. ). Almost two thirds of the patients had advanced-stage disease, and the median time since the initial diagnosis of CLL was approximately 9 years. More than 80 of the patients had unmutated IGHV, and more than 40 had 17p deletion or TP53 mutations. Patients in the two study groups had received a median of three previous agents, including regimens containing rituximab, cyclophosphamide, fludarabine, and bendamustine. A total of 110 patients were randomly assigned to each study group. All 110 patients in the idelalisib group and 107 in the placebo group actually received the assigned treatment ( Table 1 ). Of the 3 patients in the placebo group who did not receive study treatment, 2 patients withdrew from the study because of an adverse event and 1 patient had not received study treatment before the data cutoff. Receipt of Study Drug At the time of this analysis, the median time that patients had received a study drug was 3.8 months (interquartile range, 1.9 to 8.6 simple range, 0.3 to 16) in the idelalisib group and 2.9 months (interquartile range, 1.7 to 5.6 simple range, 0.1 to 14.6) in the placebo group. A total of 63 patients (39 in the idelalisib group and 24 in the placebo group) received a study drug for longer than 6 months. The duration of treatment was short for the two study groups owing to the recommendation of the data and safety monitoring board to stop the study. However, 81 of patients in the idelalisib group were still receiving the study drug at the time of study termination, as compared with only 52 in the placebo group. The most common reason for discontinuation of the study treatment was disease progression. Progression-free Survival At 24 weeks, the rate of progression-free survival was 93 in the idelalisib group, as compared with 46 in the placebo group (adjusted hazard ratio for progression or death in the idelalisib group, 0.15 95 confidence interval CI, 0.08 to 0.28 unadjusted Plt0.001, which crossed the prespecified stopping boundary for efficacy at the significance level of 0.001. Disease progression occurred in 12 patients in the idelalisib group and in 53 patients in the placebo group. The median duration of progression-free survival among patients in the idelalisib group was not reached, whereas the median progression-free survival was 5.5 months in the placebo group ( Figure 1A Figure 1 Progression-free and Overall Survival. At the time the study was stopped, the median duration of progression-free survival among 110 patients receiving idelalisib and rituximab had not yet been reached among the 110 patients receiving placebo and rituximab, the median duration of progression-free survival was 5.5 months (hazard ratio for progression or death in the idelalisib group, 0.15 95 confidence interval CI, 0.08 to 0.28 Plt0.001) (Panel A). The median duration of overall survival in the two study groups had also not been reached the overall survival rate was 92 in the idelalisib group versus 80 in the placebo group at 12 months (hazard ratio for death, 0.28 95 CI, 0.09 to 0.86 P0.02) (Panel B). ). The treatment effect of idelalisib and rituximab was similarly favorable in all prespecified subgroups, including those stratified according to the presence or absence of the 17p deletion or TP53 mutation and IGHV mutational status ( Figure 2 Figure 2 Forest Plot of Progression-free Survival in Prespecified Subgroups. Hazard ratios of less than 1.00 for disease progression or death indicate better results in the idelalisib group. ). Overall Survival The rate of overall survival in the idelalisib group was superior to that in the placebo group (92 vs. 80 at 12 months), with an adjusted hazard ratio for death of 0.28 (95 CI, 0.09 to 0.86 P0.02). The median duration of overall survival in the two groups had not yet been reached at the time of analysis ( Figure 1B ). Sixteen patients died while participating in the study: 4 patients (4) in the idelalisib group and 12 patients (11) in the placebo group. Overall Response The rate of overall response was evaluated for the 176 patients (88 patients in each study group) who had undergone at least one post-baseline assessment or had discontinued the study before the first assessment at the time of this analysis. The overall response rate was 81 (95 CI, 71 to 88) in the idelalisib group, as compared with 13 (95 CI, 6 to 21) in the placebo group (odds ratio, 29.92 Plt0.001). All responses were partial responses. Lymph-Node Response A total of 169 patients underwent at least one post-baseline imaging assessment of the lymph-node response to treatment. On the basis of a review of imaging results by the independent review committee, the proportion of patients with a reduction of 50 or more in lymphadenopathy was significantly higher in the idelalisib group than in the placebo group (93 95 CI, 85 to 97 vs. 4 95 CI, 1 to 10), for an odds ratio of 264 (Plt0.001) ( Figure 3A Figure 3 Changes in Lymph Nodes and Lymphocytes. Shown are the greatest percentage changes in the sum of the products of the perpendicular diameters of measured lymph nodes for each study patient (Panel A) and the median absolute lymphocyte counts over a period of 48 weeks (Panel B). The I bars represent interquartile ranges. ). Idelalisib-Associated Lymphocytosis Idelalisib, like other novel agents targeting the B-cellreceptor signaling pathway, has been shown to cause lymphocytosis when it is administered as a single agent. 19 The addition of rituximab to idelalisib blunted and shortened the duration of the lymphocytosis, which confirmed the findings of a previous phase 1 study. 20 The rate of lymphocytosis peaked at week 2 and resolved by week 12 in the idelalisib group ( Figure 3B ). In contrast, there was a sustained increase in the absolute lymphocyte count in the placebo group starting at week 24, which coincided with the completion of rituximab therapy. As per the modified IWCLL guidelines, this rise in the lymphocyte count was not considered to be disease progression. Adverse Events Adverse events, serious adverse events, and laboratory abnormalities that occurred during treatment are listed in Table 2 Table 2 Adverse Events, Serious Adverse Events, and Key Laboratory Abnormalities. Most of the adverse events were consistent with those expected for a population with relapsed CLL that had received extensive prior therapy. More than 90 of the patients had at least one adverse event. In the idelalisib group, the five most common adverse events were pyrexia, fatigue, nausea, chills, and diarrhea. In the placebo group, the adverse events were similar to those in the idelalisib group, with the most common being infusion-related reactions, fatigue, cough, nausea, and dyspnea. Most adverse events across the two study groups were grade 2 or lower. In the idelalisib group, grade 3 or higher diarrhea was reported in four patients and grade 3 or higher rash was reported in two patients, with no grade 3 or higher diarrhea or rash reported in the placebo group. Common laboratory abnormalities included anemia, neutropenia, and thrombocytopenia. Hepatic aminotransferase elevations occurred more frequently in patients receiving idelalisib and rituximab than in those receiving placebo and rituximab. Grade 3 or higher elevations occurred in six patients (5) in the idelalisib group, with onset at 8 to 16 weeks. The study drug was withheld and successfully reinitiated in four of these six patients. No patients discontinued the study drug because of aminotransferase elevations. At least one serious adverse event occurred in 44 patients (40) in the idelalisib group and in 37 patients (35) in the placebo group. The most frequent serious adverse events in the two groups were pneumonia, pyrexia, and febrile neutropenia. Adverse events leading to study-drug discontinuation were reported in 9 patients (8) in the idelalisib group and 11 patients (10) in the placebo group. In the idelalisib group, gastrointestinal and skin disorders contributed to 6 discontinuations. In the placebo group, infections and respiratory disorders contributed to 8 discontinuations. Discussion In our study involving patients with relapsed CLL who were not able to undergo standard cytotoxic chemotherapy, treatment with idelalisib and rituximab was associated with significant improvement in the rate of progression-free survival, as compared with placebo and rituximab, a finding that warranted termination of the study after the first prespecified interim analysis. We chose rituximab monotherapy as the comparator for this study on the basis of National Comprehensive Cancer Network guidelines and clinical-use data showing that the drug is a commonly prescribed treatment in the United States for this population and is increasingly being prescribed in Europe (see the Supplementary Appendix. available at NEJM. org). The patients were defined as less able to receive cytotoxic chemotherapy on the basis of severe myelosuppression from previous chemotherapy, reduced kidney function, or a CIRS score of more than 6 for nonCLL-related coexisting illnesses. We used a schedule for the administration of rituximab that was approved in combination with fludarabine and cyclophosphamide two additional doses were added to achieve dose intensification. Improvement in progression-free survival was observed not only in the overall study population but also in all subgroups examined, including patients with poor prognostic features, such as 17p deletion or TP53 mutations and unmutated IGHV . The rate of progression-free survival in the placebo group was similar to that reported for rituximab monotherapy in other trials involving patients who were not selected on the basis of medical fitness for chemotherapy. Furthermore, the median duration of progression-free survival among patients receiving placebo and rituximab was similar to the range of 5.7 to 5.9 months reported among patients receiving monotherapy with ofatumumab, another anti-CD20 antibody approved as monotherapy for disease that is resistant to fludarabine and alemtuzumab. 28 In addition, patients receiving idelalisib and rituximab had significant improvement in overall survival, as compared with those receiving placebo and rituximab. This improvement in survival is further evidence of the clinical importance of the progression-free survival benefit shown in this trial. Significant differences favoring the idelalisib group were also observed in rates of overall response and lymph-node response. There was no overall increase in the rate of adverse events with the addition of idelalisib to rituximab, as compared with placebo and rituximab. Grade 3 or 4 adverse events were common in the two study groups, which was an expected finding, given the large number of previous treatments, clinically significant coexisting illnesses, and prolonged time since the initial diagnosis of CLL in these patients. In earlier studies, idelalisib was associated with elevated aminotransferase elevations, rash, and severe diarrhea. 19 These adverse events were reported in the idelalisib group in our study as well, albeit at a low frequency, and severe events were generally managed with study-drug interruption and symptom treatment. Since the study was stopped early for efficacy, severe diarrhea, which is typically a late-onset event, may yet occur in some patients. A surprising finding was a reduction in rates of infusion-related toxicity from rituximab in the idelalisib group. In conclusion, the addition of idelalisib to rituximab in a population of frail, difficult-to-treat patients, including those with adverse genetic features such as 17p deletion or TP53 mutations or unmutated IGHV, was superior to rituximab monotherapy, which is commonly used in such patients. Although the follow-up in this study was short, combination therapy with idelalisib had an acceptable safety profile. Further follow-up is needed to assess whether idelalisib is safe for long-term use. Patients with CLL who are less able to undergo standard chemotherapy are frequently excluded from clinical trials because of the presence of coexisting illnesses, yet such patients are often seen in clinical practice. On the basis of response rates and progression-free survival results, the combination of idelalisib and rituximab may be a treatment option for these patients. Idelalisib is part of a growing list of agents with activity in CLL, including ibrutinib (targeting Brutons tyrosine kinase) 29 and ABT-199 (targeting B-cell lymphoma 2 protein BCL2). 30 Additional studies will be necessary to define the most effective use of these new agents. Presented in part at the annual meeting of the American Society of Hematology, New Orleans, December 710, 2013. Supported by Gilead. Disclosure forms provided by the authors are available with the full text of this article at NEJM. org. Drs. Furman, Sharman, and Coutre contributed equally to this article. This article was published on January 22, 2014, at NEJM. org. We thank the patients who participated in this study the investigators and coordinators at the clinical sites the employees of Gilead who contributed to the design, implementation, and data analysis Eugen Tausch, M. D. for the genetic analysis and Tim DiChiara, Ph. D. for assistance in the preparation of the manuscript. Source Information The authors affiliations are listed in the Appendix. Address reprint requests to Dr. Furman at the Division of HematologyOncology, Weill Cornell Medical College, 525 E. 68th St. New York, NY 10065, or at rrfurmanmed. cornell. edu. The authors affiliations are as follows: Weill Cornell Medical College (R. R.F.), Memorial Sloan-Kettering Cancer Center (A. D.Z.), the Department of Medicine, and Columbia University Medical Center (N. L.) all in New York U. S. Oncology Research, Springfield, OR (J. P.S.) Stanford University School of Medicine, Stanford (S. E.C.), and Gilead Sciences, Foster City (M. A. D. M.J. L. L.M. D. L. T. M.J. R. D.D.) both in California Lombardi Comprehensive Cancer Center, Georgetown University Hospital, Washington, DC (B. D.C.) Fred Hutchinson Cancer Research Center, University of Washington, Seattle (J. M.P.) St. Jamess University Hospital, Leeds (P. H.), and Royal Liverpool University Hospital, Liverpool (A. R.P.) both in the United Kingdom Hofstra North Shore-LIJ School of Medicine, New Hyde Park, New York (J. C.B.) University of California San Diego, Moores Cancer Center, La Jolla (T. J.K.) Sarah Cannon Research Institute, Nashville (I. F.) Universita Vita-Salute San Raffaele, Instituto Scientifico San R affaele, Milan (P. G.) David Geffen School of Medicine, University of California Los Angeles, Los Angeles (H. E.) Florida Cancer Specialists, Englewood (T. E.) Centre Hospitalier Lyon-Sud, Pierre-Bnite, France (B. C.) Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago (S. M.) University of Ulm, Ulm (S. S.), and University of Cologne, Cologne (P. C. M. H.) both in Germany and University of Texas M. D. Anderson Cancer Center, Houston (S. M.O.). References Gribben JG. OBrien S. Update on therapy of chronic lymphocytic leukemia. J Clin Oncol 201129:544-550 CrossRef Web of Science Medline Eichhorst B. Goede V. Hallek M. 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Reference Module in Biomedical Sciences. CrossRef 1 Readers Comments
LAS RACES PSICOLGICAS DE LA VIOLENCIA 1, 2 O animal possui uma agresividade, mas não há actos de violência propiamente definidos. E sua agressividade está limitada a um pré-requisito para o sustento, a defesa de su País e dentro da espécie, em conjunto com uma ordem de relacionamento para o apareamento. Violencia propiamente dicha, no hay si no es en el hombre. Jos Luis Lpez Aranguren Descargar o artculo O fenômeno da violência ha afligido a humanidade em toda sua história, convertida en una crnica de atrocidades e manifestações brutais que estão sendo sucedidas no transcurso de toda a vida. Qualquer perodo que analizramos é baado en sangue, saturado de guerras, crmenes, torturas y dems actos crueles orientados a infligir sufrimiento. Ltimamente, estes problemas se han visto fortemente agravados ao disponer a humanidade de mtodos de exterminio a bomba atmica capaces de aniquilar toda a forma de vida, no que se refere ao tema da violência do mar objeto de uma atenção especial e proliferar estudos sobre o tema Desde diferentes perspectivas. É possível que este recente inters por el tema mar porque é que existe uma maior sensibilidade frente ao mesmo, e por este motivo se intente esconder muitas das formas de violência e solo se ejetos por oculto Esto supondra um certo progresso da humanidade . O trmino da violência é usado para referirnos à prova de problemas da corrupção de tipo destrutivo, um abuso da força do poder para o malware ou subyugar aos dems. Odio es el trmino que designa os componentes afectivos como como o tipo de relacionamento do objeto que se estabelece. La complejidade do processo da violência e do polimorfismo de sus manifestações exige a pesquisa de mar multidisciplinar, investigado entre diferentes vrtices. A violência é capaz de enfocar como um indivíduo, por exemplo, a personalidade criminal como um fenomeno social, por exemplo, as subculturas da violência e as associações mafiosas e do ngulo político, por exemplo, a violência revolucionária, o terrorismo, a violência de las Instituições, la estatal, etc. A pesar de que todas estas formas de violência não estão comparadas. Estancos sino que mantem uma cierta interrelação e influência recproca, ya que como sealan J. Puget (1988) y Y. Gampel (1997) a violência social Inscreva-se na realidade psiquica, neste mercado necessario restante e exposto e cirúrgico aos psicologos da violência humana. Resumidamente, podramos considerar os pontos de vista em relação à teorização sobre as gestas da violência. Me refiero a las tesis instintivistas e as tesis ambientalistas. As quais se sustentan, no solo in base a argumentos cientficos, sino que se apoiam em gran medida em previas tomas de posicin ideolgica. Se trata de uma antiga controvérsia sobre a natureza humana, sobre su pretendida bondad o, por el contrario, su malignidad, e você pode se ilustrar com os critérios antagnicos de Thomas Hobbes e Jean-Jacques Rousseau. Enquanto isso para o primeiro estado do mundo do homem era o Bellum omnium contra omnes (Guerra de todos os todos) por um egocentrismo innato, para o segundo, o homem nace inocente e slo se corrompe e vuelve agresivo devido a a nefasta influencia da Sociedade. En el fondo, lo que impera é a gran resistência e reconocer que é o interior do ser humano, há recursos destructivos. Na atualidade, os representantes de ms aliviam as tesis instintivistas como Konrad Lorenz e Robert Ardrey, filho objeto de duras crticas por parte de Ashley Montagu, Geoffrey Gorer, Scott, Boulding, etc. acusados, injustamente, de querer perpetuar a concepção del Pecado original, e de esta moda de eximir ao homem de uma única responsabilidade por su agresividad. A su vez se lê o reprovador do defensor uma visin pesimista da humanidade, com o risco de conduzir a uma atitude de omissão das necessidades de transformações sociais e da creencia na imposibilidade de extirpar o mal. É como se considere que o reconhecimento da presença de elementos destrutores na natureza humana leva-se a uma conclusão que não seja modificável, negando as capacidades madurativas do homem para poder contender os impulsos primitivos e a possibilidade do cambio psquico. Tampoco tem en cuenta estes autores que, como postula Konrad Lorenz, junto aos instintos agresivos existem ritos vinculantes e de apaciguamento que impiden que a agresão intraespecífica revela um desenlace mortal, al menos en los animales. Em realidade, a agravação de um conjunto de funções: defesa do território onde se encontra a alimentação, orden jerrquico ao serviço da seleção natural, defesa da progênie, etc. mas dificilmente levado a la muerte, ms tudo todo lo contrario, la Agresin sera bsica para a supervivencia da espécie. O problema importante que se plantea é o homem, o ltimo peldao da escala evolutivo, o perdurar, os instintos agresivos ou as novas modalidades podem ser adquiridos ao processo de hominização. A violência no homem O psicoanlisis ha sido considerado, pode de forma excesivamente simplista, como uma concepção instintivista é uma afirmação que merece uma análise ms riguroso. En primer lugar, no is too coherente hablar de instintos em el hombre. En efecto, designamos como instintos uma forma de comportamento heredado, genrico, que se desencadena por meio de estímulos, internos, físicos, físicos, físicos, físicos, sociais, sociais, sociais, sociais, sociais, sociais. Evolucin del ser vivo. A pesar de todo, tambin existe a possibilidade de uma susceptibilidade especial a um certo aprendizagem nos animais ms evolucionados, sobre todo em lo que se tem denominado os perodos crticos, el imprinting, e que correspondem aos inicios de la vida e en en todos As circunstâncias externas de conformando o acuando os instintos. Para o homem Freud utiliza o trmino trieb que es ms traduzido por pulsin. Tal como se imprime, e que denomina um processo dinmico consistente em um impulso que faz o que é o organismo para a frente (Laplanche y Pontalis, 1971), si bem na pulsação para o elemento impulsionável, de embate o empuje , Ms que el de fijacin a un determinado fin. En realidad, trata-se de necessidades de potencialidades inatas, e de um grau elevado de plasticidad, que se desenvolve na ação de fatores de diferente ndole. Como escreve Freud (1912), El psicoanlisis nos ha llevado a prescindir de laestrills anttesis estabelecidas entre fatores externos e internos, entre o destino do indivíduo e su constitucin. Estudo do nível de plasticidad da medida das armas humanas, neste caso das agresivas, o que é a distância enorme do animal da agresividade. El bilogo Adolf Portmann (citado por D. Freeman, 1970) quando a pessoa está com os outros, como a pessoa que está com os demais, com a crueldade e a dificuldade, bem como a grande diversão de pessoas. Niveles animales. Como si hubiesen animales que hicieran um susconneres lo que se hacen os homens los unos a los otros. Precisamente aquino zologo ha de trazar uma clara linfa divisória: estas coisas malvolas, horribles, sem filho uma supervivencia animal transportada na transicina imperceptível do animal ao homem esta maldade pertencente a este lado da divisão de linha, é puramente humana. E estes estragos que causam a violência son debidos a la relativa independencia que o homem tem de sus pulsões, por assim dizer, por exemplo, no caso das pulsações agresivas, desvantagens para vnculos Sadomasoquistas. En esta misma direccin Hartmann e outros (1949) afirman que en el hombre las pulsiones estn mediatizadas por las funciones yoicas, y citan a Murphy que remarca como na espécie humana a inteligencia substituye o instinto. Psicoanlisis e violencia O reconhecimento da agresão como pulsão autônoma foi descoberto lento da teoria psicoanaltica. Respecto a este hecho Freud, en 1930, se sorprenda de su recarregar a idéia da existência de uma pulsação destrutora especifica no homem: Não comprendo como pudim passar por alto a localização da agresão sem ertica e da destruição, omitiendo asignarle A posicin que le corresponde na interpretação da vida. Y se preguntaba: Por qu hemos necesitado tanto tempo para decidir a reconocer a existência de uma pulsação agresiva. Em realidade, a importância da agresão como uma defesa contra o avanço do tratamento, foi contemplada desde os inícios do psicoanlisis. Um aspecto que atraiu a atenção de Freud foi o sadismo, como ficou de boca em boca para os ensaios de ensaios para uma sexualidade (1905), se bem em um momento para considerar como uma das pulsações parciais que formam parte da pulsação sexual. No deja de ser interessante, sem embargo, que é o mesmo, trabalhe e adiante, admitáve os impulsos para a crueldade, com o nacen de fontes de fato independentes da sexualidade e a relação com as pulsações de domínio. Se trata de uma afirmação que reaparece espórralmente em su obra, como em Pulsões e destino de pulsação (1915). Estima-se em uma obra de estúdio. Conheça um profundo estudo do odio e de su relacin com as frustrações do mundo. Externo, com os estímulos de desagrado que você recebe e que incita um intentar agredir e destruir os objetos que são filhos Das situações de malestar. Con estas formulações Freud se anticipa Algumas opções para os trabalhos da Escola de Yale sobre a frustração. Adems, Freud escrevem El odio es, como relacin de objeto, ms antiguo que o amor brota da repulsa primordial que o eu narcisista opone ao inicio da vida ao mundo exterior, que prodiga de estmulos. De esta forma, fica definida pela afinidade do odio com as pulsações de conservação, esto é, reconocem os defensivos da agresão. De todas as formas não foram ao ano 1920, en Ms all del principio del placer. Que as pulsões agresivas não estão a cargo de um estatus autônomo e sereno reconhecido por sua própria especificidade e independência. Segn Ernest Jones, al principio, a hipoteca da existência da agresiva como derivada e representante principal de uma pulsação autodestrutiva foi expressada com pouco convencimento por parte do mesmo Freud, como uma especulacin que trascenda a experiência psicoanaltica. Se trata de tratamentos de senhas, de sistemas de proteção de energia, de energia e de mecanismos de proteção do organismo, defraudamos e desvie para o mundo exterior, onde se manifeste como agresividad. Slo con el transcurso del tiempo Freud se aferr a esta conceptualizacin and the developed in the campo clnico. A pesar de todo, não encontrou uma grande aceptacin entre gran parte de psicoanalistas estas novas formulações tericas, a antítese entre as pulsações de vida e as pulsações de morte e a ltima instância representando a polaridade entre os processos anablicos e catablicos, e a luta Entre o amor e o odio como você está convidado. Empdocles: por Amistad convergen en Uno todas as coisas enquanto que, outras vezes, por odio de Discordia cada una diverge de todas A proposta de uma pulsação de morte, tal como foi postulada por Freud, Desencadear um intenso debate que persiste um homem de entre quem foi acolhido favoravelmente, e inclusive a evolução e aplicação da clnica como hicieron os psicoanalistas afins a la escola kleiniana, e os que, por o contrario, se opusieron a estes novos planteamientos tericos y Los rechazaron. En lo que s que hubo un acordo geral foi em uma necessidade de conceder a maior parte do tempo atencioso nos componentes corporativos e destrutivos da personalidade. Está interessado em saber o que é Freud, para o final de sua vida, tena algumas dudas sobre si a formulação de pulsações de morte como manifestacin primária de uma tendência autodestrutiva poda ser modificada. Strachey (1961) e as notas introdutórias ao Malestar na cultura lembrou uma carta de Freud del ao 1937, dirigida pela princesa Marie Bonaparte, na sugestão de que a agresividade está primariamente dirigida para o mundo exterior. El giro da pulsação agresiva para o interior, por descontado, a contrapartida do giro da libido para fora, quando passa dos objetos. Se podra imaginar um esquema segn el cual, originariamente, em todas as pulsações de vida são dirigidas para o investimento e toda a agresividad para fora, e que se estivessem cambiando no curso da vida. Posteriormente, Melanie Klein postul que tambin originariamente a libido estava orientada com os objetos externos, sim, por outro lado, mantém-se o fiel na consideração da agresão como uma externalização de pulsações autodestructivas. Esta divergencia entre psicoanalistas tem um paralelismo a nível sociológico, como se ha. Entre os partidários de negar uma agresividad inata no homem, e por quanto considerar a violência como o resultado de um processo de aprendizagem social, como Ashley Montagu, Geoffrey Gorer, etc. ha existido in vivo intros por descubrir sociedades com ausência de agresividad .......................................................... No obstante, este é o ponto essencial, se trata de estudos muito isolados, você pode limitar-se a avaliar a conduta externa, olvidando examinar a realidade psiquica. Em cambio, na investigação das fantasias diurnas e dos processos, a agresividade dos indivíduos sempre pode ponerse de manifiesto, ms o menos vehementemente. A observação simples dos jogos infantiles aporta dados esclarecedores sobre de sus impulsos violentos. Melanie Klein (1927) selar a analoga existente entre os jogos de nios pequenos em anlisis e alguns crmenes horribles que haban sucedido en nos tiempos. Expondr a continuação de uma vida útil que considero muito ilustrativa sobre a hostilidade latente e não se manifesta na latitude aparente. O paciente A. era um chico jovem com uma personalidade muito passiva, e que iniciou um tratamento psicoanaltico falando a fracaso escolar e uma intensa apata. Era filho nico, con um ambiente familiar muito infantilizador. O padre era um ativo fabricante, muito emprendedor e resolutivo que, além disso, estava com muita freqüência ausente do lar devido a um sus negócios, durante os ratos em que convivem com o filho era muito exigente e chave. La madre, muito sobreprotectora, tentativa de consolar na sua própria soledad a travs de trato como o filho, como si fora su pareja. A. era un filho dcil y obediente, que jams cre problemas e viva muito recluido no mundo, prcticamente sin amistades. O que é o que é mais importante para a criação de um grupo de empresas. Despus de probar diferentes tratamentos mdicos, su familia decidido por uma consulta, enviada por um dos mdicos que habam atendido ao chico. Al cabo de poucos anos de experiência, e durante a separação de uma semana de semana, teve um sueo muy violento que contrastaba com o seu comportamento fortemente inibido e apagado durante as sessões. A. so que: Estaba tumbado na praia, descansando cerca do mar. En la playa haban tambin otras personas desconocidas, y un a mo, mdico, com a esposa. De repente, de menor porte da superfície do sali un ser enorme y extrao. Era como um buzo de antiguos, dentro de uma escadaria, a cabeça em um casco de metal com uma janela de vidro frente aos olhos. Del casco sala un tubo que serva para receber oxgeno. Tambin poda ser como extraterrestre gigante. Aquel ser se dirigi amenazante haca la playa, causando um pavor extremo a todo el mundo, que huy, y yo tambin. Então pusemos uma perseguir a mis tos para embestirles. Meespert an espantado y temblando. Poco a poco, um par de parceria, pudins ir entendiendo su sueo. El ser gigante y extrao representatividade uma parte do paciente que não poda reconocer como própria, e a depositar em um ser alejado e estrambtico, como um extraterrestre. Era, adems, uma parte que é muito infantil, o que é mais fácil de usar. Se diriga contra o analista, representante dos pais, que durante o fim da semana e a sua própria parceira, e é o que é mais simbolizado pela parceria dos mdico unidos e atacados. Al cabo de alguns dos tantos outros, que vena um ser como uma continuação do anterior. Era durante a ditadura franca: Iba a la Universidad e eu encontraba com que o campus universitário estava tomado pela polícia que carregava brutalmente com porras, disparos de pelotas e fundos de humores contra os estudantes, os quais são os edifícios Universitários y se defenderam lanzando piedras y adoquines contra a polica. Eu me asustaba muito y me quedaba paralizado, sin poder mover-me para um lado para outro. No poda irme, ni meterme in the revuelta o tomar partido por algumas das partes contendientes. En este sueo podemos observar o conflito entre um supery muy cruel, representado por policiais, e uma agresividad defensiva ao serviço da supervisão representada pela rebeldia dos estudantes que intentam proteger as tendências na autoconservação, a afirmação e o desenvolvimento pessoal. Ele citou este caso por questões principais. En primer lugar, porque si bem as circunstâncias familiares estão intimamente envolvidas com a patologia de A. pode-se ver com claridade em o primer sueo a dura agresividad que le domina e que, adems, parece uma agresividad muy primigenia, que quase podramos catalogar de Fetal, por las caractersticas morfolgicas del buzo. En segundo lugar porque, tal como se observa em segundo lugar, é um caso em que nos observamos um grave conflito interno que cheguei a paralizar o paciente, sem poder de carga de situação. En este sueo se constata a presença de pulsões agresivas de muy diversa ndole. Por um lado, os objetos tiranos e destrutivos superiados, por outro, a agresividad autopreservativa de los estudiantes. Se trata do mesmo de gnero de pulsões O as diferenças qualitativas de estas de formas de agresividade dependem de outros fatores, como as personagens em que se tem concertado as pulsações agresivas y de vida. Un problema central que se plantea al abordar os fenmenos agresivos en general, o ms concretamente da violência, é cmo entenda a multiplicidade de formas em que se expressa, não nicamente em trminos de intensidade, sino tambin por sus diferentes peculiaridades e funções: autopreservativas , De domínio e bsqueda de poder, de realizacin perversa sadomasoquista, destructiva, etc. Esta heterogeneidad de pulsiones agresivas, que são a partir da literatura da destruição ou aniquilação do objeto, do próprio eu. A la expressin del anhelo de proteção do automóvel do objeto estimado, ha motivado que a nível superior dos enfoques tericos para dar uma explicação coerente a estas questões. Como, autores como Stone, Markowitz, Fenichel y Gillespie, entre outros, recusam a necessidade de admitir uma agresividad primária ou pulsional e bem como o agregado de diferentes actos com diversos orgãos, unidos pela natureza de seu impacto sobre os objetos , Por favor, por ms por sus efeitos. Outros autores em troca, e em uma lnea que continua com as sugestões de Freud, piensan que esta heterogeneidad responde aos níveis da qualidade nas comidas das mãos, das vidas e das mortes, teste quiz de forma mais simples. Provavelmente ms inexacta, prescindiendo de especulaciones de compleja verificacin, entre las pulsiones libidinales e agresivas. A mi modo de ver, esta segunda hiptesis é muito ms prxima a la clnica y pode explicarmos de forma muito ms plausível a diversidade de manifestações em que se expressa a agresividad. Participe de este ponto de vista tratar de exponer a sua própria concepção. Apresente a existência de diferentes classes de pulsações, Freud selar a necessidade de ter em conta a religião e os conflitos ou pugnas entre as mesmas na indústria laboral. En el fondo, todo acontecer vital venidero é presidido por su actitud conjunta io antagnica. Solamente por a accin concorrente ou mutuamente opuesta das pulsões primarias Eros y Pulsin de muerte, nunca por uma outra vez isolada, podemos explicar a multiplicidade dos fenmenos da vida (1937). Tambin seal Freud que en realidade, estas pulsiones quase nunca são apresentadas em forma pura sino que habitualmente estn fusionadas o misturas de forma diferente. Herbert Rosenfeld desenvolveu estas ideias e introduzindo o conceito de fusão patológica para descrever os processos em que são os impulsos liberadores de seres humanos submissos ou subordinados aos impulsos destrutadores, em que se encontram na fusão normal, os impulsos destrutadores, os que estão sendo subordinados e ao serviço de los Libidinales. Ele destacou-se que as pulsações no homem se caracterizam por su plasticidad, pelo fato de ser influentes por fatores de meio ambiente, sobre todo por as situações que afetam a primeira infancia. Desde o momento do nascimento, entre em contato com um processo incessante, entre o recinhecimento e o mundo externo, a travs dos mecanismos de introdução e criação, que é o bsico para o desenvolvimento e a organização da personalidade. A mente infantil se encontra em um lugar de fundo, de acordo com a internalização, ou menos distorsionada dos objetos externos, e, por isso, está distorcida. As situações de comodidade, bem-estar e destino, por o contrário, as de deslocamento e maldade, afetando a imagem do mundo que se vai construindo. Grotstein cree que as experiências suscitadas pelos estados de deslocamento são experientes como a invasin del self por un no-m. Melanie Klein (1934) escreve que é inevitável que a agresividad innata resultou incrementada por praças externas desfavoráveis e de forma inversa, que diminui por obra de amor e comprensão que recebe o nio, e estes fatores continuam atuando durante todo o desenvolvimento pessoal. As privaciones das necessidades emocionais e fsicas do infante não são sentidas como a ausência do objeto, como a presença de um objeto malo (a mãe) que inflinge dolor. Adems, en casos de maltrato infantil o problema se pode complicar devido à possibilidade de as identificações com o agresor. A identificação é uma forma primitiva de funcionamento mental e de vnculo objetal. Probável, um dos fatores ms influentes para que se constituyan subculturas da violência (Wolfgang y Ferracuti, 1971), é decir, territórios ou pases determinados onde a violência se manifestação de forma endmica, é o que é a causa de mecanismos identificadores familiares. Além disso, na forma de bandas violentas as identificações juegan a papel importante. Por um lado, por um lado, a identificação dos diferentes membros com o capito, que depositáve e suporta as capacidades de pensar, decidir e dirigir, e por outro as identificações recortadas entre estes membros, o nível de coerção grupal. O impacto de todos os fatores em toda a série, o que é mais difícil de aprender. Se trata de processos muito completos, em que é necessário implantar uma multiplicidade de eventos que estimulan que se fortalezcan o se atenhem os persecutorios e destruidores, por el contrario, sean los libidinales los que se afiancen. Como seala Ludwig von Bertalanffy, esta possivel destruição é debida a que el homem no vive, nicamente, em un nivel biolgico, sino que cria um universo simbólico no pensamento, a emocin, o lenguaje e a conduta. Y es en este universo simblico onde a violência, entre outras manifestações, adquiere unas caractersticas singulares privativas do ser humano, que desafortunadamente pode expresar um nível de sofisticação e de crueldad muito alejado de reações instintivas próprias de animais. Inclusão em grandes agrupamentos humanas com cierta freqüência ha existido uma idealização da violência, como tem expressado alguns poetas futuristas entre os que sobresale Filippo Tommaso Marinetti, que se torna um afiliado ao fascismo, e quem afirma que a guerra é a devuelve a las razas A virilidade perdida nas masturbações refinadas de velhas civilizações. La guerra, para Marinetti, significaba o herosmo, o amor ao perigo, o ensalamento da força e, como seala Fredric Wertham, o que é mais importante e irracional: a violência esensor como un argumento. Niveles de la conducta violenta Como você está ciente, as pulsações agresivas estn fusionadas com as libidias, o que é a empresa que é a empresa que está em condições de manter entre as diferentes categorias de pulsações e por as peculiaridades da aliança Relacin que mantengan entre s. Outro aspecto a tener em conta é o de pulsões e dirigidas para o auto para o mundo objetal. De acordo com estes pontos de vista, podramos descrever diferentes níveis bsicos u organizações mentais em que se expressam a forma em que se realizou a fusão ou a defusin pulsional. A referência a níveis u organizaciones não existe, alude a configuraciones mentales estables, de tipo caracterolgico, sino tambin a cuasas constelações mentais que se estruturan em momentos concretos e limitados, devido à presença de diferentes fatores, e que explicam a irracionalidade de alguns estados afectivos Y determinadas conductas. Existen situações de conflito pessoais e sociais que favorecem a mudança de comportamentos embrionários violentos. Me refiero principalmente a estallidos de guerras o revoluciones, onde o supery colectivo sufre uma radical transformadora e a proibição de matar se convierte na obrigação de exterminar a los enemigos. Esta transmissão de valores é propiciada por desenfrenagem de uma violência extrema e polimorfa, na que incluso participou pessoas que em perodos de tranquilidade social se haban comportado plcidamente. Isto não significa que todo o mundo se sume a cometer estas exibiciones violentas. Arthur Hyatt Williams, que antes de ser psicoanalista haba sido mdico militar, justo na guerra de Birmania durante a segunda guerra mundial e eu comunicamos informações interessantes observações que efectuam de diferentes combatientes. La guerra na jungla birmana tenia caractersticas próprias. Era uma luta de guerrilhas, na que os combatientes de um e outro estavam escondidos nas profundidades da selva e se atacaban por sorpresa, por lo que cada combatiente se daba perfecta conta dos inimigos que habam matado com sus disparos. Por la noche, a reunir a guerrilha, se comentou a luta e enquanto que alguns soldados se mostraban por causa dos japoneses e os que estão falando sobre a vida, pensando no que diz respeito ao fato, , De tipo manaco, las muertes que haban realizado. É direto, que, enquanto que alguns matá-los em defesa própria e dos valores que sustentam, e são responsáveis sententes de seus atos, habam outros soldados que vivem como um acontecimiento propício para exercitar uma violência de forma aberta, sem trabas e con a Vantagem de que não estava solo justificada, sino que até poda ser premiada. Se definish, de esta moda, das formas diferentes de agresin, da carcter autopreservative e da violência destrutiva, tal como se pona de manifiesto no segundo nível de A .. Em mi opinin, estas diferenças reposan en profundas estruturas mentais, y adems Plantean graves problemas sociales, por lo que ms avançar intentar efectuar uma descrição detalhada de pontos de vista sobre estes temas. De momento slo quisiera sealar que en la agresin autopreservativa los impulsos agresivos estn sometidos a las pulsiones libidinales que são o incitação ao processo de sublimação. Por este motivo, os impulsos primitivos se reorientan a la bsqueda de novos finos e objetos de moda que a agresin se pone, por um lado, ao serviço da maduracça, afirmando o reconhecimento do mundo pessoal, por outro lado, intentando consolidar y afianzar Unos valores e interesses sociales. Enquanto esta forma de agresividad responde a uma finalidad de ndole defensiva frente a as amenazas externas, a violência destrutiva, que pode adquirir mltiples modos de expressão e resposta a diferentes motivações, tem como finalidad infligir dao o subyugar al objeto. Esta violência própria do homem, e a sua vida é a história pessoal, está no domínio do narcisismo, com desespero e falta de preocupação pelo objeto. Um modo de preparação para a exposição, e apesar de não estar em busca de tipos de perfis, você pode se adaptar a um tipo de violência a outro, podemos agrupar a violência destructiva em quatro grandes apartados que respondem a uma continuação : Reaccin frente a um perigo interno, organizador mental sadomasoquista, defusin pulsional e sobretodo, por su gran trascendencia social e as problemáticas que plantea, a motivada por influencias situacionales. Reaccin frente a um perigo interno Contrariamente a as opiniões comnmente admitidas, Freud (1916) postul que la relacin culpadelito se poda invertir en muchos casos. No era el delito el que generaba sentimientos de culpa, sino que existan previamente unos sentimientos de culpa de origen desconocido para o sujeito vinculado à la situacin edpica que incitaba um cometer el delito, bsicamente por does por um lado, para poder concretar la Culpa y, por el otro, para a bsqueda de castigo expiatorio. Antes se ha mencionado como las ansiedades frente a las pulsiones de muerte, actuando en el interior de la mente, pueden llegar a no ser tolerables, por lo que el yo las intenta desviar hacia el exterior en forma de agresin. A pesar de las dudas que suscita la aceptacin de una pulsin de muerte, lo que parece indudable es que la accin intimidatoria de un supery muy arcaico adquiere una dramtica importancia en el origen de ansiedades extremadamente persecutorias y generadoras de culpa insoportable. La desviacin hacia el exterior de las pulsiones destructivas, no solo es debido al propsito de evitar las amenazas internas, sino que tambin se proyecta en el exterior al perseguidor interno para conseguir librarse del mismo, y de esta manera poder controlarlo y atacar para aniquilarlo. Un episodio paranoide, del cual fui testigo, va en esta misma lnea. En una ocasin un individuo que haba asesinado precisamente al polica que le vigilaba, por sus antecedentes y las sospechas que despertaba, me dijo con un tono muy convencido y de forma sigilosa: durante mucho tiempo, y paseando por la calle vi que me segua la misma persona. Como es lgico, empec a sospechar que tramaba algo, asesinarme clavndome un cuchillo por la espalda, o algo as, de forma que decid librarme de este hombre. Sbitamente me tir encima de l y le hund mi navaja en su pecho. Cuando la proyeccin encuentra obstculos imposibles de superar, como ocurre en situaciones de aislamiento, la amenaza interna puede adquirir caractersticas verdaderamente terrorficas como, por ejemplo, el temor de volverse loco presente en los presos recluidos en celdas de aislamiento. En entrevistas realizada en la crcel, diferentes presos me han confiado el profundo pnico que les inspira el que les encierren en estas celdas: su miedo a la locura. Y esto es quiz ms frecuente e intenso en presos con una personalidad conflictiva y un historial delictivo grave. Cuando se les priva de la continua actuacin a la que les lleva su ansiedad y quedan en una situacin de incomunicacin, les invade el miedo a la enajenacin mental. Es como si hubiesen de huir perpetuamente de ellos mismos, descargando su ansiedad por las vas motrices. Es tambin la ansiedad lo que les estimula a la ingesta de drogas, como forma de adormecer la mente y vivir en un mundo ms insensible, opaco y con sensaciones ms sosegadas. Por este motivo, la privacin brusca de la droga puede desencadenar en un individuo adicto una reaccin extremadamente violenta. Una breve vieta clnica puede ilustrar la importancia de la presin superyoica en el desencadenamiento de una brusca crisis violenta. P. era un chico joven que inici una psicoterapia por sus problemas de conducta. Adems de fracaso escolar, cometa pequeos hurtos bolgrafos, caramelos, objetos de escritorio, etc. en las tiendas de su vecindad, eligiendo sobre todo aquellas de las que su familia era cliente, como si desease ser descubierto, y que sus padres se enteraran de sus actividades y le castigasen. Tambin, a menudo se peleaba con sus compaeros y casi siempre se llevaba la peor parte al elegir a los ms forzudos. P. tenia unos acentuados y vagos sentimientos de culpa, que llevaban aparejada una necesidad de castigo. El padre de P. era un hombre de gran fortuna, que controlaba cuidadosamente y con cierta tacaera. Era muy viejo, enfermo y un poco invlido, y se pasaba la mayor parte del da metido en cama. P. era el mayor de una familia con pocos hermanos. Era el favorito de la madre, una mujer aun joven y muy angustiada, con quien mantena una relacin simbitica. Un da, mientras la familia coma junta, el padre atendi una llamada por telfono de un tendero que se quej de que P. haba vuelto a robar en su tienda. El padre, disgustado y con un tono dolorido, recrimin al hijo dicindole: Tu, lo que quieres, es matarme a disgustos. La respuesta de P. irritado, fue lanzar con clera un cuchillo que tenia en la mano contra el padre, como si se lo quisiese clavar. El padre, afortunadamente, se pudo apartar y as evitar ser herido. El anlisis de este suceso puso en evidencia que la incriminacin del padre de que el hijo le matara, determin que la figura paterna ocupase el lugar de un supery acusatorio. Muchas veces el hijo se haba sentido culpable por la vejez y enfermedad del padre, como si l fuera el culpable debido a los ataques verbales o de pensamiento que le haba infligido, as como por el hecho de tener a la madre tan copada. Ante la recriminacin del padre, P. sinti una culpa insoportable ya que pona al descubierto sus celos y encarnaba la realizacin del deseo de disponer para l slo de toda la dedicacin y el afecto de la madre. El ataque contra el padre, en realidad, representaba un ataque a su supery que le criticaba severamente por abrigar en su interior estos deseos prohibidos y que le humillaban. Toda la escena se constituy como una herida narcisista que desencaden una furiosa crisis destructiva. No se trataba de una simple rplica a quien ha lanzado un agravio, sino de una reaccin ms profunda, una respuesta al dolor que puede significar la prdida de la autoestima producida por la ofensa al propio narcisismo. Los acontecimientos que afectan el equilibrio narcisista, fcilmente pueden desencadenar reacciones violentas. En muchos conflictos sociales graves, los problemas de tipo narcisista juegan un importante papel ya que, a pesar de que puedan responder a otras motivaciones econmicas, polticas, etc., los factores psicolgicos en conexin con los aspectos narcisistas de la personalidad, que estn en la base de ciertas efervescencias pasionales, adquieren una enorme importancia. Freud (1917) describi un fenmeno que nombr con el ttulo de el narcisismo de las pequeas diferencias, y que ampli ms tarde (1930) y que hace referencia a los sentimientos de intensa hostilidad que pueden quedar reprimidos y por tanto inconscientes y que se oponen a los sentimientos de confraternidad que seran propios de grupos o individuos vecinos con una cierta convivencia. El destino de estos sentimientos de enemistad puede ser diverso, aunque las consecuencias son similares. Pueden crear situaciones extremadamente conflictivas, como el racismo, el maltrato a la mujer, la lucha entre comunidades con distinta religin o tipo de creencias, etc. Los graves problemas que pueden surgir responden, bsicamente, al temor a la prdida de la propia identidad, a confundirse con el extrao, con quien, por otra parte, se siente cierta afinidad y el odio es una forma de tomar distancia, un intento de autoafirmarse. Por este motivo retrata una actitud propia de individuos con un sentimiento de identidad poco consolidado, y escasamente delimitado. Tambin es posible que los impulsos agresivos sean desviados hacia nuevos objetivos con tal de mantener la cohesin social. Es de sobras conocido que en momentos de crisis social buscar un enemigo o emprender una accin blica es una actitud que ha sido utilizada por bastantes pases para intentar mantener la paz interna. Entre nosotros, durante la poca de la dictadura franquista, cuando las protestas sociales iban en aumento, a menudo se hacan reclamaciones sobre Gibraltar para desviar la agresividad hacia un pas extranjero. En trminos similares, Franco Fornari ha considerado que la guerra representa una institucin social con una funcin defensiva frente las ansiedades paranoides y depresivas que existen, con mayor o menor intensidad, en todo el mundo, y que si bien aparentemente se presenta como una defensa contra peligros externos es, en realidad, una defensa contra peligrosas fantasas internas inconscientes. Estrechamente vinculados con el problema del narcisismo de las pequeas diferencias existen los casos en que la agresin se ejerce contra las personas que pueden representar aspectos rechazados de uno mismo. Z. era una chica joven con grandes necesidades emocionales que intentaba negar, debido a las mltiples frustraciones que haba sufrido desde su tierna infancia. Para sentirse segura, se haba construido una imagen de s misma como de alguien que se bastase por s sola. En la relacin transferencial haba un constante uso de la identificacin proyectiva. La negacin de la dependencia se manifestaba ostentosamente. Actuaba intentando despertar curiosidad, hablaba de forma ambigua incluso dando a entender que haba muchos hechos que no explicaba a menudo llegaba con retraso, hacindose esperar, y las primeras vacaciones las adelant un par de das. En las relaciones de pareja era muy seductora, intentando cautivar al hombre, y cuando consegua que su pareja dependiese de ella, se desenamoraba, ya que su pareja pasaba a representar los aspectos dependientes que odiaba. Entonces, empezaba a maltratarlo hasta que al fin lo abandonaba. El uso patolgico de la identificacin proyectiva tambin tiene una dimensin social que explica la perpetuacin de ciertos regmenes violentos, fundamentalmente en pases poco desarrollados. Citara, a modo de ejemplo, los tpicos golpes de Estado destinados a derribar un tirano y que, en caso de tener xito, es frecuente que a pesar de las promesas de libertad solo implique la sustitucin del antiguo dspota por otro de idntica condicin, que instaura una nueva dictadura. Friedrich Schiller, en la tragedia La conjuracin de Fiesco dramatiza admirablemente este riesgo. Para evitar que Fiesco se pueda convertir en un nuevo dictador, el conjurado Verrina, el amigo de Fiesco, lo asesina una vez que ste ha vencido al antiguo dictador Andrea Doria. Las relaciones entre el poder y el ejercicio de la violencia son algo que ha sido reiteradamente sealado, as como tambin el hecho de que mantener alguna forma de poder se presta a su abuso y a que se estimulen los aspectos regresivos de tipo destructivo de la personalidad, en gran parte por la inmunidad que otorga. Los estudios de Philip Zimbardo, a los que me referir ms adelante, corroboran experimentalmente estas opiniones. En un artculo anterior (Bassols, 1980) intent perfilar diferentes formas de poder, huyendo de criterios polticos y de legitimidad, centrndome nicamente en los aspectos psicopatolgicos, es decir, en los estados mentales en que se apoyan. Distingua entre las formas sanas o al servicio de la maduracin, basadas en unas capacidades y conocimientos y, por tanto, que solo afectaban a aspectos parciales de la relacin y que tendan a anularse progresivamente propias de la posicin depresiva, y las formas en que predominaba la explotacin violenta y el ejercicio del dominio sobre los otros, propias de la posicin esquizo-paranoide. Organizacin mental sadomasoquista He puesto sadomasoquista porque son dos componentes de una misma personalidad en que la presencia de uno implica a su vez la presencia del otro, lo que no impide que exista un predominio de uno u otro, y que el restante est en estado larvado o inconsciente. Aqu, por la orientacin de este trabajo, me ocupar nicamente de los elementos sdicos. Al sadismo en la actualidad se le ha dado un significado ms amplio que el de una perversin sexual. Entendemos por sadismo el abuso de poder que conduce a infligir dao fsico o moral, como malos tratos o humillaciones a otros seres, para obtener una satisfaccin, sentido de dominio, de superioridad, sexual o de sexualidad inconsciente, etc. Lo que define estos estados mentales es la fusin patolgica de las pulsiones, la primaca de las pulsiones destructivas, que establecen una alianza perversa con las pulsiones libidinales, las cuales quedan subordinadas a las agresivas y proporcionan el elemento de fruicin al perpetrarse actuaciones violentas. Al quedar los aspectos libidinales del self atados o en complicidad con los destructivos, las capacidades de vida y de crecimiento mental quedan paralizadas. Para Donald Meltzer, en los estados mentales donde reina el sadismo, se quiere crear un mundo que es el negativo del de la naturaleza, un mundo de no-vida, donde no existen las grandes angustias de los que estn vivos y constreidos por sus lmites. Se tratara, por tanto, de defensas manacas: No es la sensualidad lo que se codicia, sino la triunfante abolicin de la angustia depresiva, y aun de la persecutoria, aunque de la depresiva sobre todo (Meltzer, 1974). Estas defensas manacas que se utilizan ofrecen gran fascinacin. La proliferacin de espectculos de personajes reales o irreales perversos, los temas crueles y la asistencia multitudinaria de pblico que reciben avala este atractivo (el boxeo en muchos pases, adems de otras fiestas sangrantes). Muchas veces queda restringido nicamente a la mera contemplacin, aunque en ocasiones y ciertas personas pueden inducir al paso a actitudes sdicas. Hyatt Williams ha llamado la atencin sobre muchos crmenes que han estado precedidos por periodos en los que se ha cultivado el uso de armas violentas y otros utensilios ofensivos o belicosos, acompaados por fantasas diurnas de carcter violento y la tendencia a frecuentar espectculos brutales como si el futuro delincuente buscara estmulos externos para cometer sus delitos. Esto, adems, como es de fcil observacin, tambin est vigente a un nivel colectivo de ciertos Estados el cultivo primordial de armamento previo a una aventura blica. La organizacin mental sdica es de ndole narcisista, con absoluto desprecio y falta de preocupacin por la vctima, sin sentimientos de culpa o de compasin por el dao que se le ocasiona, incluso puede ser motivo de burla, todo lo cual hace que nada impida la ejecucin de la violencia. Para el autor de una violencia sdica lo nico que es imprescindible es que la vctima padezca un sufrimiento, que es lo que le provoca excitacin. Un problema muy preocupante es que los comportamientos sdicos pueden estar activos en pocas precoces de la vida, en nios y nias al inicio de la pubertad e incluso antes. En muchas clases escolares de nios de estas edades se presentan actitudes de desprecio y asedio moral hacia alguno de los escolares, de forma crnica y prolongada durante mucho tiempo. De pronto, un grupo dirigente deja de comunicarse con un escolar, no le contestan, prescinden de l en los juegos, hacen como si no existiera o se burlan y hablan groseramente de l manifestndole una abierta hostilidad. Un conjunto de actitudes que han sido definidas como mobbying (acoso laboral) o bullying (acoso escolar), y que con la aparicin del Facebook ha tenido una mayor difusin al facilitar las comunicaciones entre escolares. Las causas pueden ser mltiples y los motivos desencadenantes a veces son nimios. En ocasiones se puede elegir la vctima por tratarse de un nio apocado y tmido, pero tambin puede ocurrir con estudiantes brillantes y emprendedores, debido a la envidia que pueden despertar. Tambin puede ser motivo de bullying el hecho de introducir un nuevo compaero en un grupo de clase ya formado, o que el asediado pase por momentos difciles, enfermedades familiares, familia desestructurada, etc. En el bullying . el grupo violento en general est formado por nios mediocres, en ocasiones muy forzudos. La vctima, ante una situacin de este tipo, puede sufrir trastornos mentales graves, depresin, prdida de todo inters y de la autoestima. Por ltimo, existen los compaeros de clase que generalmente consienten la situacin por miedo de que si ayudan a la vctima van a ser tambin motivo de asedio. En el fondo, es una situacin muy parecida a la de muchas poblaciones adultas. Una caracterstica frecuente en las personalidades sdicas son los vivos sentimientos de resentimiento por las muchas injusticias que creen haber sufrido. Se trata de injusticias la mayor parte reales, aunque tambin otras son imaginarias, pero todas tienen como principal funcin disculpar al delincuente por sus actividades violentas. Bastantes presos en la crcel se dedican a escribir sus biografas, memorias, poemas, proyectos de reforma del rgimen penitenciario, etc. Un hecho que he podido constatar en la abundante produccin literaria que me han entregado delincuentes con un cargado historial sdico, es que nunca aparecen sentimientos de culpa sino, por el contrario, una amplia exposicin de agravios, con gran rencor y odio. Muchos de los tatuajes que habitualmente se hacen practicar los presos aparte del popular amor de madre son tambin una ostentosa exhibicin de impulsos violentos. Por esta razn, un sdico puede estar buscando vengarse de forma indiscriminada de una sociedad que ha sentido muy hostil, lo haya sido o no. Hace muchos aos, cuando colaboraba con una institucin dedicada a la reinsercin social de delincuentes, tuve ocasin de estudiar a un joven atracador que nombrar D. Era un chico de gran corpulencia y que trataba a sus vctimas de forma despectiva y sdica, con continuas amenazas y burlas. D. era el supuesto cabecilla de una pequea banda, compuesta por cuatro o cinco miembros, que cometan sus asaltos en un barrio residencial y preferentemente los sbados por la noche. Debido al hecho de actuar siempre en un rea limitada, fue fcilmente detenido gracias a la vigilancia que mont la polica. Lo que sorprendi es que una vez detenido se mostrase aterrado y se pusiera a llorar como un nio. La imagen que se tenia de l cambi radicalmente. En lugar de un chico sdico, que disfrutaba causando pnico a los viandantes, a las parejas elegantes, que eran sus vctimas predilectas, a las que insultaba y amenazaba exhibiendo un peine metlico que haba afilado y que acercaba a los rostros de los atracados a los que alguna vez incluso haba causado algn ligero araazo en la cara, se mostraba como un chico inseguro y tmido. Despus, se supo que trabajaba de camarero en un restaurante donde era muy obediente, con una conducta muy correcta y respetuosa. Era el hijo pequeo de una familia de dos hermanos. El padre y el hermano mayor eran personas agresivas, independientes y que ejercan un oficio muy duro y se burlaban de D. al que despreciaban debido a que lo vean muy dependiente de la madre. La madre tambin haba sido camarera de joven en un restaurante, y era una persona muy dominante que haba deseado que su segundo hijo hubiese sido una nia. Este deseo haba afectado a la relacin con D. que aunque de forma penumbrosa, se haba sentido poco aceptado en su sexo. D. haba sido un nio solitario y con pocos amigos, que en los inicios de la adolescencia iba slo al cine los domingos donde haba sufrido dos agresiones homosexuales y que al fracasar en los estudios la madre le haba colocado de camarero. D. viva sometido a la madre, idealizada y a la vez persecutoria, y luchaba internamente entre el deseo de continuar bajo su dependencia y el deseo de afirmar su personalidad y su virilidad. El conflicto interno se resolvi en la adolescencia adoptando una doble vida, como la del Dr. Jekyll y Mr. Hyde. Durante la semana predominaban las identificaciones con los deseos maternos, cumpliendo sus obligaciones pasivamente y con docilidad en el restaurante, y durante los fines de semana se opona activamente a adoptar esta actitud y deseaba mostrar una masculinidad violenta y sdica. En realidad, el dinero producto de los atracos se reparta entre los otros compaeros de la banda, sin que l participase del reparto, ya que l tenia un sueldo adems de las propinas propias de su trabajo. Ms que ser el lder del grupo, era alguien utilizado por los compaeros que lo estimulaban a ocupar el lugar de mayor riesgo debido a su corpulencia. Para D. esto era una situacin muy satisfactoria, ya que lo que verdaderamente le apeteca era sentir las vctimas atemorizadas y contemplar la cara de terror que ponan, hecho que le proporcionaba una gran sensacin de poder. De esta manera, por medio de las identificaciones proyectivas, poda depositar en las personas asaltadas su parte de nio dbil e indefenso. Hyatt Williams insiste en que cuando los elementos crueles no pueden ser mitigados por los aspectos libidinales del self . tiene lugar una disociacin que provoca que el individuo se comporte como si tuviese dos diferentes personalidades: una brutal y violenta, y otra amable y con capacidad para sentir amor, como en la mencionada disociacin: Dr. Jekyll y Mr. Hyde. Hay ocasiones en que las dos actitudes pueden manifestarse hacia la misma persona, si bien en otros casos existen elecciones claramente diferenciadas para cada una de las actitudes. Un ejemplo tpico es el del miembro de una pareja que maltrata a su conyugue, mientras es complaciente y afable con su amante, o el marido que es impotente con la esposa y en cambio puede ser sexualmente activo con prostitutas. Tambin en el terreno de los negocios o del trabajo podemos observar estas disociaciones con cierta frecuencia. Personas muy correctas en el mundo familiar yo social, y capaces de hacer graves deshonestidades cuando se trata de asuntos econmicos. Esta posibilidad de que un individuo exhiba una distinta personalidad segn determinadas circunstancias, explica el elemento sorpresa, casi de incredulidad, con la que las amistades o conocidos de alguien acusado por un crimen puede recibir las noticias del hecho. Herbert Rosenfeld (1990) describe el caso de una de sus pacientes, mdico generalista y en ejercicio adems como psiquiatra, casada y que pareca feliz en el matrimonio, con buenas relaciones con el hijo y los padres, que tenia en su personalidad una parte criminal y destructiva de la cual su psicoanalista slo se enter, igual que el propio marido, por la noticia que dieron los peridicos de su detencin por la polica por dedicarse al trfico de drogas. Lo que resultaba ms sorprendente es que daba la impresin que mostraba una gran preocupacin e inters para ayudar a sus pacientes. En muchos casos la culpa es negada e incluso pueden idealizarse perversamente las partes criminales de la personalidad, con lo cual los problemas existentes pueden hacerse ms graves ya que el sujeto puede adherirse fanticamente a creencias irracionales destructivas o sdicas, lo que favorece que se dedique a actividades altamente antisociales y malignas como el terrorismo, la tortura, etc. Mientras, por otro lado, contina con sus ocupaciones habituales, intentando anular la culpa y teniendo una vida aparentemente normal. De todas formas, es difcil que las consecuencias de su conducta perversa no se inscriban, aunque sea de forma inadvertida, en el fracaso del proceso de integracin y de maduracin personal, deteriorando al sujeto psquica o somticamente. Precisamente en la obra teatral La doble historia del Doctor Valmy . Antonio Buero Vallejo aborda con gran sutileza el tema de un torturador, miembro de la polica poltica, con buenas relaciones familiares, pero que de resultas de sus actividades de torturador deja castrado a un preso poltico. A pesar de no lamentar ni arrepentirse de su accin de forma consciente, y sin relacionarlo, el torturador lo expa con la aparicin de una impotencia sexual de origen psquico. He conservado el ttulo que utiliza Philip Zimbardo para referirse a este tema, a pesar de que mis puntos de vista sobre estos fenmenos difieren sensiblemente de las suyos. Los graves problemas ticos que ha atravesado la sociedad estos ltimos aos, los terribles horrores de los genocidios, los asesinatos de colectividades enteras, las torturas en lugares de reclusin, crmenes contra la humanidad, vejaciones de toda clase con una absoluta falta de respeto por la vida humana y por su dignidad, han estado efectuados por gobiernos, principalmente los tirnicos, con la colaboracin o el silencio de gran parte de la sociedad. Lgicamente, estos graves hechos han atrado el inters de mltiples disciplinas que se han interesado en investigar sus motivaciones profundas. En este apartado intentar analizar los estudios psicolgicos que me parece gozan de mayor garanta y nos permiten una aproximacin al salvajismo imperante de una violencia desenfrenada. Stanley Milgram (1963), preocupado por la pasividad del pueblo alemn y su obediencia a los crmenes de Hitler, realiz un experimento muy interesante en la Universidad de Yale para detectar hasta qu punto las personas pueden sentirse obedientes a las autoridades. Mediante anuncios, Milgram consigui que cuarenta varones se prestaran a colaborar en un estudio sobre la memoria y el aprendizaje, aunque con este ttulo disimulaba el verdadero objetivo del experimento: el estudio de las actitudes obedientes ( Behavioral study of obedience ). Las personas que se ofrecieron para participar representaban a la poblacin normal de New Haven (EE. UU.), desde simples jornaleros a personas con ttulo universitario, a los que se les pag por su colaboracin. El experimento consista en investigar la influencia del castigo en el aprendizaje. Para esto, Milgram dividi el personal en maestros y en aprendices mediante un sorteo apaado de forma tal que los sujetos que participaban quedaron seleccionados como maestros, mientras que unos cmplices del experimentador hicieron de vctimas o aprendices. Una vez hecha la seleccin, maestro y alumno pasaban a una sala contigua, donde el alumno era sujetado con correas a una especie de silla elctrica, donde recibira descargas elctricas cada vez que cometiese un error de aprendizaje. Las descargas elctricas iban subiendo de intensidad ante los errores del alumno, y eran aparentemente cada vez ms dolorosas. En realidad, las descargas de electricidad eran fingidas y los aprendices hacan teatro quejndose horriblemente del dolor. Lo que interesaba en el fondo era ver cmo los maestros obedecan al aplicar un mtodo torturante, obedeciendo las rdenes del experimentador que instaba a continuar aplicando el suplicio ante les presuntas equivocaciones de los aprendices. Entre los maestros se observaron grandes inquietudes, temblores, sudores, morderse los labios, todos sntomas de su gran inquietud. En catorce casos hubo, entre los que hacan de maestro, risas y carcajadas extraas fuera de lugar, como si intentasen descargar su tensin interna. Un caso tuvo que ser interrumpido por nerviosismo extremo del maestro. Un hecho inesperado fue que ninguno de los casos se tuvo que detener antes de llegar al nivel de shock de 300 voltios, cuando las victimas parecan sufrir intensamente, empezaban a patear la pared y no respondan al maestro. Solo cinco de los 40 maestros se negaron a obedecer rdenes y prolongar el experimento aumentando la dosis de las supuestas descargas. Cuatro aplicaron otra descarga, dos interrumpieron al nivel de los 330 voltios, uno a los 345, otro a los 360 y, finalmente, uno a los 375 voltios de descarga. Es completamente sorprendente ver el alto nivel de obediencia, ya que solo catorce personas (el 35) se rebelaron y se negaron a continuar, y aun, en ciertos casos, de forma muy tarda. Es notable observar la gran tensin en muchos de los obedientes que manifestaban gran inquietud, temblores, etc. y que, sin embargo, continuaban aplicando descargas. Al momento de finalizar el estudio respiraron relajados, sintindose aliviados, cuando hubiesen podido interrumpir el experimento renunciando a la escasa ganancia econmica que perciban. Da la impresin de que a nivel externo se dramatizaba el conflicto interno entre los aspectos violentos del self . puestos mediante la identificacin proyectiva en el experimentador, y sus partes sanas que se oponan a continuar las torturas a los aprendices. Lo que resulta muy negativo es que en la mayora de casos triunf la parte sdica. Como dijo Erich Fromm, este experimento es muy interesante, no solo como estudio de la obediencia y conformidad, sino tambin de la crueldad y destructividad. De igual manera, son importantes los estudios de Philip Zimbardo (1973) quien efectu unas interesantes y demostrativas experiencias que a mi parecer complementan las de Milgram. Sus estudios proporcionan datos tangibles, a pesar de que creo deberan ser objeto de una reinterpretacin, sobre la influencia de la ubicacin o emplazamiento en la escala de la jerarqua social, como inductora quedando siempre un sector de libertad de las elecciones identificativas que efecta el sujeto. En sntesis, el experimento de Zimbardo y otros consisti en un estudio en el que se intentaba valorar en qu medida un entorno institucional poda influir sobre las disposiciones internas de las personas que habitaban en este entorno. El tema que escogieron para realizar esta investigacin fue el carcelario, estudiando el comportamiento de unos supuestos presos y guardianes, y cmo el ambiente determinaba unos cambios disposicionales. Todos los participantes fueron seleccionados a travs de un anuncio en el que se pedan estudiantes voluntarios para participar en una investigacin psicolgica sobre la crcel, cobrando un sueldo de quince dlares diarios. Se dividieron a los voluntarios, mediante el azar, en dos grupos: uno de carceleros y otro de reclusos. Dejo al margen un conjunto de detalles del escenario que ya desde el primer momento pretendan degradar y despersonalizar a los presos, como el hecho de tener que ir con muy poca ropa y, adems, de tipo femenina. Al cabo de unos pocos das, algunos de los participantes que ejercan de guardianes, aproximadamente la tercera parte, se haban identificado con su papel y trataban de forma humillante y desptica a los presos. De este modo, corroboraron lo que escribi Lord Acton en 1887 al afirmar que el poder corrompe, y el poder absoluto corrompe absolutamente. Mientras tanto, los prisioneros se convertan en personas aterrorizadas y sumisas, motivo por el cual se tuvo que suspender el experimento antes del tiempo previsto. Es importante sealar que los guardianes que mantuvieron una actitud correcta frente a los presos no hicieron, sin embargo, nada para protegerlos del grupo ms sdico, como si las mortificaciones y malos tratos que all se infligan no tuviesen nada que ver con ellos. Se convirtieron en una mayora silenciosa. En un estudio sobre las crceles efectuado conjuntamente con el Dr. Josep Oriol Esteve, tambin encontramos que la identificacin de los funcionarios con sus funciones represivas y administradora de castigos, estaban mucho ms asumidas que el destino de vctima por parte de los presos. El mismo fenmeno se ha descrito en el holocausto alemn, en que algunos de los nombrados policas judos se comportaron de forma brutal, parecida a las fuerzas de las SS. Todo un indicativo de los aspectos violentos latentes en muchas personas, y que se manifiestan cuando tienen ocasin de ejercerlos sin riesgo y con total impunidad. Hellman . el que podra catalogarse como el guardin ms duro y sdico en el experimento de Zimbardo, que humillaba y degradaba constantemente a los presos, se excus diciendo que: si te pones un uniforme color caqui, te dan una porra y te dicen que tu trabajo es mantener a raya a unos prisioneros, no eres la misma persona que si llevaras ropa de calle, y por lo tanto tienes que actuar en consecuencia. El resultado de estas pruebas deja un triste sabor. En las exploraciones psicolgicas previas que se hicieron a los sujetos elegidos, se les consider como personas normales. Sin embargo, al entrar a formar parte de la experiencia la mayor parte de los individuos sufri unos cambios de actitud y se revelaron como seres enormemente inmaduros, faltos de un self slido y fuerte que les permitiera desobedecer unas rdenes crueles, e incapaces de poder tomar decisiones de forma autnoma. Este mismo self dbil haca que supliesen sus ineptitudes identificndose con el uniforme y con situaciones externas, sin poder utilizar sus recursos mentales personales para formarse un criterio propio y poder dirigir su conducta. Aunque sera preferible tener un mayor conocimiento de los sujetos de estas experiencias, y pese a que su vida anterior al parecer haba transcurrido normalmente, al someterlos a unas situaciones lmite, una parte, puede que cerca de la mitad, se descompensaron y manifestaron sntomas autnticamente patolgicos. En estos casos sobresale la pasividad ante el entorno, la dificultad para mantener unos criterios personales que les permitiera una libertad de eleccin. Adems, exista una escasez de relaciones afectivas con los compaeros con quienes compartan la misma situacin, y falta de empata ante el sufrimiento de los dems. La pasividad estaba en la base de sus identificaciones mimticas, de un supery pegado a las normas que se les haca aplicar por los que detentaban la autoridad. Todo ello hace pensar en los posibles dficits familiares sufridos por los afectados desde la ms tierna infancia y que habran dificultado la construccin de una identidad slida, lo cual puede tener importantes consecuencias. Mi impresin personal es que en el momento actual los cuidados a nivel psicolgico de los nios ms pequeos y la satisfaccin de sus necesidades mentales es, en general, deficiente y ayuda poco a la integracin de su personalidad, como reflejan los casos de estos estudios. En estos experimentos, tanto la crueldad que se manifest en ciertos momentos, como los diferentes comportamientos exhibidos, nos recuerdan, por la actitud adoptada con cierto parecido, a aquellas personas que colaboraron activamente en los crmenes de Estado ms despiadados y desalmados de estos ltimos tiempos, como han sido el nazismo y otros genocidios como los de Ruanda, los Balcanes, etc. Al plantear estas cuestiones de carcter sociopoltico, creo que una ligera revisin del Caso Eichmann, el mayor criminal del siglo XX que se encarg de llevar a seis millones de seres humanos a campos de concentracin para ser reducidos a cenizas, puede aportar una visin ms amplia. Para ello me guiar por el libro de Hannah Arendt (1999) que estuvo presente durante todo el juicio y escribi un amplio relato del mismo, y de sus propias reflexiones. Intentar profundizar en la mente de Adolf Eichmann crea importantes dificultades por las contradicciones y divergencia de su personalidad. Seis psiquiatras examinaron a Eichmann en Jerusaln, y lo encontraron sano mentalmente. Incluso uno lleg a decir que era ms sano que l mismo, y otro consider ejemplar el trato de Eichmann con su familia. No dejan de ser curiosos estos dictmenes si se observan las actitudes ms ntimas de este hombre. Probablemente las opiniones expresadas y las observaciones efectuadas se referan nicamente a la forma en que Eichmann se presentaba, como un ser adulto normal. Sin embargo, a travs de ciertas observaciones es fcil darse cuenta de su intento de ocultar el enorme vaco de se personalidad, la falta de un pensamiento propio, y su pasividad y falta de emotividad. Ya de joven pretendi ingresar en una logia masnica, pero su amigo Ernst Kaltenbrunner le propuso hacerse de la SS, lo que Eichmann acept. Es decir, una eleccin tan comprometida se hizo de forma superficial, sin saber demasiado lo que significaba ya que conoca poco el nazismo. Lo habitual en Eichmann era dejarse guiar por otros y obedecer rdenes, incapaz de responsabilizarse de sus actos. Su defensa en el juicio fue no sentirse culpable ya que slo haba obedecido las rdenes que reciba, y aadi que no odiaba a los judos cosa que parece cierta ya que tuvo una novia juda. Adems, antes de que se eligiese la Solucin Final, haba hecho el proyecto de mandar a los judos a Madagascar. Pues por qu acept llevar a los judos a una muerte horrible La impresin es que su falta de capacidades emocionales y de juicio las supla mediante unas identificaciones mimticas masivas con las figuras dominantes, y que lo que se le ordenaba se tenia que cumplir sin plantearse ningn juicio moral. Eichmann se poda sentir culpable si un tren se retrasaba, sin embargo no tenia ningn remordimiento por los asesinatos que ayudaba a cometer. Cuando la derrota de Alemania, Eichmann estuvo muy preocupado porque no tendra un jefe que le dirigiera, y estara sin recibir rdenes y sin reglamentos que cumplir. Parece que se trataba de una personalidad como las que describi Helen Deutsch y que denomin personalidades como s, precisamente por su falta de autenticidad. Parecen seres adultos, pero con un gran vaco emocional, son personajes como de teatro, desempean un papel, pero se conducen como tteres, faltos de un vivo mundo interno y una absoluta falta de criterios morales. El problema es que en muchas persona existen rasgos como s que pueden pasar a un primer plano ante una situacin lmite como evidenciaron las experiencias de Milgram y de Zimbardo, con un resultado catastrfico. Como dice Hanna Arendt, lo ms grave en el caso de Eichmann, era precisamente que hubo muchos hombres como l y que estos hombres no fueron pervertidos ni sdicos, sino que fueron y siguen siendo, terrible y terrorficamente normales. He intentado hacer una breve revisin de los puntos que creo ms fundamentales de la agresividad humana, de sus funciones estructurantes y de los efectos destructivos de la violencia. Tambin he elegido los aspectos que creo que tienen un mayor relieve social. Creo que el estudio y la profundizacin en estos temas desde las diferentes disciplinas es una de las tareas ms perentorias, si deseamos vivir en una sociedad menos conflictiva. 1. Este artculo es una nueva versin ampliada de un anterior trabajo titulado Les arrels psicolgiques de la violncia (Bassols, 2001), publicado en la Revista Catalana de Psicoanlisi . Vol. XVIII, nms. 1-2, pp. 5-21. 2. Traducido del cataln por Ramon Bassols y Sacha G. Cuppa. Aranguren, J. L. L. (1992), Problemas ticos de la utilizacin de la violencia, Revista Internacional de Sociologa . nm. 2. Ardrey, R. (1969), Gnesis en frica . Hispano Europea. Arendt, H. (1999), Eichmann en Jerusaln. Un estudio sobre la banalidad del mal . Barcelona, Lumen. Bassols, R. (1980), Reflexions sobre el poder des duna perspectiva psicoanaltica, Quaderns de Psicologia . nm. 2. (1988), Aspectos dinmicos de la delincuencia y adicin a drogas en la delincuencia, Ponencia al Simposio Nacional Sociedad Rorschach . Madrid. (1999), Sobre fanatismo y violencia, Temas de Psicoanlisis (en papel), vol. IV. (2001), Les arrels psicolgiques de la violncia, Revista Catalana de Psicoanlisi . Vol. XVIII, nms. 1-2, pp. 5-21. Buero Vallejo, A. (1976), La doble historia del Doctor Valmy . Selecciones Austral, Espasa-Calpe, S. A. Empdocles. (1944), Poema, en Los Presocrticos . Fondo Cultura Econmico, Mxico. Fornari, F. (1972), Psicoanlisis de la guerra . Siglo XXI. Freeman, D. (1970), La agresin humana en perspectiva antropolgica, en Historia natural de la agresin . compilado por Carthy, J. D. y Ebling, F. J. Mxico, Siglo XXI. Freud, S. (1968), Obras Completas . Biblioteca Nueva, Madrid. (1912), Sobre los tipos de adquisicin de la neurosis . (1915), Los instintos y sus destinos . (1916), Varios tipos de carcter descubiertos en la labor psicoanaltica . (1917), El tab de la virginidad . (1920), Ms all del principio del placer . (1930), Malestar en la cultura . (1932), Nuevas aportaciones al psicoanlisis . (1937), Esquema del psicoanlisis . Gampel, Y. (1997), The role of social violence in psychic reality, en The perverse transference 038 others matters . Ed. por Jorge L. Ahumada y Otros, Jason Aronson. Hartmann, H. Kris, E. Loewenstein, R. M. (1949), Notes on the theory of agresin, Psychoanalytic Study of the Child . nm. 3-4, pp. 9-36. Hyatt-Williams, A. (1964), The psychopathology and treatment of sexual murderers, en The pathology and treatment of sexual deviation . Ed. por Ismond Rosen, Oxford University Press. (1978), The criminal character, 8 Congreso Internacional de Criminologa . Lisboa. Jones, E. (1959), Vida y obra de Sigmund Freud . Editorial Nova. Joseph, B. (1993), La desesperacin engendra la violencia, la violencia engendra la desesperacin, Psicoanlisis . Vol. XV, nm. 1. Klein, M. (1989), Obras Completas . Paids. (1927), Tendencias criminales en nios normales . (1934), Sobre la criminalidad . Laplanche, J. y J. B. Pontalis. (1971), Diccionario de psicoanlisis . Trabalho. Lorenz, K. (1971), Sobre la agresin: el pretendido mal . Siglo XXI. Meltzer, D. (1974), Los estados sexuales de la mente . Kargieman. Montagu, A. y Otros (1970), Hombre y agresin . Kairos. Puget, J. (1988), Social violence and psychoanalysis in Argentina: the unthinkable and the unthought, Free Associations . nm. 1, pp. 84-140. Rof Carballo, J. (1967), Violencia y ternura . Ed. Prensa Espaola. Rosenfeld, H. (1971), A clinical approach to the psychoanalytic theory of the life and death instincts: an investigation into the aggresive aspects of narcissism, International Journal of Psychoanalysis . Vol. 52, pp. 169-178. (1990), Impasse e interpretacin . Madrid, Tecnipublicaciones. Schiller, C. F. (1882), La conjuracin de Fiesco . Biblioteca Arte y Letras. Strachey, J. (1979), Nota introductoria al Malestar en la cultura de Freud, Amorrortu. Wolfgang, M. y Ferracuti, F. (1971), La subcultura de la violencia . Mxico, Fondo Cultura Econmico. Zimbardo, P. J. y Otros (1986), La psicologa del encarcelamiento: privacin, poder y patologa, Revista de Psicologa Social . 1, pp. 95-105. Ramon Bassols Pars Psiquiatra. Psicoanalista de la Sociedad Espaola de Psicoanlisis (SEP-IPA). Presidente de la SEP (1994 8211 1998).Editoraposs Note: The narration and closed captions in this video are in English. For subtitles in 13 other languages, see this video on the website of the World Health Organization . Idelalisib and Rituximab in Relapsed Chronic Lymphocytic Leukemia Richard R. Furman, M. D. Jeff P. Sharman, M. D. Steven E. Coutre, M. D. Bruce D. Cheson, M. D. John M. Pagel, M. D. Ph. D. Peter Hillmen, M. B. Ch. B. Ph. D. Jacqueline C. Barrientos, M. D. Andrew D. Zelenetz, M. D. Ph. D. Thomas J. Kipps, M. D. Ph. D. Ian Flinn, M. D. Ph. D. Paolo Ghia, M. D. Ph. D. Herbert Eradat, M. D. Thomas Ervin, M. D. Nicole Lamanna, M. D. Bertrand Coiffier, M. D. Ph. D. Andrew R. Pettitt, Ph. D. F. R.C. Path. Shuo Ma, M. D. Ph. D. Stephan Stilgenbauer, M. D. Paula Cramer, M. D. Maria Aiello, M. A. Dave M. Johnson, B. S. Langdon L. Miller, M. D. Daniel Li, Ph. D. Thomas M. Jahn, M. D. Ph. D. Roger D. Dansey, M. D. Michael Hallek, M. D. and Susan M. OBrien, M. D. N Engl J Med 2014 370:997-1007 March 13, 2014 DOI: 10.1056NEJMoa1315226 Comments open through March 19, 2014 Background Patients with relapsed chronic lymphocytic leukemia (CLL) who have clinically significant coexisting medical conditions are less able to undergo standard chemotherapy. Effective therapies with acceptable side-effect profiles are needed for this patient population. In this multicenter, randomized, double-blind, placebo-controlled, phase 3 study, we assessed the efficacy and safety of idelalisib, an oral inhibitor of the delta isoform of phosphatidylinositol 3-kinase, in combination with rituximab versus rituximab plus placebo. We randomly assigned 220 patients with decreased renal function, previous therapy-induced myelosuppression, or major coexisting illnesses to receive rituximab and either idelalisib (at a dose of 150 mg) or placebo twice daily. The primary end point was progression-free survival. At the first prespecified interim analysis, the study was stopped early on the recommendation of the data and safety monitoring board owing to overwhelming efficacy. The median progression-free survival was 5.5 months in the placebo group and was not reached in the idelalisib group (hazard ratio for progression or death in the idelalisib group, 0.15 Plt0.001). Patients receiving idelalisib versus those receiving placebo had improved rates of overall response (81 vs. 13 odds ratio, 29.92 Plt0.001) and overall survival at 12 months (92 vs. 80 hazard ratio for death, 0.28 P0.02). Serious adverse events occurred in 40 of the patients receiving idelalisib and rituximab and in 35 of those receiving placebo and rituximab. Conclusions The combination of idelalisib and rituximab, as compared with placebo and rituximab, significantly improved progression-free survival, response rate, and overall survival among patients with relapsed CLL who were less able to undergo chemotherapy. (Funded by Gilead ClinicalTrials. gov number, NCT01539512 .) Media in This Article Figure 1 Progression-free and Overall Survival. At the time the study was stopped, the median duration of progression-free survival among 110 patients receiving idelalisib and rituximab had not yet been reached among the 110 patients receiving placebo and rituximab, the median duration of progression-free survival was 5.5 months (hazard ratio for progression or death in the idelalisib group, 0.15 95 confidence interval CI, 0.08 to 0.28 Plt0.001) (Panel A). The median duration of overall survival in the two study groups had also not been reached the overall survival rate was 92 in the idelalisib group versus 80 in the placebo group at 12 months (hazard ratio for death, 0.28 95 CI, 0.09 to 0.86 P0.02) (Panel B). Figure 2 Forest Plot of Progression-free Survival in Prespecified Subgroups. Hazard ratios of less than 1.00 for disease progression or death indicate better results in the idelalisib group. Article Activity Chronic lymphocytic leukemia (CLL) is the most prevalent leukemia among adults. Standard treatments include combinations of purine analogues, alkylating agents, and monoclonal antibodies. In younger patients without major coexisting illnesses, these regimens can provide high response rates of durable length but have substantial toxic effects. As a result, these treatments often have unacceptable side effects in older patients and those with coexisting illnesses. 1 Patients with relapsed CLL often have limited options because of the development of resistance to, or persisting toxic effects of, previous therapies. This is particularly true for elderly patients and those with coexisting illnesses. 2 For these patients, the guidelines of the National Comprehensive Cancer Network recognize rituximab (Rituxan, GenentechBiogen Idec) as a treatment option. 3 Rituximab is commonly used in such patients, although it has not been approved as monotherapy. Rates of response to rituximab vary, and the duration of progression-free survival is generally short. 4-7 The B-cellreceptor signaling pathway plays a key role in the pathogenesis of CLL. 8-11 Signaling through the B-cell receptor is mediated in part by the activation of the delta isoform of phosphatidylinositol 3-kinase (PI3K). The delta isoform is one of four catalytic isoforms (p110 , , , and ) that differ in their tissue expression, with PI3K being highly expressed in lymphoid cells 12 and the most critical isoform involved in the malignant phenotype in CLL. 13 It activates the serinethreonine kinases AKT and mammalian target of rapamycin (mTOR) and exerts pleiotropic effects on cell metabolism, migration, proliferation, survival, and differentiation. 14,15 Additional surface receptors that may play important roles in CLL pathophysiology (e. g. CXCR4, 16 CD40, 17 and CD49d 18 ) also transduce their signals in part through PI3K. Idelalisib (formerly called GS-1101 and CAL-101) is a potent, oral, selective small-molecule inhibitor of PI3K. 15 In phase 1 studies, idelalisib (both as a single agent and in combination with other agents, including rituximab 19,20 ) had clinically significant activity with an acceptable toxicity profile in patients with relapsed or refractory CLL. On the basis of these encouraging results, we conducted Study 116 a phase 3, randomized, double-blind, placebo-controlled trial of combination therapy with idelalisib and rituximab in patients with relapsed CLL. Study Design and Conduct The trial was designed by the sponsor, Gilead, with input from all the authors. Gilead implemented the study and provided data analysis. The trial was conducted, according to the principles of Good Clinical Practice, at 90 centers in the United States and Europe after approval by the relevant regulatory authorities and the institutional review board at each study site. All patients provided written informed consent. All the authors had full access to the study data and were involved in the interpretation of the data and in the preparation, revision, and final approval of the manuscript. All the authors made the decision to submit the manuscript for publication and vouch for the accuracy and completeness of the data and adherence to the study protocol (available with the full text of this article at NEJM. org). Study Treatment All patients were assigned to receive rituximab intravenously (at a dose of 375 mg per square meter of body-surface area), followed by 500 mg per square meter every 2 weeks for 4 doses and then every 4 weeks for 3 doses, for a total of 8 infusions. Patients were stratified according to the presence of 17p deletion (a deletion of the 17p13 chromosomal region in the gene encoding tumor-suppressor p53 TP53 ) or other TP53 mutations or the lack of somatic hypermutation in the gene encoding the immunoglobulin heavy-chain variable region ( IGHV ), all of which are associated with an inferior outcome. The patients were then randomly assigned to receive rituximab with either oral idelalisib (at a dose of 150 mg) (idelalisib group) or placebo (placebo group) twice a day. Patients in the placebo group who had disease progression while enrolled in Study 116 could enroll in Study 117 to receive idelalisib. Patients in the idelalisib group who had disease progression could receive an increased dose of the drug (300 mg twice daily). Eligibility Eligible patients had CLL that had progressed within 24 months after their last treatment and were not able to receive cytotoxic agents for one or more of the following reasons: severe neutropenia or thrombocytopenia caused by cumulative myelotoxicity from previous therapies, an estimated creatinine clearance of less than 60 ml per minute, or a score on the Cumulative Illness Rating Scale (CIRS) 21 of more than 6 for coexisting illnesses not related to CLL. 2 (The CIRS score ranges from 0 to 56, with higher scores indicating an increased number or greater severity of coexisting illnesses.) Previous treatment must have included either a CD20 antibodybased regimen or at least two previous cytotoxic regimens. Assessments We scheduled clinic visits, which included laboratory testing, every 2 weeks for the first 12 weeks, then every 4 weeks for 12 weeks, and then every 6 weeks for 24 weeks, followed by visits every 12 weeks. The treatment response was assessed on the basis of serial computed tomography or magnetic resonance imaging of the neck, chest, abdomen, and pelvis (performed every 8 weeks for 6 months and every 12 weeks thereafter) and laboratory hematologic measurements. We used the criteria of the International Workshop on Chronic Lymphocytic Leukemia (IWCLL) 22 to determine rates of response and progression, including Richters transformation (in which CLL is transformed into an aggressive lymphoma). These criteria were recently modified to exclude lymphocytosis as an isolated criterion for disease progression in patients treated with agents inhibiting the B-cell receptor. 23,24 Independent review by a committee whose members were unaware of study-group assignments determined rates of response and disease progression for each patient and the dates of occurrence. Centralized reference diagnostic procedures were performed at Ulm University (Ulm, Germany) or Cancer Genetics (Rutherford, NJ) with the use of fluorescence in situ hybridization for genomic aberrations, DNA sequencing for IGHV mutation status, and WAVE DNA fragment analysis and confirmatory Sanger sequencing for TP53 analyses, as described previously. 25-27 Adverse events were graded with the use of the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE), version 4.03. End Points The primary end point of the trial was progression-free survival. Secondary end points were rates of overall and complete response, lymph-node response, and overall survival. Statistical Analysis We calculated progression-free survival, which was defined as the interval from randomization to disease progression or death from any cause (whichever came first), using the KaplanMeier method and compared rates using a stratified log-rank test. We used a Cox model with adjustment for stratification to calculate hazard ratios. The rate of overall response was defined as the proportion of patients who had a complete or partial response on the basis of the IWCLL modified criteria. 25 The lymph-node response rate was defined as the proportion of patients who had a decrease of 50 or more in lymphadenopathy. Overall survival was defined as the interval from randomization to death from any cause. All efficacy analyses were based on the intention-to-treat principle unless otherwise stated. For binary-response end points, we used the CochranMantelHaenszel chi-square test, adjusted for stratification, to assess between-group differences. A sequential testing procedure was applied to adjust for the overall type I error rate in other words, if the primary end point was significant, the secondary end points of rates of overall response, lymph-node response, and overall survival would be tested sequentially. The sample size provided a power of more than 85 to detect a 75 improvement in the median progression-free survival. Two interim analyses were prespecified after approximately 50 and 75 of the anticipated 119 events had occurred, at alpha levels of 0.001 and 0.005, respectively. The 220 patients who were included in the study were enrolled between May 2012 and August 2013. The data cutoff for this analysis was August 30, 2013. A total of 78 of the patients were 65 years of age or older, 40 had at least moderate renal dysfunction (creatinine clearance, lt60 ml per minute), 35 had poor bone marrow function (grade 3 or higher anemia, thrombocytopenia, or neutropenia), and 85 had a CIRS score of more than 6. The median CIRS score in each study group was 8 ( Table 1 Table 1 Characteristics of the Patients at Baseline and Study Status. ). Almost two thirds of the patients had advanced-stage disease, and the median time since the initial diagnosis of CLL was approximately 9 years. More than 80 of the patients had unmutated IGHV, and more than 40 had 17p deletion or TP53 mutations. Patients in the two study groups had received a median of three previous agents, including regimens containing rituximab, cyclophosphamide, fludarabine, and bendamustine. A total of 110 patients were randomly assigned to each study group. All 110 patients in the idelalisib group and 107 in the placebo group actually received the assigned treatment ( Table 1 ). Of the 3 patients in the placebo group who did not receive study treatment, 2 patients withdrew from the study because of an adverse event and 1 patient had not received study treatment before the data cutoff. Receipt of Study Drug At the time of this analysis, the median time that patients had received a study drug was 3.8 months (interquartile range, 1.9 to 8.6 simple range, 0.3 to 16) in the idelalisib group and 2.9 months (interquartile range, 1.7 to 5.6 simple range, 0.1 to 14.6) in the placebo group. A total of 63 patients (39 in the idelalisib group and 24 in the placebo group) received a study drug for longer than 6 months. The duration of treatment was short for the two study groups owing to the recommendation of the data and safety monitoring board to stop the study. However, 81 of patients in the idelalisib group were still receiving the study drug at the time of study termination, as compared with only 52 in the placebo group. The most common reason for discontinuation of the study treatment was disease progression. Progression-free Survival At 24 weeks, the rate of progression-free survival was 93 in the idelalisib group, as compared with 46 in the placebo group (adjusted hazard ratio for progression or death in the idelalisib group, 0.15 95 confidence interval CI, 0.08 to 0.28 unadjusted Plt0.001, which crossed the prespecified stopping boundary for efficacy at the significance level of 0.001. Disease progression occurred in 12 patients in the idelalisib group and in 53 patients in the placebo group. The median duration of progression-free survival among patients in the idelalisib group was not reached, whereas the median progression-free survival was 5.5 months in the placebo group ( Figure 1A Figure 1 Progression-free and Overall Survival. At the time the study was stopped, the median duration of progression-free survival among 110 patients receiving idelalisib and rituximab had not yet been reached among the 110 patients receiving placebo and rituximab, the median duration of progression-free survival was 5.5 months (hazard ratio for progression or death in the idelalisib group, 0.15 95 confidence interval CI, 0.08 to 0.28 Plt0.001) (Panel A). The median duration of overall survival in the two study groups had also not been reached the overall survival rate was 92 in the idelalisib group versus 80 in the placebo group at 12 months (hazard ratio for death, 0.28 95 CI, 0.09 to 0.86 P0.02) (Panel B). ). The treatment effect of idelalisib and rituximab was similarly favorable in all prespecified subgroups, including those stratified according to the presence or absence of the 17p deletion or TP53 mutation and IGHV mutational status ( Figure 2 Figure 2 Forest Plot of Progression-free Survival in Prespecified Subgroups. Hazard ratios of less than 1.00 for disease progression or death indicate better results in the idelalisib group. ). Overall Survival The rate of overall survival in the idelalisib group was superior to that in the placebo group (92 vs. 80 at 12 months), with an adjusted hazard ratio for death of 0.28 (95 CI, 0.09 to 0.86 P0.02). The median duration of overall survival in the two groups had not yet been reached at the time of analysis ( Figure 1B ). Sixteen patients died while participating in the study: 4 patients (4) in the idelalisib group and 12 patients (11) in the placebo group. Overall Response The rate of overall response was evaluated for the 176 patients (88 patients in each study group) who had undergone at least one post-baseline assessment or had discontinued the study before the first assessment at the time of this analysis. The overall response rate was 81 (95 CI, 71 to 88) in the idelalisib group, as compared with 13 (95 CI, 6 to 21) in the placebo group (odds ratio, 29.92 Plt0.001). All responses were partial responses. Lymph-Node Response A total of 169 patients underwent at least one post-baseline imaging assessment of the lymph-node response to treatment. On the basis of a review of imaging results by the independent review committee, the proportion of patients with a reduction of 50 or more in lymphadenopathy was significantly higher in the idelalisib group than in the placebo group (93 95 CI, 85 to 97 vs. 4 95 CI, 1 to 10), for an odds ratio of 264 (Plt0.001) ( Figure 3A Figure 3 Changes in Lymph Nodes and Lymphocytes. Shown are the greatest percentage changes in the sum of the products of the perpendicular diameters of measured lymph nodes for each study patient (Panel A) and the median absolute lymphocyte counts over a period of 48 weeks (Panel B). The I bars represent interquartile ranges. ). Idelalisib-Associated Lymphocytosis Idelalisib, like other novel agents targeting the B-cellreceptor signaling pathway, has been shown to cause lymphocytosis when it is administered as a single agent. 19 The addition of rituximab to idelalisib blunted and shortened the duration of the lymphocytosis, which confirmed the findings of a previous phase 1 study. 20 The rate of lymphocytosis peaked at week 2 and resolved by week 12 in the idelalisib group ( Figure 3B ). In contrast, there was a sustained increase in the absolute lymphocyte count in the placebo group starting at week 24, which coincided with the completion of rituximab therapy. As per the modified IWCLL guidelines, this rise in the lymphocyte count was not considered to be disease progression. Adverse Events Adverse events, serious adverse events, and laboratory abnormalities that occurred during treatment are listed in Table 2 Table 2 Adverse Events, Serious Adverse Events, and Key Laboratory Abnormalities. Most of the adverse events were consistent with those expected for a population with relapsed CLL that had received extensive prior therapy. More than 90 of the patients had at least one adverse event. In the idelalisib group, the five most common adverse events were pyrexia, fatigue, nausea, chills, and diarrhea. In the placebo group, the adverse events were similar to those in the idelalisib group, with the most common being infusion-related reactions, fatigue, cough, nausea, and dyspnea. Most adverse events across the two study groups were grade 2 or lower. In the idelalisib group, grade 3 or higher diarrhea was reported in four patients and grade 3 or higher rash was reported in two patients, with no grade 3 or higher diarrhea or rash reported in the placebo group. Common laboratory abnormalities included anemia, neutropenia, and thrombocytopenia. Hepatic aminotransferase elevations occurred more frequently in patients receiving idelalisib and rituximab than in those receiving placebo and rituximab. Grade 3 or higher elevations occurred in six patients (5) in the idelalisib group, with onset at 8 to 16 weeks. The study drug was withheld and successfully reinitiated in four of these six patients. No patients discontinued the study drug because of aminotransferase elevations. At least one serious adverse event occurred in 44 patients (40) in the idelalisib group and in 37 patients (35) in the placebo group. The most frequent serious adverse events in the two groups were pneumonia, pyrexia, and febrile neutropenia. Adverse events leading to study-drug discontinuation were reported in 9 patients (8) in the idelalisib group and 11 patients (10) in the placebo group. In the idelalisib group, gastrointestinal and skin disorders contributed to 6 discontinuations. In the placebo group, infections and respiratory disorders contributed to 8 discontinuations. Discussion In our study involving patients with relapsed CLL who were not able to undergo standard cytotoxic chemotherapy, treatment with idelalisib and rituximab was associated with significant improvement in the rate of progression-free survival, as compared with placebo and rituximab, a finding that warranted termination of the study after the first prespecified interim analysis. We chose rituximab monotherapy as the comparator for this study on the basis of National Comprehensive Cancer Network guidelines and clinical-use data showing that the drug is a commonly prescribed treatment in the United States for this population and is increasingly being prescribed in Europe (see the Supplementary Appendix. available at NEJM. org). The patients were defined as less able to receive cytotoxic chemotherapy on the basis of severe myelosuppression from previous chemotherapy, reduced kidney function, or a CIRS score of more than 6 for nonCLL-related coexisting illnesses. We used a schedule for the administration of rituximab that was approved in combination with fludarabine and cyclophosphamide two additional doses were added to achieve dose intensification. Improvement in progression-free survival was observed not only in the overall study population but also in all subgroups examined, including patients with poor prognostic features, such as 17p deletion or TP53 mutations and unmutated IGHV . The rate of progression-free survival in the placebo group was similar to that reported for rituximab monotherapy in other trials involving patients who were not selected on the basis of medical fitness for chemotherapy. Furthermore, the median duration of progression-free survival among patients receiving placebo and rituximab was similar to the range of 5.7 to 5.9 months reported among patients receiving monotherapy with ofatumumab, another anti-CD20 antibody approved as monotherapy for disease that is resistant to fludarabine and alemtuzumab. 28 In addition, patients receiving idelalisib and rituximab had significant improvement in overall survival, as compared with those receiving placebo and rituximab. This improvement in survival is further evidence of the clinical importance of the progression-free survival benefit shown in this trial. Significant differences favoring the idelalisib group were also observed in rates of overall response and lymph-node response. There was no overall increase in the rate of adverse events with the addition of idelalisib to rituximab, as compared with placebo and rituximab. Grade 3 or 4 adverse events were common in the two study groups, which was an expected finding, given the large number of previous treatments, clinically significant coexisting illnesses, and prolonged time since the initial diagnosis of CLL in these patients. In earlier studies, idelalisib was associated with elevated aminotransferase elevations, rash, and severe diarrhea. 19 These adverse events were reported in the idelalisib group in our study as well, albeit at a low frequency, and severe events were generally managed with study-drug interruption and symptom treatment. Since the study was stopped early for efficacy, severe diarrhea, which is typically a late-onset event, may yet occur in some patients. A surprising finding was a reduction in rates of infusion-related toxicity from rituximab in the idelalisib group. In conclusion, the addition of idelalisib to rituximab in a population of frail, difficult-to-treat patients, including those with adverse genetic features such as 17p deletion or TP53 mutations or unmutated IGHV, was superior to rituximab monotherapy, which is commonly used in such patients. Although the follow-up in this study was short, combination therapy with idelalisib had an acceptable safety profile. Further follow-up is needed to assess whether idelalisib is safe for long-term use. Patients with CLL who are less able to undergo standard chemotherapy are frequently excluded from clinical trials because of the presence of coexisting illnesses, yet such patients are often seen in clinical practice. On the basis of response rates and progression-free survival results, the combination of idelalisib and rituximab may be a treatment option for these patients. Idelalisib is part of a growing list of agents with activity in CLL, including ibrutinib (targeting Brutons tyrosine kinase) 29 and ABT-199 (targeting B-cell lymphoma 2 protein BCL2). 30 Additional studies will be necessary to define the most effective use of these new agents. Presented in part at the annual meeting of the American Society of Hematology, New Orleans, December 710, 2013. Supported by Gilead. Disclosure forms provided by the authors are available with the full text of this article at NEJM. org. Drs. Furman, Sharman, and Coutre contributed equally to this article. This article was published on January 22, 2014, at NEJM. org. We thank the patients who participated in this study the investigators and coordinators at the clinical sites the employees of Gilead who contributed to the design, implementation, and data analysis Eugen Tausch, M. D. for the genetic analysis and Tim DiChiara, Ph. D. for assistance in the preparation of the manuscript. Source Information The authors affiliations are listed in the Appendix. Address reprint requests to Dr. Furman at the Division of HematologyOncology, Weill Cornell Medical College, 525 E. 68th St. New York, NY 10065, or at rrfurmanmed. cornell. edu. The authors affiliations are as follows: Weill Cornell Medical College (R. R.F.), Memorial Sloan-Kettering Cancer Center (A. D.Z.), the Department of Medicine, and Columbia University Medical Center (N. L.) all in New York U. S. Oncology Research, Springfield, OR (J. P.S.) Stanford University School of Medicine, Stanford (S. E.C.), and Gilead Sciences, Foster City (M. A. D. M.J. L. L.M. D. L. T. M.J. R. D.D.) both in California Lombardi Comprehensive Cancer Center, Georgetown University Hospital, Washington, DC (B. D.C.) Fred Hutchinson Cancer Research Center, University of Washington, Seattle (J. M.P.) St. Jamess University Hospital, Leeds (P. H.), and Royal Liverpool University Hospital, Liverpool (A. R.P.) both in the United Kingdom Hofstra North Shore-LIJ School of Medicine, New Hyde Park, New York (J. C.B.) University of California San Diego, Moores Cancer Center, La Jolla (T. J.K.) Sarah Cannon Research Institute, Nashville (I. F.) Universita Vita-Salute San Raffaele, Instituto Scientifico San R affaele, Milan (P. G.) David Geffen School of Medicine, University of California Los Angeles, Los Angeles (H. E.) Florida Cancer Specialists, Englewood (T. E.) Centre Hospitalier Lyon-Sud, Pierre-Bnite, France (B. C.) Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago (S. M.) University of Ulm, Ulm (S. S.), and University of Cologne, Cologne (P. C. M. H.) both in Germany and University of Texas M. D. Anderson Cancer Center, Houston (S. M.O.). References Gribben JG. OBrien S. Update on therapy of chronic lymphocytic leukemia. J Clin Oncol 201129:544-550 CrossRef Web of Science Medline Eichhorst B. Goede V. Hallek M. 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