Psychosis and Near Psychosis

Ego Function, Symbol Structure, Treatment

Eric Marcus

• Publisher: Routledge
• Year: 2017
• Print ISBN: 9781138925977
• eBook ISBN: 9781317383413
• Topic: Psychologie
• Subtopic: Klinische Psychologie

The goal of psychotherapy as formulated in this revision of a classic text is to improve ego function of severely disturbed patients who are often hospitalized. This book shows why and how. It describes the psychotherapeutic techniques that aid patients to understand the meaning of the psychotic symbols so that they can experience reality and their emotions as separate entities. Medication effects and the neurobiology of psychotic and near psychotic patients are explained and evaluated in terms of specific ego dysfunction so that psychopharmacology may be targeted. With the first edition originally a recipient of the prestigious Heinz Hartmann Award, this valuable resource is a go-to guide for clinicians who treat patients suffering from crippling mental disorders.

The Open Access version of this book, available at http://www.taylorfrancis.com, has been made available under a Creative Commons [Attribution-Non Commercial-No Derivatives (CC-BY-ND)] 4.0 license.

Chapter 1

Ego Functions

Introduction

The ego is the term psychoanalysis uses to categorize and describe mental processes that regulate and mediate between the experience of reality and the experience of emotions. This chapter discusses those mediating and regulating ego functions, experiences, and organizations of experiences that are particularly relevant to understanding psychotic and near psychotic illnesses.

According to Hinsie and Campbell (1963), the ego is “a part of the psychic apparatus which is the mediator between the person and reality; the perception of reality and adaptation to it” (cf. Campbell, 1989).

Laplanche and Pontalis (1967) review the history of the term ego in psychoanalysis. They clearly describe the evolution of Freud’s use of this term: the ego meaning person or self, the ego meaning a collection of emotional defenses, and the tension between these two uses.

Hartmann (1939, 1964) focused on a third aspect of the ego: mechanisms of regulation between reality and the person, which he called ego apparatuses. These processes mature from birth onward according to their own timetable. They are aspects of mental functioning which especially mediate the perception, organization, and use of reality. Examples are vision, memory, and certain kinds of logic. I will later subdivide and add to these.

Because of Hartmann’s focus on reality rather than unconscious fantasy, because the apparatuses seem to mature according to a neurological rather than only a psychological timetable, because the apparatuses are said to be relatively free of unconscious emotional conflict, and because apparatuses correlate with conscious and cognitive functioning as well as other aspects of general psychiatry, Hartmann’s apparatus concept has been criticized as nonpsychoanalytic, i.e., nondynamic or nonemotional.

But the concept is not easily dismissed. Schafer (1968b), Blanck and Blanck (1979, 1986), and Loewald (1988) all focus in varying ways on the ego as a set of integrative regulations. They especially focus on the superordinate result of the functioning of this apparatus which mediates the integration we know as normal mental life. (For a review of Hartmann’s description of ego function as an integrative and regulatory process, see L. Friedman [1989]; also Rapaport [1951a, 1959] and Holt [1965]).

All psychoanalysts agree that the term ego is used, in part, to describe the mental interaction with reality. It is this aspect of ego function in particular that this book focuses on, because in psychotic and near psychotic illnesses, alterations in reality ego function are the most dramatic and distinguishing feature.

When specific problems with the ego’s interaction with reality are described, one ends up describing specific ego functions that Hartmann called autonomous ego apparatuses and ego functions. This is the clinical fact. A careful description of psychotic and near psychotic ego functioning leads inevitably to some apparatus concept. The exact relationship between these functions and emotional or dynamic material varies, and hence the degree of autonomy varies. But I believe it is a damaged ego apparatus function that gives psychotic and near psychotic organization to dynamic, emotional material and to object relations. This hypothesis grows out of the observation that intercurrent psychotic illness can cause a dramatic reorganization of dynamic elements without necessarily changing the dynamic content.

Hartmann’s ego psychology divides ego functions not by reality experience and emotional experience but into autonomous ego functions or apparatuses, primary or secondary, and defensive functions. I will be discussing primary autonomous apparatuses. Though these apparatuses can also perform defensive functions, primary autonomous apparatuses refer to aspects of reality-oriented cognitive thinking ability and perceptual ego functioning in the area of reality experience. The autonomous ego function apparatuses deal, for the most part, with outside phenomena. They deal with percepts, their recording and organization. Schafer (1968b) discusses autonomous ego functions which include nonperceptual aspects of cognition. Autonomous ego functions are also integration functions. They are reality based and organize reality experience. They also organize certain relationships between reality experience and emotional experience. In healthy people, these functions are relatively free of, and hence not completely distorted by, emotional experience. In this sense, they are autonomous.

How do these ego functions get damaged? No one knows. I believe there are biological factors in the etiology of psychosis which operate especially at the ego apparatus level because we observe that the apparatuses that deal with reality are so altered in psychotic and near psychotic states. These apparatuses have neurological properties (e.g., sometimes known neurological pathways as in sensation and memory) in addition to psychological properties, which are clearly also influenced by learning and emotional state. I hypothesize but am unable to prove that, in psychosis, the apparatuses are a major area where neurobiological factors exert their effect on adult psychology.

Emotional conflict may play a role in triggering apparatus decompensation in some illnesses. The mechanisms of this triggering are unknown, but the effects and treatments are known. Psychological stress, a crucial factor that often plays a describable role, is unique to each individual and is encoded in mental structures along with apparatus function. For some patients, specific psychological stress can trigger biologically determined psychotic or near psychotic reactions. This relationship can be described.

Emotional life is encoded, translated, and experienced differently when ego apparatus functions are damaged. For each patient, one can describe specific ego deficits and conflicts. One can then prescribe a treatment that will address the combination.

I will now describe ego functions relevant to psychotic and near psychotic structure.

The Ego and the Experience of Reality

Reality Experience

I need a term for the mental sensation and organization of outer reality. I will use the simple, descriptive term reality experience.¹ I distinguish reality experience from reality per se and also from the perception of that reality.

There probably can be no universal agreement or descriptive definition of the experience of reality. However, the unusual, striking, and descriptively definitional phenomenon of psychosis and near psychosis is the special experience of reality that occurs.

The experience of reality often involves the experience of external stimuli (Kraepelin, 1915). Reality-mediating mental processes form sensory information out of perceptual data. Reality experience is, therefore, often built on sensory information. But reality experience also uses abstract concepts built by conscious, conceptual, logical thinking. Reality experience tends to be organized logically, with inductive and deductive reasoning building links between perceptual information and concepts. Reality experience builds in complexity from the interaction of perception with conceptual thinking.

Reality experiencing capacity is mediated by a complex, partly autonomous, neuropsychological, maturational and developmental ego function apparatus. This is why Piaget (1954) can describe its evolving course throughout childhood (see also White, 1963; Weil, 1970; Sterm, 1985; Greenspan, 1988, 1989; see also Table 1.1). Reality experience depends on many subsidiary, partly autonomous ego functions, the major group of which is called logical or secondary process thinking.

Table 1.1 Reality Experience

1 Relies on percept
2 Relies on reality-oriented logic
3 Evaluates inside and outside
4 Uses as information processing strategies: learned patterns, deductive and inductive reasoning
5 Builds abstract concepts; generalizes and applies
6 Recruits emotional experience for validity, motivation, and decision but not for percept or for logic
7 Requires regulating and modulating functions of the ego
8 Often relies on observing ego
9 Makes judgments for action

Table 1.2 Ego Functions Important for Reality Experience

Logic	Secondary Process Sequential Time Cause-Effect
Memory	Sequential events
	Spatial
	Coordinated Working Memory
Percept	Registration Recording Accessing Manipulation Integration
	(forms a “virtual perceptual reality” based on real sensorial events and secondary process logic)
Boundaries
Reality Testing Observing Ego	Keeping faculties separate and intact in conscious experience

One cannot equate ego apparatus function and the ego’s reality experience (Table 1.2). Reality experience is an experience and not a function. This experience has qualities, quantities, modalities, and domains. In addition, the ego’s apparatus function can be used at times defensively for emotional purposes. Also, aspects of reality stimuli are registered and encoded by the emotions. Nonetheless, reality experience is mediated by, and depends upon, certain autonomous ego functions and integrations of functions. Those integrations of functions are sometimes called superordinate ego function.²

Secondary Process

Freud called conscious, reality-oriented logic secondary process because he thought this capacity developed later than emotional experience organization, which he called primary process. Freud was probably wrong, because the latest research with infants seems to demonstrate secondary process development from birth (Sterm, 1985; see also Piaget and Inhelder, 1958; Piaget, 1977). I will use this traditional psychoanalytic term nonetheless.

Secondary processes are those mostly conscious, reality-oriented, logical thinking processes that gather data via percepts and assemble those percepts into information according to learned schemes and also according to deductive and inductive reasoning. Concepts are built, abstracted, generalized, and applied. Various levels of abstraction are used and related to each other and to real-world tasks. Words and numbers are used to sort and arrange information. Words and numbers are defined and specific, and therefore have relatively finite information contents.

Autonomous apparatuses tend to be organized around these principles of secondary process logical thinking. These logical principles include the ideas that cause is different from effect, the part is separate from the whole, a part is separate from another part, and time is sequential. This type of thinking relies upon clear categories, usually with definable boundaries and finite date contents. Data and categories tend to be digital. Categories group ideas and data logically and describe relationships to larger entities. Relationships are congruent with perceptually based rules following spatial, temporal, and sequential experience. There are distinctions between concept, percept, and affect with concept or percept as the main organizer. These categories mature as cognitive skills mature, and develop as reality experience accumulates.

Secondary process capacities use functions of cognition that should be relatively uninfluenced by emotional conflict. Secondary processes mediate and buttress reality experience but are not the same as reality experience. Reality experience includes more than secondary process. Reality experience is an experience and not just a group of processes.

The Experience of Emotions

Emotional experience is quite different from reality experience. Emotional experience is the experience especially of emotion with its own quality, quantity, organization, and ideational content. It has a different base, follows different rules of organization, and has a different mental locus of experience. The base of emotional experience is feelings, also called affects. The rules of their organization are psychological rules called primary processes. These processes use different types of categories and different causal relationships from reality experience. Emotional experience is based on but not limited to primary process.

The mental locus of emotional experience is partly a visceral body and sensation locus that may take pictorial form. The quality is the experience of percept, of physical sensation, and of affect. The pictures are visual transformations of affects and have the quality of percepts. This percept aspect is a normal link to reality experience.

The ego can attach and experience affect in association with events, concepts, percepts, or as “free-floating.” Different levels of consciousness, processing systems (primary or secondary process), psychiatric illnesses, phases of illness, and stages of normal development all influence the ego’s positioning, organization, and experience of affect.

Affect often provides motivating force and hence positive or negative direction to behavior, ideas, and pictorial forms. Affects vary in quality from pleasurable to unpleasurable; they vary in intensity from strong to faint; they vary in content such as anger and love; they vary in domain from visual to visceral.

Primary process is an information processing system especially for affects. Hence intensities, qualities, and domains form the organizing basis of contents and their categories. Infinite information contents, each within inexact limits based on intensity and quality, form the basis of concepts or, more precisely, contain the concepts.

Emotional experience builds in complexity by mixing intensities, qualities, and domains in complex patt...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Acknowledgments
• Introduction
• 1 Ego Functions
• 2 Psychotic Structure
• 3 Near Psychotic Structure
• 4 Mental Status Examination
• 5 Psychiatric Illnesses and Mental Structure
• 6 Medication and Mental Structure
• 7 Psychoanalytic Psychotherapy and Psychoanalysis of Psychosis
• 8 Psychoanalytic Psychotherapy and Psychoanalysis of Near Psychosis
• 9 Hospital Treatment
• References
• Name Index
• Subject Index