On Being Normal and Other Disorders

A Manual for Clinical Psychodiagnostics

Paul Verhaeghe

• Publisher: Routledge
• Year: 2020
• eBook ISBN: 9780429916762
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

The central argument of On Being Normal and Other Disorders is that psychic identity is acquired through one's primary intersubjective relationships. Thus, the diagnosis of potential pathologies must also be founded on this relation. Given that the efficacy of all forms of treatment depends upon the therapeutic relation, a diagnostic of this sort has wide-ranging applications. The author's critical evaluation of the contemporary DSM-diagnostic shows that the lack of reference to and governing metapsychology impinges on the therapeutic value of the DSM categories. In response to this problem, the author sketches out the foundations of such a metapsychology by combining a Freudo-Lacanian approach with contemporary empirical research. Close attention is paid to the processes of identity acquisition to show how the self and the Other are not two separate entities. Rather, subject formation is seen as a process in which both the subject's and the Other's identity, as well as the relationship between them, comes into being.

III
Positions and Structures of the Subject

Overview

This third and final part deals with structural diagnostics as such. Based on the theory sketched out in Part II, we can make a distinction between positions and relational structures. Each subject can be situated on a continuum between the actualpathological and psychopathological positions. The former implies a direct, unmediated confrontation with (a) whose chief effect on the subject is automatic anxiety. Progression to the psychopathological position implies a processing at the level of the signifier and the construction of symptoms as defensive attempts to process the Real. Besides the position, we distinguish three different structures between the subject and the Other, each implying a specific way of being-in-language and a particular relation toward others. These are the neurotic, perverse, and psychotic structures. Accompanying my explanation of the various positions as they appear in each specific subjective structure will be an indication of its relevance for how the treatment should be approached.

One might imagine that, organized logically, the discussion of psychosis should come first, starting with its actualpathological variation (schizophrenia) and followed by its psychopathological elaboration (paranoia). The perverse structure should come next, divided once more between its actualpathological and psychopathological positions. Last but not least should come the typical neurotic structure, again with the two possible positions. However, clinical praxis is not logical. I have thus organized this part in a way that I see as more clinically relevant. Nevertheless, the reader should be able to recognize the implicit logic behind it without too much difficulty.

Chapter 11 discusses a problem that formerly was rarely seen in the clinic but is increasingly being referred to us from the medical world. That these patients seldom come to us voluntarily has to do with the overwhelming actualpathological character of the complaint: somatization. However, in cases where the accent is on the chief actual-pathological phenomenon, anxiety, there tends to be a more rapid demand for clinical psychological consultation. The following discussion will enable us to understand contemporary panic disorder as a synonym for Freud’s anxiety neurosis.

In Chapter 12 we encounter the main protagonist of today’s clinic: post-traumatic stress disorder (PTSD). Empirical research emphasizes the intensely relative nature of the pathogenic effect of actual trauma, with the result that the etiology of PTSD must be sought elsewhere. We will see how little use it is as a descriptive category, and that PTSD must be reconsidered in terms of its relation to actual- and psychopathology as well as from the perspective of the three subjective structures. In connection with this, we will discuss the problem of borderline personality and show how it belongs to the actualpathological side of the neurotic structure.

In Chapter 13 we enter into familiar territory. Hysteria and obsessional neurosis have always been classics of the clinic. This is not by coincidence: they pertain to the psychopathological position and present classically interpretable symptoms founded upon the fundamental fantasy. I will pay special attention to the relational aspect through which these symptoms are constructed and must be understood. Particularly for cases of hysteria, this is the only feasible way of obtaining a correct diagnosis.

Lying in wait for us in Chapter 14 is the perverse subject. This largely forensic clinical aspect is anything but straightforward and its diagnosis pertains predominantly to the juridical field, with the emphasis on the “perpetrator.” As a result, we must clear away a certain amount of brushwood before we can actually discuss the perverse relation. More than ever, the relational structure through which the perverse subject has been installed will need to be emphasized as the basis for clinical psychodiagnostics and potential treatment.

In the final chapter, I examine the most enigmatic of all structures of the subject, that is, psychosis. I chose to present psychosis last because it confronts us with the limits of our own symbolically determined subjectivity. With it, too, the difference between the actualpathological and the psychopathological position can be applied, and there, too, the psychotically installed relation is determinative for the diagnosis. In its otherness, psychosis above all shows us how each relational structure between the subject and the Other is simultaneously a relation with language.

11
The Actualpathological Position: Panic Disorder and Somatization

Our metapsychological discussion of identity formation has enabled us to distinguish a position of the subject in relation to (a) and the Other where the secondary defense and psychological processing have not taken place. The initial problem—which is simultaneously the motive for identity formation—remains focused on the body, that is to say, on the demand arising out of the real body and the impotence of the Other to answer it.

Should such a subject position be empirically verifiable, the consequences would be the following. First, in the psychodiagnostic field, the differential diagnostic becomes relatively simple. For such a subject position, there will be no symptoms a fortiori, that is, no signifying constructions in the Symbolico-Imaginary. The accent will remain on the starting point of the development, namely, on certain somatic phenomena and their accompanying (un-)pleasure and anxiety. Still within the context of diagnosis, this implies that such patients today will initially find themselves in the medical field and only later in a clinical psychological setting. Secondly, at the level of treatment we are confronted with a problem that is structurally different from our customary psychopathology, the latter having already undergone secondary processing. The usual psychotherapeutic treatment will be of little use here, and the potential psychotherapeutic approach to such problems must also be completely reconsidered in the light of the structural diagnostic.

There are two arguments in favor of the existence of such an actual-pathological position. One is classical and conceptual: we must look again at what has long since been a forgotten part of Freudian theory and clinical practice, at what in 1898 he called the “actual neuroses.” The other draws on more recent empirical work: we must call upon the flood of contemporary research into somatization, alexithymia, and the panic disorders.

Freud’s Actual Neurosis: A Forgotten Category

At its outset, clinical practice was utterly unlike that of today. One of the chief differences was its lack of specialization, with the result that doctors could be confronted with more or less any type of patient. Into this often vaguely differentiated group, Freud quickly introduced divisions. On one side is what he called the neuro-psychoses of defense (Freud 1978 [1894a], [1896b] and manuscript B and E).¹ The origin of these disorders must be sought in infantile sexual development; its associated symptoms are signification-rich and their typical characteristic is defense against an inner conflict at the level of sexuality and desire. On the other side are the actual neuroses. Their origin is also sexual, by which we must understand that it is located in the present life of the patient, not in the past. The symptoms are limited to somatic phenomena and have no further meaning, the emphasis lying largely on anxiety and the somatic anxiety equivalents (Freud 1978 [1895b], [1896a]).

Throughout the subsequent course of his career, Freud will place his emphasis on elaborating the first group, which will come to form the basis of many of today’s psychodiagnostic categories. The second group remains underdeveloped, despite Freud’s continuing to confirm its existence right to the end. The reason for this relative lack of interest is a pragmatic one. This group failed to respond to the psychoanalytic treatment of his time. Indeed, the symptomatic superstructure and accompanying fantasmatic developments are completely absent; there is quite simply nothing to analyze.

Nevertheless, this didn’t stop him from providing a thorough description of this group, for whose etiology he offers a number of hypotheses. Within the actual neuroses, he distinguishes between anxiety neurosis and neurasthenia, later adding hypochondria to these (Freud, 1978 [1914c], pp. 82–85).

Freud’s emphasis is clearly on anxiety neurosis, whose name and discovery are both Freud’s (Freud 1978 [1895b], [1898a]). It is worth recalling his clinical description. He identifies seven characteristics:

1. General irritability. This indicates an increase of excitation and an inability to tolerate it. Sleeplessness is fairly common.
2. Anxious anticipation. There is a quantum of free-floating anxiety that can be secondarily associated with any content whatsoever. For Freud, this is the symptomatic kernel.
3. Anxiety attacks. Such attacks occur suddenly, without any connection with a preceding train of thought. This anxiety can be secondarily associated with fears of dying or of becoming mad. The combination of anxiety with disturbances in certain bodily functions is fairly common, such as “spasms of the heart,” respiratory difficulties, sweating, ravenous hunger.
4. A continuum from rudimentary anxiety attacks to somatic anxiety equivalents. The proportional combination of the two varies widely in the clinic, but the central phenomenon remains anxiety. Among the somatic anxiety equivalents, Freud distinguishes heart palpitations, disturbances of respiration, sweating, tremor and shivering, ravenous hunger, diarrhea, locomotoric vertigo, congestion, and paresthesias. Freud calls such somatic anxiety-equivalents “larval anxiety-states” and adds that the anxiety is not always experienced as such by the patient.²
5. Nocturnal fears (pavor nocturnis). An anxiety attack at night, usually in combination with sweating and respiratory difficulties, although not associated with a nightmare.
6. Vertigo. Also usually in combination with anxiety, although not always. The patient’s legs feel like they are giving way and it seems impossible to remain standing but without actually falling.
7. Two kinds of phobias. The first group boils down to the reinforcement of previously existing and, according to Freud, probably instinctive aversions in the patients (anxiety about thunderstorms, vermin, darkness), thereby turning them into a phobia. The second group concerns agoraphobia, often beginning with an attack of vertigo and later taking hold of the patient’s motor abilities. Freud highlights the difference between both types of phobias and psychopathology: there is no associative link to an underlying repressed train of thought—thus making it impossible to moderate this phobia through analysis or psychotherapy—and the underlying affect is anxiety as such (Freud 1978 [1895b], pp. 92–97).

For Freud, the etiological ground of anxiety neurosis or, more broadly, of the actual neuroses, must lie in the somatic-sexual factor, operating as an endogenic arousal. More specifically, he locates its etiology in the failure to psychically process this excitation and thus abreact it—and hence gives general irritation as its first characteristic. The accumulated tension is immediately transformed into anxiety. Freud will further specify this etiology by referring to the role of sexual abstinence. Its kernel nevertheless remains the absence of psychological elaboration of something that pertains to the body.

The second form of actual neurosis is what was called neurasthenia. Originally described by Beard, this category enjoyed immense success and was extensively developed by Janet, for one. Freud remained critical of this broadening of the term, limiting his description of its core characteristics to three elements.³ Firstly, the characteristic physical exhaustion that has no physical explanation. Secondly, the accompanying somatic phenomena, normally headaches, dyspepsia, constipation, and spinal paresthesia. Thirdly, the decline of sexual activity. An important difference between this and the previous group is that here anxiety is almost entirely absent. Its etiology is the same as that of anxiety neurosis, that is, the impossibility of psychically processing an internal sexual somatic arousal. In neurasthenia, the cause is not so much anxiety as exhaustion resulting from a conflict between the subject and its drive. As a special etiological factor, Freud mentioned masturbation, something that accorded perfectly with the medical-moral discourse of that time.

This more or less sums up the Freudian theory of actual neurosis (with the exception of hypochondria; see Chapter 15). As I said, it gets little attention in the rest of his oeuvre and, after Freud, this piece of his theory and clinical praxis becomes more or less forgotten. One reason for this has to do with the supposed etiology of the condition: these days, sexual abstinence and masturbation no longer mean the same thing as in the 1900s—although I am still convinced that their psychological impact should not be underestimated even today. However, along with this one tends to forget how these are merely the specific etiological manifestations of an underlying general cause, that is, the fact that the endogenic arousal has not been psychically processed. As far as this arousal is concerned, Freud even accounts for the classic psychiatric “surmenage,” or in contemporary terms stress by overwork (Freud 1978 [1898a], [1905d]). The second reason why it has been forgotten doubtless has to do with the fact that, because of the growing medical specialization, such patients tend to arrive in an increasingly exclusive medical setting. We will have to wait for the reconciliation of the medical and clinical psychological discourses before this problem is addressed. However, this brings us to two contemporary topics that have been widely researched: panic disorders and somatization phenomena.

Panic Disorder: Old Wine in New Bottles

Panic disorder is a modern success story. Psycinfo cites only 22 studies for the 1970s; this increases to 2.588 in the 1980s, and that number more than doubles over the next decade. As has often happened, the discovery of this condition was purely coincidental, occurring moreover outside the context of any historical awareness. In the 1960s, an American psychiatrist, Donald Klein, conducted research into the pharmacological treatment of schizophrenia. One particular group of schizophrenic patients, characterized by an absence of delusions and hallucinations, and displaying acute anxiety attacks, failed to react to the usual medication of those days. This was in contrast to the other group that did indeed display hallucinations and delusions, along with a chronic anxiety.⁴ He then discovered that another drug (imipramine) diminished the acute anxiety and concluded that the anxiety in both groups must be essentially different (D. Klein 1964).

After that, things begin to move fast. This particular form of anxiety is described as the so-called panic attack. This, in turn, will give rise to a number of diagnostic entries in the DSM. We will first discuss the description of the panic attack itself, and then the diagnostic entries in the light of the associated empirical research.

In the DSM-IV (American Psychiatric Association 2000, p. 432), panic attack is described as an isolated, acute-anxiety experience in which the patients display at least four of the following symptoms, arriving at a peak in a very short time:

Panic Attack

A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

• 1) palpitations, pounding heart, or accelerated heart rate
• 2) sweating
• 3) trembling or shaking
• 4) sensations of shortness of breath or smothering
• 5) feeling of choking
• 6) chest pain or discomfort
• 7) nausea or abdominal distress
• 8) feeling dizzy, unsteady, lightheaded, or faint
• 9) derealization (feelings of unreality) or depersonalization (being detached from oneself)
• 10) fear of losing control or going crazy
• 11) fear of dying
• 12) paresthesias (numbness or tingling sensations)
• 13) chills or hot flushes

Comparing this description with the characteristics of anxiety neurosis described above, we are forced to conclude that they both concern the same thing. Not only does the DSM contain all of the phenomena described by Freud, Freud moreover contains more. The shortcoming of the DSM lies for the most part in its lack of a certain insight not absent in Freud, namely, that the somatic anxiety equivalents can appear in place of anxiety, with the result that the patient is barely aware of his own anxiety. Recent discussion since then has revolved around the paradoxical NFPD, the “non-fearful panic disorder,” as yet unmentioned in the DSM. Research has shown that such panic attacks without anxiety may occur in both clinical and noncli...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• Preface
• Acknowledgments
• I: DIAGNOSTICS AND DISCOURSE
• II: METAPSYCHOLOGY
• III: POSITIONS AND STRUCTURES OF THE SUBJECT
• CONCLUSION: DIAGNOSIS AND TREATMENT
• References
• Index