Vulnerability to Psychosis

A Psychoanalytic Study of the Nature and Therapy of the Psychotic State

Franco De Masi, Philip Slotkin

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780367329600
• eBook ISBN: 9780429923739
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This book postulates that the trigger of the psychotic condition is located in the basic processes which structure the first emotional relations. It presents some of the reasons why patients succumb to the attraction of a course doomed to result in the permanent derangement of their minds.

CHAPTER ONE
Some psychoanalytic models of psychosis

“Analysts have to admit that where quantitatively massive upheavals of the personality are concerned, such as in the psychoses, the purely psychological methods by themselves are inadequate and the organic and chemical means have the advantage over them”

(A. Freud, 1968, p. 131)

The analytic model

Biological models postulate that psychosis stems from a genetic vulnerability that is expressed in structural or biochemical alterations of the central nervous system. By investigating the symptoms—manifestations of underlying organic changes—we can seek out and identify the biological defect that lies upstream of them.

According to psychological models, on the other hand, the symptoms are the expression of a psychic dynamic whose origins can be traced back to the patient’s current or childhood relationships. The psychoanalytic view is that the reasons for mental disorders are unconscious; thus, psychoanalytic investigation is based on a general theory of psychopathology and follows an eminently individual path. Psychoanalytic theory itself stems from in-depth study of a small number of individual clinical cases, which, however, allowed the development of general theories of mental functioning. Based as it is on clinical experience, psychoanalysis proceeds through theories that are open to modification in time, with new paradigms replacing and supplementing earlier ones. In this respect, it is no different from other disciplines whose theories are subject to verification and change.

Although psychoanalytic theories may change, the method itself remains the same. The analyst thereby reconstructs the patient’s infantile history and relationships with significant figures, identifies primal traumas, and seeks to understand the dynamics of the patient’s mental suffering, starting from the first emotional experiences. It is, therefore, important, in the case of psychosis, for the psychoanalyst to have a valid theory for understanding the genesis and particularity of that state—a theory that accounts for the patient’s vulnerability and differentiates it qualitatively from other psychopathological conditions.

The encounter between psychoanalysis and psychosis occurred very early on: many analytic intuitions stemmed from the observation of psychotic states or were used to explain them. For example, the theories of primary narcissism, autoerotism, and withdrawal of libido from the outside world owe their existence to the study of psychotic processes. Many characteristics of the unconscious, such as the primary process, timelessness, and the absence of contradiction, closely resemble those of psychosis, understood as an invasion of the ego by the unconscious. The idea of hallucinatory wish fulfilment in children is also based on this analogy.

In his description of the unconscious processes that underlie dream production, Freud uses psychotic phenomenology as his model. In An Outline of Psycho-Analysis (1940a [1938], p. 172), he writes that a dream is nothing but a minor psychosis that occurs every night: “A dream, then, is a psychosis, with all the absurdities, delusions and illusions of a psychosis . .. an alteration of mental life [that] can be undone and can give place to the normal function”.

The earliest psychoanalytic theories linked psychological disorders to corresponding phases of infant development. According to such theories, mental disease corresponded to primitive modes of psychic functioning and there was an equivalence between the primitive and the pathological. Psychosis, too, was included in this hypothesis: Freud’s view was that psychosis coincided with an autoerotic withdrawal and a regression to forms of primitive development.

Melanie Klein (1946) also believed that the impulses and anxieties underlying states of schizophrenic persecution corresponded to primitive functioning dominated by sadism and the death drive. In her opinion, the disposition to psychosis depended on primitive impulses and anxieties that were normally transformed in the course of infantile development. If this did not happen, the psychotic nuclei remained unmodified and were destined to emerge in adulthood. As I shall explain more fully later (Chapter Two), although the analogy between the primitive and the pathological has opened the way to stimulating research, it postulates equivalences which are difficult to uphold and might at times prove misleading.

Bion (1967), on the other hand, presented a model in which psychosis did not represent a return to primitive stages of development, but was rather the expression of an altered capacity to think: the disorder concerned the functions which transformed sensory perceptions into thoughts. For this reason, the patient was unable to work through the events of his mental life on the symbolic level.

Continuity-based and discontinuity-based models

In the analytic theory of the psychotic state, explanatory models based on continuity and on discontinuity exist side by side. Continuity-based models present the development of psychosis as the outcome of the operation of mechanisms that are also active in normal development and in the neuroses, whereas discontinuity-based models regard psychosis as a radical breakdown of the normal functions of thought and emotionality, these being replaced by mental processes that are totally different and of which little is known (London, 1973).

Continuity-based models, which can also be termed unitary, seek to maintain the connection between the analytic theories of psychosis and neurosis, respectively. They tend to interpret psychotic behaviour as unconsciously stemming from intrapsychic conflicts similar in nature to those of neurotic patients. Discontinuity-based theories, on the other hand, are specific, postulating as they do that psychosis is a distinct disorder. I shall now give a somewhat partial summary of the development of psychoanalytic thought on psychosis, mentioning the theories that I consider most important. I shall not describe here the development of analytic technique in the treatment of psychotic states, an exhaustive account of which can be found in Rosenfeld (1969).

Sigmund Freud

In Freud’s writings, it is possible to find both a unitary theory and a specific theory of psychosis. At times, he explicitly states that the interpretation of psychosis does not differ substantially from that of neurosis:

The psycho-analyst, in the light of his knowledge of the psychoneuroses, approaches the subject with a suspicion that even thought-structures so extraordinary as these and so remote from our common modes of thinking are nevertheless derived from the most general and comprehensible impulses of the human mind; and he would be glad to discover the motives of such a transformation as well as the manner in which it has been accomplished. [Freud, 1911c, p. 17]

Again:

The same research workers who have done most to deepen analytic knowledge of the neuroses, such as Karl Abraham in Berlin and Sándor Ferenczi in Budapest (to name only the most prominent), have also played a leading part in throwing analytic light on the psychoses. The conviction of the unity and intimate connection of all the disorders that present themselves as neurotic and psychotic phenomena is becoming more and more firmly established despite all the efforts of the psychiatrists. [Freud, 1924f, p. 204]

Freud describes the mechanism of projection as the externalization of an intrapsychic conflict into external reality. Thus, for example, Senatspräsident Schreber’s mental illness resulted from a homosexual conflict which manifested itself in the following sequence: intrapsychic conflict, anxiety, projection on to the outside world, and regression to an earlier stage of fixation. On the scale of phases of psychosexual development, in which the more severe disorders lie on the more primitive levels and the mildest higher up, schizophrenic psychosis occupies the lowest level, that of autoerotism. While these Freudian concepts may appear somewhat simplistic today, nevertheless they contain extraordinary insights, considering when they were formulated.

Psychotic withdrawal and the expansion of the delusional world do indeed correspond to the libidinal decathexis described by Freud. In neurosis, it is repression that produces the symptom; in psychosis, on the other hand, it is libidinal decathexis that leads to a withdrawal from reality and induces regression to the autoerotic stage.

Elsewhere, however, Freud distinguishes between neurosis and psychosis and outlines a specific theory of the latter. He writes as follows to Abraham on 21 December 1914:

I recently discovered a characteristic of both systems, the conscious (cs) and the unconscious (ucs), which makes both almost intelligible and, I think, provides a simple solution of the problem of the relationship of dementia praecox to reality. All the cathexes of things form the system ucs, while the system cs corresponds to the linking of these unconscious representations with the word representations by way of which they may achieve entry into consciousness. Repression in the transference neuroses consists in the withdrawal of libido from the system cs, that is, in the dissociation of the thing and word representations, while repression in the narcissistic neuroses consists in the withdrawal of libido from the unconscious thing representations, which is of course a far deeper disturbance. [Freud & Abraham, 1965, p. 206]

From this point of view, Freud characterizes psychosis as an internal catastrophe resulting from the withdrawal of libido, a loss which leads the patient to decathect the mental representation of the object, and, consequently, of his link with the world. The catastrophe is followed by a recathexis of libido, which corresponds to an attempt at reconstruction.

In two other important works, Freud (1915e, 1917d) again hypothesizes that psychosis is specific in nature. Taking as his starting point the difference between thing presentations and word presentations, Freud suggests that in schizophrenia it is words that enter into the so-called primary process. Having decathected both the thing presentation and the word presentation, schizophrenics attempt to recover by setting “off on a path that leads to the object via the verbal part of it, but then find themselves obliged to be content with words instead of things” (1915e, pp. 203–204). In this way the psychotic treats words, which are condensed and involve substitutions, as if they were things. These insights of Freud are, in my view, still useful for understanding how words and word associations have the power concretely to potentiate the delusional imagination.

Freud (1924f) writes that under normal conditions the ego is governed by the reality principle. In neurosis, relations with reality are maintained as a result of drive repression, whereas in psychosis they are lost because a more radical mechanism, which may be called disavowal, is at work (Freud, 1924e). In psychosis, it is not the drive that is repressed, as in neurosis, but the perception of external reality: the psychotic patient obliterates the mental representation of the object. When reality is annihilated because the id triumphs over the reality principle, the ego must find something to replace the lost reality. Delusion then represents an attempt at healing and at the reorganization of reality.

Freud emphasizes on a number of occasions that the alteration produced by psychosis concerns the ego and not the relationship between the three psychic agencies (ego, id, and superego), as occurs in neurosis. In “Fetishism” (1927e), Freud describes the mechanism of splitting, which gives rise to an irreducible alteration of the ego and enables two contradictory thoughts to coexist. On the colonizing power of psychosis, he writes:

They [the pathological phenomena] are insufficiently or not at all influenced by external reality, pay no attention to it or to its psychical representatives, so that they may easily come into active opposition to both of them. They are, one might say, a State within a State, an inaccessible party, with which co-operation is impossible, but which may succeed in overcoming what is known as the normal party and forcing it into its service. If this happens, it implies a domination by an internal psychical reality over the reality of the external world and the path to a psychosis lies open. [Freud, 1940a (1938), p. 76]

Freud’s thoughts on the treatment of psychosis and its outcomes varied greatly over time. He sometimes had recourse to a psychoanalytic model to explain the patient’s symptoms, for example in the case of Schreber, yet he also declared that analytic treatment was unsuitable for psychotic patients.

To sum up, Freud neither delved systematically into the clinical aspect of the analytic therapy of psychosis nor described any treatments of psychotic patients. However, he expressed his confidence on various occasions, praising colleagues, such as Abraham and Ferenczi, who undertook such work. For the rest of his life, Freud remained undecided between, on the one hand, a pessimistic view stemming from psychotic patients’ observed inability to develop a transference, and, on the other, the more optimistic notion that effective therapy would become available one day. Freud held that the difficulties of treating psychotic patients derived from their narcissistic entrenchment and the consequent denial of dependence on the object.

Rosenfeld (1969) rightly remarks that there was always a dichotomy between the theoretical and clinical levels in Freud. Despite having formulated the concept of the splitting of the ego into a normal part and a psychotic part, Freud did not use this insight in treatment. Neither did he postulate the existence of a conflict between the sick and healthy parts, nor between libidinal and destructive aspects, even though he had identified this in the theory of the life and death drives.

Karl Abraham

Karl Abraham was the first psychoanalyst after Freud to shed light on the genesis of psychotic disorders. Abraham’s attempts to understand psychosis (dementia praecox) date from his time at the hospital in Zurich. When he moved to Berlin, his interest shifted to manic–depressive psychosis. I have shown elsewhere (De Masi, 2002) why Abraham was unable to pursue his interest in psychotic patients further after moving to Berlin.

At the Salzburg Congress in 1908, he presented an important paper, entitled ‘The psychosexual differences between hysteria and dementia praecox’, in which he linked the disease in adults to the vicissitudes of infantile development. This was the first attempt to apply the psychosexual theory to psychotic disorders. Abraham saw in psychotic patients a total break with reality and a complete inability to transfer libido on to external objects.

Whereas hysterical patients were excessively attached to one of their parents, their psychotic counterparts (or rather those suffering from dementia praecox as defined by Kraepelin) showed indifference or hostility towards them. Abraham postulated that the main feature of psychosis was the absence of libidinal cathexis of objects and that object libido, recathected in the ego, was a source of megalomania.

Another interesting observation by Abraham was that the mechanism of repression was lacking in psychotic patients. Consequently, their behaviour was concrete and characterized by exhibitionistic, eroticized, or regressive–faecal acting-out. Moreover, dementia praecox coincided with a regression to the infantile autoerotic stage. A few years later, in his famous contribution on schizophrenia, Bleuler (1911) introduced the concept of autism, which is similar to Freud’s and Abraham’s description of autoerotism. The correspondence between Abraham and Freud includes some joking references to the fact that Bleuler had borrowed the concept of autism from that of autoerotism. Yet, it should be remembered that the concept of autoerotism was formulated by Freud; it first appears in his letter to Fliess of 9 December 1899 (Freud, 1985, p. 390). Freud stated then that autoerotism constituted the primitive state of sexuality, which could reappear in paranoia.

Whereas delusions of grandeur could be traced back to the afflux of libido to the ego, those of persecution resulted from the patient’s terror of the outside world, which became threatening and inhuman. Dementia, Abraham noted, concerned the patient’s emotions, which were distorted or blocked, and not his intellectual performance, which could remain intact.

Otto Fenichel

Fenichel (1945) classified psychosis in accordance with the psychosexual model. Although neurosis and psychosis both had infantile sexual impulses as their precipitating factor, their defence mechanisms were different. Unlike neurotics, psychotic patients used a very archaic defence, withdrawal from reality, which caused them to regress to primary narcissism, where no distinction existed between ego and id. The regressive collapse of the ego also led to the abolition of the differentiations acquired in the course of psychic development. Psychosis began with regressive symptoms followed by symptoms of restitution, such as hallucinations and delusions, which constituted an attempt to reconstruct reality after th...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Dedication
• ACKNOWLEDGEMENTS
• ABOUT THE AUTHOR
• PREFACE
• FOREWORD
• INTRODUCTION
• CHAPTER ONE Some psychoanalytic models of psychosis
• CHAPTER TWO The primitive and the pathological in psychosis
• CHAPTER THREE An example of psychotic transformation
• CHAPTER FOUR The unconscious and psychosis
• CHAPTER FIVE The meaning of dreams in the psychotic state
• CHAPTER SIX Intimidation at the helm: superego and hallucinations in the analytic treatment of a psychosis
• CHAPTER SEVEN Difficulties in therapy: relapses into psychosis
• CHAPTER EIGHT Intuitive and delusional thought
• CHAPTER NINE Transference psychosis
• CHAPTER TEN The fate of the transference in psychosis
• CHAPTER ELEVEN Psychotic withdrawal and jeopardization of the sense of reality
• CHAPTER TWELVE Disturbance of identity in the psychotic process
• CHAPTER THIRTEEN Trauma and psychosis
• CHAPTER FOURTEEN Some modes of entry into psychosis
• CHAPTER FIFTEEN Concluding remarks
• REFERENCES
• INDEX