Psychotic States

A Psychoanalytic Approach

Herbert A. Rosenfeld

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780367326487
• eBook ISBN: 9780429918339
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Psychotic States brings together a number of the author's papers written between 1946 and 1964 dealing with the psychopathology and treatment of various psychotic and borderline conditions from a psychoanalytic viewpoint. Taking the theories and techniques developed by Melanie Klein in her work with infants and young children, the author investigated their application to a range of psychotic syndromes, including chronic and acute schizophrenia, severe hypochondriasis, drug addiction, severe depression and manic depression, both to determine their possible therapeutic efficacy and to see what light they might shed on the etiology of the psychosis.

1
Analysis of a Schizophrenic State with Depersonalization¹(1947)

THE patient I shall now discuss was sent to me for a variety of physical complaints of a functional origin. In the course of treatment it became apparent that I was dealing with a psychosis of the schizophrenic type. In this paper I shall concentrate only on certain aspects of the case; namely, the schizoid symptomatology and some of the schizoid mechanisms encountered. An additional aim will be to throw some light on depersonalization, and I will try to show the connexion between processes of ego disintegration and depersonalization.

Short History of the Case

My patient, Mildred, is a young woman who was twenty-nine when the treatment started in March 1944. She is of average height and build, with straight fair hair. Her face is not exactly plain, but it usually appeared so because of its lack of expression. During the latter part of the treatment her expression became more alive and she sometimes smiled. She had her first breakdown in health when she was seventeen. Her second breakdown occurred at the age of twenty-five, in the early part of the war, while she was serving in the Auxiliary Territorial Service. She developed one physical illness after another, e.g. influenza and sore throats, until she had to be invalided from the Service. After some time she recovered and made another attempt to defeat the recurring illnesses by joining the Land Army, but again the physical disturbances prevented her from continuing. When I saw her in March 1944 for consultation she had been suffering from a so-called influenza for about four or five months. She agreed to analysis; but we soon realized that she had no desire to come for treatment, and this was in the main due to a deepseated hopelessness about any recovery.

Family and Early History

There were no known schizoid disorders in the family, but one uncle is an alcoholic, and her father has suffered from a neurosis all his life. The patient described him as avoiding company and depending a great deal on his wife. She thought him old-fashioned, extremely dominating and very 'nervy'. She had always disliked him, but had, for the most part, ignored him. During the treatment her relationship with him improved considerably. She had always been very much attached to her mother, and had turned to her frequently in her childhood troubles. As a child she wrote poems and fairy stories and always found her mother a ready audience, and an adult who would treat her as an equal. She had one brother, Jack, nineteen months younger, and a sister, Ruth, six years younger.

Jack seems to have been a very attractive and intelligent boy, adored by everybody. Mildred, however, was ambivalent, but on the whole very fond of him and depended on him a great deal. She had quite consciously tried to adopt his personality and his interests, but had failed. When Jack was killed in a flying accident round about Christmas, 1940, she did not feel anything about it at the time; but during treatment she began to realize what a shock his death had been to her, and how responsible she felt for it. Her sister was very neurotic, suffering as a child from many anxieties, and as long as Ruth was small, Mildred felt quite motherly towards her, which enabled her to accept without much jealousy the greater attention which was shown to the anxious little sister. In contrast to Mildred, Ruth improved when she got older, and during the War did very well in the Women's Auxiliary Air Force. Socially, too, she became more self-confident; but both these circumstances roused considerable jealousy in my patient.

About Mildred's early development nothing abnormal was reported to me. I gathered that she cried but little as an infant and apparently showed no reaction on being weaned. We must remember, however, that schizoid reactions in small children are generally overlooked and we often get a history of a particularly good baby, as in this case. She started to talk and walk normally. In addition to her mother, who breast-fed her, she had a nurse who was very devoted to her. As she was born in 1915, she did not see much of her father, who served all through the 1914-18 war; but whenever he was on leave he took a great deal of interest in his little daughter. When she was nineteen months old, Jack was born, and for three weeks her mother was away in a nursing home. This was the first time Mildred was separated from her mother for any length of time, and it was not until the tenth day that Mildred was allowed to visit her and the baby. Her mother told her later on that from the time she first saw Jack she became completely silent and withdrawn; and this reaction had disturbed the mother very much, since up to that time the child had talked normally. Four weeks after Jack's birth Mildred's nurse left to get married, and the new nurse had mainly to look after Jack. During the following years there were frequent changes of nurses. Mildred disliked them all, complaining to me that they treated her cruelly and often hit her, which might have been true, because she must have been an extremely difficult child to handle. She was frequently told she was no good, while Tack was held up to her as an example of goodness.

I had the impression that there was not only an impairment in her development after Jack's birth, but a definite regression to an earlier level of development. Not only did she give up speaking for a considerable time, but her ability to walk suffered as well, so that Jack developed far in advance of her. When Mildred was six a governess arrived, who seems to have been very prim and proper, but was liked by both children for her other good qualities. At eight years of age, Mildred fell ill with mastoiditis and had to have two operations, which greatly increased her paranoid reactions. She remembers feeling that for no apparent reason the doctors descended on her to frighten and hurt her, and afterwards she never quite overcame her fear of doctors. It took her many months to recover from these operations, and when she was better again she had to face another hard blow. Jack had been sent to school and they were no longer educated together.

She was educated at home by the governess, and for a long time she found it impossible to learn. Only when she was about twelve years of age did her intellectual capacity develop once more, and then she went to boarding-school, where she got on well, sometimes reaching the top of the class. On leaving school, she had a breakdown, which consisted in one physical illness after another, and culminated in a period of uncontrollable crying. The analysis revealed that envy of her best school friend, who got on better than she did, started this breakdown more than a year before leaving school. After school, until shortly before the war, she lived at home and was allowed to do exactly what she wanted. On the whole she felt fairly well, read a great deal; but took no interest in the running of the house. She had frequent periods of withdrawal from both friends and parents, and at these times she felt physically unwell, spending most of the time in bed. In addition, her mental state was always worse at the time of her periods when she suffered great discomfort and pain. As was mentioned earlier, she afterwards served in the A.T.S. and in the Women's Land Army.

Condition when First Seen and during Early Stage of Treatment

When I saw her first, she was living in a large flat in London with her parents, and for some considerable time she continued to be withdrawn from the family life, leaving all the work of the flat to her mother and an elderly maid. Though consciously very fond of her mother, during analysis we realized that she tried to keep her mother completely under her control, ignoring her desire to be assisted, even when she was not feeling well. On the other hand, she wanted her mother to look after her, and give her her meals in bed, if she herself felt unwell. She expected her mother to take an interest in whatever she was doing, but she could stand no criticism from her nor even a suggestion or question referring to anything she might be doing. For example, she did not allow her mother to ask her whether she intended to stay in bed for the day or not, and when she was engaged in some occupation, such as reading, even a comment would be resented. If her mother did make one, Mildred immediately lost any desire to continue what she was doing, and would withdraw into herself. I later found out that there was a gradual improvement in this attitude after about a year's analysis.

Shortly after starting treatment she took up work again, doing some hours at an aircraft factory, and later on she succeeded in getting afternoon work at a well-known bookshop. Her physical health improved gradually and she attended analysis quite regularly, even while she had her periods, though at times she was very late. There were great difficulties with free association, and these increased rather than decreased. She generally made a long pause at the beginning of the hour, and at times she was silent for the whole session or only said a few words at the end. Sometimes the lack of material made it necessary to interpret on the basis of only one sentence. In addition, previous interviews or observations on her general behaviour had to be used for interpretations which were frequently of only a tentative character, and this created difficulties in assessing her reactions in the working-through period. Only on very rare occasions did she succeed in talking fairly fluently for most of the session, and then she spoke predominantly of actual events in the past or present.

Another technical difficulty was a particularly strong resistance to interpretations connecting together material of several interviews, because she could very seldom consciously remember what had been discussed at previous sessions.¹ This made it difficult to obtain the conscious and intellectual cooperation which is so helpful in those schizoid disorders when the intellect is little affected.

The Depersonalization

Her conscious behaviour in analysis was marked by a rigid detachment and denial of all feelings, an attitude which at rare intervals was interrupted by paranoid suspicions or by despair about her lack of progress. Already at an early stage of the analysis she described symptoms and sensations of a distinctly schizoid type and feelings of depersonalization. She felt dim and sleepy, half unconscious and could hardly keep awake. At times when describing her experience she would say that there was something like a blanket separating her from the world, that she felt dead, or not here, or cut off from herself. At other times she called these feelings 'deadlock feelings', and explained that they had increased a few months before the treatment had started. She had felt giddy and faint at the time too.² She was frequently afraid of not being able to speak at all and of getting into a completely unconscious state. I realized that she was aware of the danger of insanity, because she said if she tried to join up with herself she might force her mind completely out of joint.

I have the impression that although this state occurred frequently as a defence against impulses of all levels it was also, indeed perhaps mainly, a defence against feelings of guilt, depression and persecution. From time to time there seemed a small improvement in her condition, but the slightest difficulty, particularly any positive transference interpretation, produced long silences, and when she was able to speak again she related that she had experienced some of the schizoid symptoms I enumerated just now. As usual there was an amnesia of everything we had discussed previously. Her inability to deal particularly with positive transference interpretations had its basis in her marked ambivalence, which I shall discuss more fully later on.¹ Whenever the opportunity arose I interpreted her love and hate impulses towards the analyst, but I had to dose these interpretations very carefully because of the seriousness of the schizoid reactions which followed. The positive transference towards the analyst as a parent, sister or brother figure was always displaced on to other people; but her object-relations at this stage were very insecure, and on analysis it turned out that more often than not the other people represented a part of herself.

To give a short example of this process: Denis, the husband of her best friend, had a nervous breakdown while he was separated from his wife, who was expecting her second child. He tried his best to seduce my patient. At first she had great difficulty in controlling him. The wish to take him away from his wife soon came up as a conscious impulse, but it did not seem that she had any difficulty in coping with this wish directly. Her whole anxiety turned on whether she could control his wishes and arguments. She repeated some of his arguments to me, and it was clear that Denis stood for her own greedy sexual wishes which she had difficulty in dealing with and which she therefore projected on to him. Denis seemed a particularly suitable person for projection, because the precipitating factor of his neurosis corresponded to my patient's early situation, when the birth of her brother precipitated her first breakdown. The analysis of this mechanism helped Mildred to cope with Denis without having to avoid meeting him. Apart from the projection of impulses which were felt by the patient to be bad, there was also a continuous projection of good impulses into other people, particularly women friends, who not only represented good mother-figures, but the good part of herself. She felt excessively dependent on these friends and could hardly function without them. Her great dependency on Jack, which led to her inability to learn without him, was probably of the same nature.

Details of the Analysis

Coming now to the details of the actual analysis, I shall bring forward the instances mainly in chronological order, but it will be understood that I have to select points from a vast collection of material, and I am trying to choose only that which is most relevant to the main theme of my paper. In the winter of 1944-5 the patient developed influenza for the first time since she started treatment. She was afraid that the illness would drag on for months, but it cleared up in the normal time. When she returned to analysis, she told me she had found out quite a lot about the meaning of her influenza, namely, that she liked her 'flu' and enjoyed staying in bed and withdrawing from the world. She spontaneously described fantasies of living warmly and comfortably inside another person whom she thought must be her mother, and remembered that she always told her mother that she had not wanted to be born. She herself related her overwhelming desire to go to sleep, or to become unconscious, to this particular state, and she admitted that she sometimes simply could not bear to remain awake and had to disappear into unconsciousness.¹

This part of the analysis had a distinctly good effect on her physical symptoms; her difficulties then concentrated mostly on getting up in the morning to come to analysis at 10.30 a.m. For weeks she appeared up to forty minutes late. At first she seemed quite unworried about her inability to cooperate. Only gradually was I able to show her the anxiety which was hidden underneath her lack of feeling, and she then started to complain in these words: 'There is nothing to make me get up and come for treatment.' I was at first not sure what she meant by this oft-repeated complaint. Then one day she came almost in tears. She had asked her mother to give her breakfast in bed; she hoped that with her breakfast inside her she would be able to get up. But when she got it, it did not work, and she said: 'It is no good to make it up in all sorts of ways.' I analysed this incident and similar ones in terms of internal and external object-relationships, and felt that her difficulties were mainly due to a failure in introjecting and maintaining a good inner object as represented by the breakfast. Her complaint that there was nothing to make her get up would therefore mean there was no good inner object inside her to help her to get up; the breakfast was supposed to fill this gap but had failed.

Shortly after this she told me of another spontaneous fantasy, which she had had since childhood and which she related now to her difficulties in cooperating. She felt there was a devil who attacked what she called the good people and was keeping them tied up in dungeons. They could not move and had gags in their mouths. No sooner did they manage to get a little freer than the devil appeared, attacked the victims violently and tied them up even more tightly than before. The victims were not killed, yet it was uncertain whether they were still alive. There was no point in fighting this devil because he was stronger than everybody. The only possible method of defence against him was to ignore him. This fantasy threw a light on the very strong negative therapeutic reaction of the patient which followed any improvement or freeing of her personality; it foreshadowed the depth of the paranoid situation which was to be expected in the analytic transference, when the analyst would turn into the devil father. For a while there was an improvement in her ability to come in time for treatment, and the positive transference then appeared, displaced, as always, on to a young relative whom she scarcely knew. After she heard that he was engaged, she felt very disappointed and became afraid of not being able to control her tears during the analytic session. She explained that if she started to cry she might not be able to stop again and would feel very ill. For a week she would not disclose the reason for her sadness. The hour after admitting what had happened, she felt dead and had lost her feelings so completely that she could not believe that she had ever had any feelings of love before. When I interpreted to her the strength of her love and hate, her fear of not being able to control them, and that she was defending herself against depression, she was at first incredulous and felt I was only reassuring her that she had feelings. By the end of the hour she realized that she was warding off feelings of pain and said: 'It is like squeezing one's finger in a door and saying one didn't feel anything.' In this situation the depersonalization was very marked. It followed a disappointment and appeared to be a mechanism of defence against depression. But this view appeared later on to be incomplete.¹

During the next interview the depersonalization increased and was accompanied by feelings of persecution and sensations of being split in two. She talked about her fear of doctors and later on my talking was felt as an attack, making her feel I was pushing her into a hole, putting a lid over her and leaving her there. As a result of this assault she felt dead and although there was another part of her which was alive, the live part and the dead part did not know anything of each other. The connexion of this material with the devil fantasy where the objects were put into dungeons was obvious, and it seemed that the persecuting devil attacked not only her objects but her very self. After the attack her ...

Table of contents

• Cover
• Title
• Copyright
• Foreword
• Contents
• Acknowledgements
• Introduction
• 1 Analysis of a Schizophrenic State with Depersonalization (1947)
• 2 Remarks on the Relation of Male Homosexuality to Paranoia, Paranoid Anxiety, and Narcissism (1949)
• 3 Notes on the Psychopathology of Confusional States in Chronic Schizophrenias (1950)
• 4 Notes on the Psycho-Analysis of the Superego Conflict in an Acute Schizophrenic Patient (1952)
• 5 Transference-Phenomena and Transference-Analysis in an Acute Catatonic Schizophrenic Patient (1952)
• 6 Considerations regarding the Psycho-Analytic Approach to Acute and Chronic Schizophrenia (1954)
• 7 On Drug Addiction (1960)
• 8 The Superego and the Ego-Ideal (1962)
• 9 Notes on the Psychopathology and Psycho-Analytic Treatment of Schizophrenia (1963)
• 10 On the Psychopathology of Narcissism: A Clinical Approach (1964)
• 11 The Psychopathology of Hypochondriasis (1964)
• 12 An Investigation into the Need of Neurotic and Psychotic Patients to Act Out during Analysis (1964)
• 13 The Psychopathology of Drug Addiction and Alcoholism: A Critical Review of the Psycho-Analytic Literature (1964)
• Bibliography
• Index