Understanding Psychosis

A Psychoanalytic Approach

Joachim Küchenhoff

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9781138494671
• eBook ISBN: 9781351025928
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Do psychotic disorders make sense? Are psychotic symptoms amenable to interpretation? Understanding Psychosis: A Psychoanalytic Approach takes the various pathways to psychotic illness outlined by psychoanalytic clinicians and scholars and integrates them into a model that allows a systematic assessment of relevant psychodynamic dimensions in the diagnosis of psychotic disorders, and which serves as a guide to psychotherapy with psychotically ill patients.

Joachim Küchenhoff reviews and integrates various psychoanalytic concepts and theories about psychosis into a multi-dimensional psychodynamic model that allows an assessment and understanding of the patient's subjective experience, objective psychological capabilities, and interpersonal resources. Küchenhoff helps the therapist to establish a basic attitude in working psychodynamically with patients and to understand the dynamics of the therapeutic relationship. Understanding Psychosis also addresses specific issues that can arise in work with clients experiencing psychosis, including understanding imminent crises or precursor states, elucidating semiotic qualities in seemingly negative symptoms, differentiating the psychotic and a non-psychotic part of the personality and providing a dynamic approach to the psychopharmacological treatment. Clinical vignettes and three detailed case reports are included in the book.

Understanding Psychosis will be an essential guide for psychiatrists, psychotherapists and psychoanalysts working with patients experiencing psychosis. It will also be of use to psychologists, and academics and students of psychotherapy, psychiatry and psychoanalysis for psychosis.

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Chapter 1
Psychiatry, psychopathology and psychodynamics

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Psychiatric classifications and the limitations of the psychiatric classification systems

As a generic concept the term ‘psychosis’ has almost completely disappeared from the psychiatric classification systems by now. Although we still can find the term ‘psychotic’ in the ICD-10 (WHO 2016) as well as in the DSM-5 (APA 2013), it is no longer applied in order to describe a wider spectrum of mental suffering. Although it is to be expected that the ICD-11 will provide in the near future a more differentiated assessment of the acute psychotic disorders, we can assume that there will be no major change or significant shift in the fundamental approach. The use of the term ‘psychosis’ as a generic concept was historically justified, as it covered a spectrum of mental disorders not to be subsumed under the opposite generic term of ‘neurosis’, a concept, which is also practically no longer used in psychiatric diagnosis today.

In the past neurosis was defined as a functional mental disorder involving specific symptoms that do not affect and impair the individual’s whole personality, since apart from the neurotic parts of the personality the more healthy parts of the personality continue to persist. It was once the accepted view that neurosis was largely the human psyche’s response to excessive and unresolved mental strain and stress often originating in early childhood.

Psychosis, by contrast, was considered as a condition of the mind which involved a loss of contact with reality and difficulties with social interaction, and that’s why it was viewed as affecting the whole person. But as it is frequently the case, the nomenclature refers to the aetiology and pathogenesis of the disease. Neurosis was considered as being the product of an unfavourable developmental history marked by predominantly adverse and stressful learning experiences; or else the product of a psychic conflict that had to be denied and repressed, so that the conflict was permanently banned from consciousness only to then manifesting itself indirectly in the form of a symptom. Accordingly the hypothesis was made that while psychoses are always the result of somatic illness and are therefore a disease process, neuroses have psychological biographical causes and are therefore a development on a continuum with health. The dichotomy of process and development was followed by a dichotomisation of methods, natural causal explanations of psychoses, on the one hand, and psychological comprehension of neuroses on the other. So, following this line of argumentation, neuroses were basically thought of as psychogenic diseases, whereas psychoses were considered as being either organically caused (exogenous psychosis’) or else as being the result of more or less unknown biological processes (endogenous psychosis’). But that there might be something in between these two positions, that is, the possibility of a so-called psychogenic psychosis, or to put it differently, that psychotic suffering could also arise from psychic conflict, this has been the subject of a controversial debate for a very long time. Take, for instance, hysterical psychosis, which belongs to this category and which essentially corresponds to what Freud described as a ‘psychosis marked by a state of over-dramatisation’: the hysterical mechanism escalates and thus finally develops a momentum of its own, so that in the end the individual is completely caught up and trapped in his own theatrical enactments and hysterical dramatisations.

Looking back, it stands out even more noticeably that this very strong dichotomising tendency, reflected in the choice of terminology mentioned above, whereby descriptive and aetiologically relevant theories and concepts are unduly confused and mixed-up, did not in any way contribute to the reduction of the existing prejudices. And so it is hardly surprising that something had to be done about this and that eventually it was decided that the clinical diagnostics had to be radically renewed. In the ICD-10 the concept of illness or disease was dropped and eliminated, and instead the concept ‘disorder’ was introduced with the following explanation: ‘The term “disorder” is used throughout the classification, so as to avoid even greater problems inherent in the use of terms such as “disease” and “illness”’ (WHO 2016).

And thus we can see, the concept ‘disorder’ first of all bears significance in that it seems to serve a ‘negative’ function, namely: the function to ‘negate’ the other existing concepts. By choosing an ultimately empty and more or less meaningless concept it was intended to dismiss the narrowing and one-sided nosological thinking where diseases are often prematurely classified by their cause or aetiology, or one could say, by the mechanisms by which the disease is caused or by its symptoms. And so the hope was that the use of the concept ‘disorder’ would be an incentive to call into question received ideas and old and long-established thought patterns and to thus expand our field of vision. Although one had to soon admit to the shortcomings and problems the introduction of such a non-specific concept as ‘disorder’ involved, it was nevertheless considered as valuable and as having primarily the function of escaping the influence of the dominant nosographical grid with its detrimental effect that frequently only those symptoms are investigated that are supposed to have a diagnostic value, a fact that consequently excludes the scrutiny of the manifold manifestations of what is really there in the patients’ experience, which is, after all, the essential prerequisite to understanding the inner and outer worlds our patients live in. And thus the concept ‘disorder’ was basically used ‘to imply the existence of a clinically recognizable set of symptoms or behaviour associated in most cases with distress and with interference with personal functions’ (WHO 2016).

We can thus retain that the term ‘disorder’ was deliberately chosen in order to make available to psychiatry and psychopathology a neutral nosological concept. It should be said, though, that the concept did not achieve this aim, because, subtly and involuntarily, disorders would once again be viewed as diseases. As ever the language being used is telling. Is it not a sign of the return of the repressed if one, all good intentions notwithstanding, continues to use a term like ‘co-morbidity’ whenever the presence of one or more additional disorders is co-occurring with a primary disorder? As is well known, morbus designates illness or disease. Certainly, the use of the term ‘co-morbidity’ opposes the basic idea of neutrality and, by the same token, refutes the negation of the idea of disease that the concept ‘disorder’ pretends to pursue.

The second main objective was to create a method of diagnostic classification, which is free of theory and thus foregoes the prejudices of aetiological concepts. The goal was to replace any theory-led or theory-driven prejudices by a rigorous and precise description of the specific phenomena. This, of course, implied to adopt a phenomenological position in the attempt to abstract from, that is, leave aside all of the currently existing theoretical approaches including their theoretical and conceptual prejudices with the explicit aim to go back to the phenomena per se, each of which can (and probably has to) be interpreted differently. The inventories of the classification systems had set themselves the task of being strictly and exclusively descriptive: according to certain predefined criteria the various behavioural patterns and modes of experience are broken down into a great number of psychiatric diagnoses. This in turn results in a broad array of diagnoses that in its sheer diversity and complexity bears the risk of becoming so complex and thus confusing that in the end the clinician may be left without a clue.

In view of this situation the question has to be asked: Is a discipline – a science – that relies upon a ‘theory-free’ modus operandi at all possible? It should however, and I shall say this from the start, be noted that such a claim would contradict the principles of any hermeneutics. And this is actually also in line with Hans-Georg Gadamer’s famous critique of the ‘prejudice against prejudices’, in which preconceptions are seen not only as obstacles but as inevitable and enabling components of any process of knowing (Gadamer 1960). The philosopher even claimed that prejudices are the ground on which we can experience at all; and furthermore he stated that it is a fact that one’s own worldview does not develop ‘ab ovo’, instead we construct reality according to the various traditions incorporated into our languages and cultures.

Now, the further question would be then: What exactly is the modus operandi of diagnostic classification? What one can definitely say about this is that the method of rigorously describing the diagnostic findings boils down to a method which dispenses with all contextual thinking, and which instead collects and lists meticulously and in a non-hierarchical order the entirety of the pathological syndromes observed without looking at them in a wider perspective or without putting them in context to each other. This diagnostic classification method that pretends that it can operate without any pre-suppositions and without any theoretical prejudices, depends solely on its own algorithms for the criteriology of every single diagnosis, thereby disregarding aspects of subjective experience and biography, a method which is predicated on – and this already has to be considered a theoretical basic position – what has become known as an elemental psychology. The idea behind this was to empower psychiatry with a valid and reliable method, which enables the psychiatrist to assess and determine the pathological mental states in their patients. To this purpose, Karl Jaspers in his Allgemeine Psychopathologie [General Psychopathology] (1913) created an approach where he broke up the mental state of his patients in single elements or isolated entities to bring order into the chaos of abnormal psychic phenomena by way of rigorous description, definition and classification. The resulting descriptive phenomenology with its analysis of isolated mental entities has served as the basis for psychopathology in the field of psychiatry until today, one hundred years later.

In the German-speaking countries the system of the AMDP (Broome et al. 2017) has become widely accepted. It particularly helps the young psychiatrist in his continuous process of education to learn to distinguish between different types of pathological conditions, when he is faced, for instance, with the following questions: Is it a hallucination? Is it a thought disorder? Is there a cohesive sense of self or not? Do the affects appear mood-congruent or mood-incongruent? Etcetera, etcetera … To identify all these specific entities or isolated mental features may then provide the ground for a diagnosis. Let’s, for example, consider the issue of thought disorders: ‘flight of ideas’ is always an indication of a manic condition; schizophrenic thinking, by contrast, appears incoherent and absentminded or scatter-brained. Although no single mental feature allows one to establish a diagnosis, it nevertheless, may prove an essential element in the process of eventually reaching a valid and reliable diagnosis (cf. Scharfetter 2002). But what is falling irrevocably by the wayside with this phenomenological approach is the psychology of meaningful connections. Let’s just for a moment consider such an example as a thought disorder, where the view at the wider perspective might be worth taking and one might thus ask the following questions: Are there particular conversational situations with specific persons, or perhaps particular issues that, whenever addressed, could be considered as triggering the symptoms of the thought-disorder?

Such a mechanical, simplistic and elementary application of a merely criteriological approach implies that diagnostic entities are empirically derived on descriptive ‘primary’ sources of data, which are, in effect, the clinician’s account of psychological constructs. And these constructs or definitions seem entirely based on an ‘operationalisation’ of the psychiatric diagnostic process which is in line with particular algorithms While the introduction of operationalised diagnosis in psychiatry was once deemed a useful accomplishment, it has subsequently brought to light evidences of its major short-comings. Mind, for instance, that the clinician’s constructs, or definitions, as it were, are unavoidably reductive and conventional, since in the clinician’s attempt to verbally pin down his observation and find a suitable definition for it, he has necessarily to conform with the linguistic usage, etc. The clinical gaze looking for specific criteria necessarily selects from the great variety of clinical data and thus blanks out and excludes other possible data contents and therefore inevitably ignores possible relevant contexts. And do not forget that the selection of the criteria as such will always depend on some sort of interpretation.

The claim of an atheoretical or theory-free approach is detrimental, since it bears the fundamental risk of, firstly, promising something that, as a matter of principle, cannot be fulfilled, and since it, secondly, disregards certain tacit and implicit presuppositions that – all the same and all the more – exert a decisive influence on the clinical approach. Following this line of argumentation it has to be stated that it is an epistemological requirement to consider the applied criteria as being prejudices, as theoretical presuppositions. To not obscure this fact, but rather bring it to light may help us to become aware of the underlying ‘biases’ or ‘theoretical filters’ and scrutinise them as best as we can. But this is far from common practice today. Unfortunately, the claim for a theory-free diagnostics still hasn’t been laid to rest and thus continues to distract from the fact that any discipline inevitably relies on theoretical presuppositions which, of course, we must never cease to critically scrutinise and reflect upon.

One should certainly not obscure the fact that the diagnostic classification systems create new conventions and new preconceptions with the unfortunate result that they may then exclude the scrutiny of the manifold clinical manifestations of what is really there in the patient’s experience. These classification systems create the language for the many dialects and jargons spoken by the clinicians in the field of mental health, who then are liable to (mis-)take this common language for the reality (i.e. for the knowledge of the phenomena of experience they pretend to grasp). Although they seem to be promising and facilitating in several ways, these classification systems, at the same time, impede other valuable and alternative ways of understanding and looking at things. Against this background we strongly advocate that an epistemological discourse analysis should stand at the beginning of any serious debate. Such an epistemological analysis may open our horizon for alternative perspectives left out and neglected in the diagnostic classification systems of the DSM and ICD. And one of these alternative perspectives most certainly is the psychoanalytic approach.

Psychotic disorders in the ICD-10

Whatever justified criticism may have been levelled at them, it is not possible to flinch from taking notice of the diagnostic classification systems, which nevertheless form a uniform standard for the common technical terminology in psychiatry. The current book mainly focusses upon the psychodynamics of psychosis, and not upon the descriptive diagnostics. In spite of that, it may be of some relevance to become, to a certain extent at least, familiar with some of the clinical pictures linked to the concept of ‘psychosis’. What follows therefore is a brief overview of the psychotic disorders as described in the ICD-10.

First, reference is made to the different types of schizophrenia and the schizotypal and delusional disorders, which are listed under F 20 to F 29.

Paranoid schizophrenia (F 20.0) is dominated by relatively stable, often paranoid delusions, usually accompanied by hallucinations, particularly of the auditory variety and perceptual disturbances.

Hebephrenic schizophrenia (F 20.1) is a form of schizophrenia that is normally only diagnosed in adolescents and young adults, and in which affective changes are prominent, delusions and hallucinations fleeting and fragmentary, behaviour irresponsible and unpredictable, and mannerisms common. The mood is shallow and inappropriate, thought is disorganised, and speech is incoherent. There is a tendency to social isolation.

Catatonic schizophrenia (F 20.2) is dominated by prominent psychomotor disturbances that may alternate between extremes such as hyperkinesis and stupor, or automatic obedience and negativism.

In the ICD-10 undifferentiated schizophrenia (F 20.3) is characterised by psychotic conditions meeting the general diagnostic criteria, but not conforming to any of the subtypes (F 20.0–20.2).

Post-schizophrenic depression (F 20.4) – here only briefly referred to – is followed by residual schizophrenia (F 20.5). It is described as a chronic stage in the development of a schizophrenic illness in which there has been a clear progression from an early stage to a later stage characterised by long-term though not necessarily irreversible, ‘negative’ symptoms, such as psychomotor slowing; underactivity; blunting of affect; passivity and lack of initiative; poverty of quantity or content of speech; poor nonverbal communication by facial expression, eye contact, voice modulation and posture; poor self-care and social performance.

Simple schizophrenia (F 20.6) is described as a disorder in which there is an insidious but progressive development of oddities of conduct, inability to meet the demands of society, and decline in total performance. The characteristic negative features of residual schizophrenia (e.g. blunting of affect and loss of volition) develop without being preceded by any overt psychotic symptoms (anxiety, delusion, hallucinations etc.).

F 20.8 refers to other forms of schizophrenia. F 20.9 refers to schizophrenia, unspecified. Schizotypal disorders (F 21) are characterised by eccentric behaviour and anomalies of thinking, and affect which resemble those seen in schizophrenia, though no definite and characteristic schizophrenic anomalies occur at any stage. In the DSM-5 these disorders are attributed to the group of personality disorders.

If we are concerned with psychotic disorders, we must not forget to also pay special attention to the purely delusional modes of experience, where other characteristic features of schizophrenic disorders are not present, and only delusion is prominent. Delusion is, according to Gruhle (1953), a ‘delusion of reference’. This means that the deluded subject relates a specific external event exclusively to himself, whereby the deluded subject often feels watched, followed or controlled by it. For instance, the subject may be convinced that...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface
• 1 Psychiatry, psychopathology and psychodynamics
• 2 Psychoanalytic theories about psychosis
• 3 Conditions of psychotic experience
• 4 Psychotherapeutic work with psychotic patients
• 5 Psychotherapeutic engagement with psychotic
• References
• Index