Ordinary Psychosis and The Body

A Contemporary Lacanian Approach

J. Redmond

• Publisher: Palgrave Macmillan
• Year: 2014
• ISBN:
  9781137345318
• Topic: Psychologie
• Subtopic: Psychologie clinique

Current Lacanian ideas on psychosis have much to contribute to the complex and often surprising forms of psychotic symptomatology encountered in clinical practice. By focussing on the unique experience of individuals with psychosis, this book examines the centrality of body phenomena to both the onset and stabilisation of psychosis.

1

Mild Psychosis, the Body and Ordinary Psychosis

In this chapter, I discuss body disturbances in mild psychosis related to symptom stabilisation in schizophrenia. First, I outline how contemporary psychiatric nosology has moved away from the notion of mild psychosis. Here I show how clinicians have veered away from using the idea of mild psychosis through the focus on symptom severity coupled with the introduction of borderline personality disorder (BPD) in contemporary psychiatric nosology. Next, I focus specifically on the category of body disturbances in mild psychosis by examining how both the Diagnostic and Statistical Manual, Fifth Edition (DSM-5) and the International Classification of Disease, tenth revision (ICD-10) address (or lack) body phenomena in psychosis. These texts help inform the nosological debates in contemporary psychiatry concerning mild psychosis in the context of body phenomena in psychosis. Contemporary psychiatric approaches to body disturbances in schizophrenia are characterised by inconsistency due to the varying significance given to body disturbances in symptomatology. I maintain that the DSM-5 constitutes a reductive conception of psychosis, and that phenomenological approaches linked to the ICD-10 miss the significance of body disturbances to the onset and stabilisation of psychosis. Finally, I introduce contemporary Lacanian approaches to mild psychosis by examining the field of ordinary psychosis. I conclude by advocating for a sustained engagement with the idea of body disturbances in mild psychosis as it provides clinicians with an opportunity to develop a more complex understanding of onset, triggering and stabilisation in psychosis.

1.1 The decline of mild psychosis in contemporary psychiatry

In Anglo-American psychiatry, BPD emerged as a response to difficult-to-classify cases. As the name suggests, BPD lies on the ‘border’ or exists ‘in between’. The border refers to a clinical problem— psychoanalysts tend to use the term for those patients who are ‘too sick’ to be considered neurotic and ‘not sick enough’ to be labelled schizophrenic (Gabbard, 2000). Conceptually, the border also refers to the so-called midpoint between neurosis and psychosis. In terms of clinical praxis, BPD refers to a group of patients that are difficult to ‘classify’ under the neurosis/psychosis distinction.¹ For example, schizophrenia may be ruled out if psychotic phenomenon were transitory and brief; conversely, neurosis was to be excluded in the absence of obsessions, phobias and conversions, and the presence of an impulsive, riddled, chaotic, character organisation (Kernberg, 1967). This may leave the clinician in a difficult situation. However, as nosological systems evolved throughout the twentieth century, particularly with the advent of the DSM, newer nosological systems superseded the neurosis/psychosis distinction.

Clinicians in the Lacanian field have been consistently opposed to the borderline concept owing to the misguided diagnostic assumptions underlying this nosological group. The introduction of a ‘midpoint’ between neurosis and psychosis, based on the symptom severity, cannot be the basis for diagnosis. In contrast, the Lacanian approach to the neurosis/psychosis distinction aims to elucidate the mechanism— repression or foreclosure—underlying clinical phenomena. The distinction between structure and phenomena is essential: a diagnostic impression is predicated on structure, the subject’s relation to the key signifier the Name-of-the-Father, rather than the phenomena of symptom severity. The Lacanian emphasis on structure, that is on the subject’s relation with the Other of language, and, in particular, on the signifier the Name-of-the-Father, has nothing to do with symptom severity. Lacan’s structural approach to diagnosis is premised on the subject’s relation to the Other and language in particular, an emphasis that is only possible when there is clear separation between the imaginary and symbolic registers (Grigg, 2008).

From a Lacanian perspective, the borderline concept is problematic on several counts.² Perhaps the most important point is that symptom severity cannot be the basis for making a diagnosis (Fink, 2007). I suggest that the focus on symptom severity is particularly important because it precipitates movement away from the idea of mild psychosis. The diagnostic index symptom severity was the central driver underlying the perception that the neurosis/psychosis distinction had significant clinical limitations. As borderline pathology is focused, in part, on a cluster of psychotic symptomatology irreducible to classical forms of schizophrenia and neurosis, creating a new diagnostic category continues to minimise the importance of abstract and subtle symptomatology in psychosis (Hriso, 2002a). I argue that the study of mild psychosis and of stabilisation mechanisms has been relatively ignored, and the psychosis concept weakened as a direct consequence of focusing on symptom severity in approaches to psychotic diagnosis.

In the American psychiatric tradition, the symptom severity and transitory psychotic phenomena was a pivotal factor leading to the emergence of BPD and reclassification of schizophrenia. In part, BPD emerged from the challenges generated by the existence of transitory and reversible psychotic phenomena. Individuals with BPD are often referred to as ‘difficult’ cases owing to the complex array of symptoms and the intense therapeutic encounter that can develop during the course of treatment. Well-known factors that make treatment of this group challenging include the intensity of the transference and countertransference, rapid mood lability, intense regression and transitory psychosis (Fonagy et al., 2002; Kernberg, 1967).

Prior to its inclusion in the DSM-III (1980), debate concerning the validity of BPD was focused extensively on differentiating it from schizophrenia (Grinker, 1979; Kernberg, 1979; Liebowitz, 1979; Rieder, 1979; Spitzer and Endicott, 1979; Stone, 1979). BPD emerged from the tensions involved in debates concerning the clinical utility of mild schizophrenia; terms such as ‘pseudo-schizophrenia’, ‘latent schizophrenia’ and ‘ambulatory schizophrenia’ were used to denote cases in which transitory psychotic states were evident (Gabbard, 2000; Gunderson, 1979). The neurosis/psychosis distinction is augmented by borderline personality organisation and a series of related subtypes that are situated on a continuum of severity between neurosis and schizophrenia (psychosis).

In contemporary psychiatry, debate over BPD and schizophrenia often focus on the significance of transitory and reversible psychotic phenomena. The question of how these phenomena should be categorised was, and remains, controversial. Liebowitz (1979) summarises the debates concerning symptom severity and the differentiation of BPD and schizophrenia. Arguments supporting the borderline concept have been linked to the phenomena of transient psychotic disorganisation; for some individuals, psychotic states are brief, and other ego functions, such as language, cognition and goal-directed activity, remain intact. Hence, transient psychotic states run counter to classical schizophrenic disturbances to associations, autistic withdrawal, disturbances to language, cognition, and the presence of hallucinations and delusions (Liebowitz, 1979). Conversely, arguments against utilising BPD also focus on transient psychosis; that is, theorists dispute the notion that ‘mild’ or ‘transient’ psychotic states should be the basis for differential diagnosis. The existence of mild psychotic states and the reversibility of psychotic symptomatology are grounds for making a diagnosis of schizophrenia despite the existence of intact ego functions such as insight and reality testing (Liebowitz, 1979). Thus, the presence of psychotic phenomena will entail classifying patients called ‘borderline’ as psychotic.

In psychiatry, using symptom severity to differentiate borderline patients from schizophrenic ones remains central. In the DSM-5, BPD is differentiated from the schizophrenias according to the duration of psychotic symptoms. The primary difference between the psychotic symptoms in BPD and schizophrenia in the DSM concern the duration and severity of symptoms. In BPD, psychotic symptoms are brief and transitory—if they occur for longer than a month then the diagnostic impression will move toward schizophrenia. Moreover, in BPD transitory psychotic states are associated with stress-related events that diminish once the stressor is removed. In BPD, stressor-induced psychotic phenomena such as paranoid ideation and delusions remitting quickly will not meet the criteria of schizophrenia. Thus, in contemporary psychiatry, the advent of the borderline concept correlates with a move away from the notion of mild psychosis as transitory psychotic states become dissociated from the definition of psychosis.

More recently, in Anglo-American psychoanalysis the dimension of severity underlying BPD has also been a pivotal factor in the movement away from the notion of mild psychosis, as evident in the Psychoanalytic Diagnostic Manual (PDM) (PDM Task Force, 2006). This diagnostic manual provides the most recent example showing the importance of symptom severity to the borderline concept. In the PDM, classical BPD symptomatology is clustered into three groups:

1. an anaclitic type (affectively labile and intensely dependent);

2. an introjective type (over-ideational and characterised by social isolation and withdrawal); and,

3. borderline schizophrenics (characterised by the potential for psychotic decompensation and the blurring of ego boundaries) (PDM Task Force, 2006).

The PDM, like other psychoanalytic theories of BPD (Kernberg, 1967; McWilliams, 1994), presumes that the borderline concept constitutes a midpoint between psychosis and neurosis, and that differential diagnosis is formalised according to symptom severity. However, in the PDM symptom severity has become formalised and now constitutes a separate dimension for the assessment of personality organisation.³ The dimension of severity is assessed according to seven dimensions, including identity, objections, affect tolerance, affect regulation, morality, reality testing and ego, strength and resilience. In the PDM, the dimension of symptom severity underlying the midpoint between neurosis and psychosis is derived from a deficit model of psychopathology. The deficit model underlies the dimension of severity and is derived primarily from object relations and ego-psychology; terms such as ‘seriously limited’, ‘compromised’, ‘damage’ and ‘most disturbed’ indicate limitations to psychical functions, such as reality testing. The authors indicate that borderlinelevel personality organisation is probable when the first five abilities are seriously limited. While disturbances to moral sensibility are consistent with narcissistic and psychopathic variants of BPD, deficits in reality testing are considered to be evident in only the most disturbed patients (PDM Task Force, 2006). Disturbances to reality testing are equated with the most severe forms of BPD, a notion that parallels the notion of severity in the Type I psychotic border group (Grinker et al., 1968).

Grinker et al. (1968) famously asserted that borderline pathology occupied a continuum between the psychotic border and the neurotic border. Their approach to BPD is also predicated on the symptom severity and a midpoint between neurosis and psychosis. Moreover, he subdivided the borderline group into four subtypes along a continuum moving from the most to least severe: Type I—psychotic border; Type II—core borderline syndrome; Type III—as-if group; Type IV—neurotic-border.

The borderline concept of Grinker et al. (1968) is a heterogeneous notion that does not appear to show any particular clinical unity across the different subtypes apart from the movement from most to least severe. The psychotic border is situated in opposition to schizophrenia; thus, the focus on symptom severity, particularly with reference to transitory psychotic states, is evident in this attempt to differentiate BPD from schizophrenia. However, the Type III ‘as-if’ category clearly demonstrates the movement away from the idea of mild psychosis.

Grinker’s (1979) BPD continuum, the Type III ‘as-if’ group is, in fact, derived, in part, from Deutsch’s (1942) theory of schizoid mechanisms in psychosis. On this continuum, symptom severity in the ‘as-if’ group lies adjacent to the neurotic border group (Type IV), indicating a relatively mild form of borderline pathology. The ‘as-if’ group is situated here because of the absence of florid psychotic states and the capacity of social adaptation (Gabbard, 2000). This group of borderline pathology is characterised by the tendency to identify with others, the absence of affect, and a lack of genuineness and spontaneity in relationships (Gabbard, 2000). However, the displacement of the ‘as-if’ category from schizophrenia into the border concept demonstrates the movement away from the notion of mild psychosis in contemporary psychiatry and psychoanalysis. For Deutsch (1942), the ‘as-if’ phenomena are evident in certain cases of schizophrenia where an individual’s life seems complete, while also lacking genuineness and depth. While the individual appears reasonably well adjusted to social demands and does not exhibit positive or negative psychotic symptoms, ‘as-if’ patients exhibit a superficial emotional range, have an inauthentic identity due to the propensity to imitate others and display an extreme passivity that functions to mask aggression (Deutsch, 1942). Deutsch claims that the ‘as-if’ personality organisation is not psychically structured by repression; instead, an absence of object cathexis and the lack of significance placed on emotional ties with others is a primary feature of this group. Of course, it should be observed that the absence of libidinal investment in objects highlights the narcissistic component of the ‘as-if’ phenomena, an issue congruent with Freud’s (1911 [1957], 1914 [1957]) discussion of narcissism in psychosis, and schizophrenic withdrawal in particular. However, in BPD, the ‘as-if’ concept with its connection to schizoid mechanisms is no longer associated with schizophrenia, and is described in the context of ‘identity diffusion’ (Akhtar, 1984; American Psychiatric Association, 2000).

In contrast, Lacan (1993) suggested that ‘as-if’ variants of schizophrenia are cases of untriggered psychosis. In Lacanian psychoanalysis, Deutsch’s (1942) notion of the ‘as-if’ personality is important as it is used in discussions of both untriggered psychosis (Lacan, 1993) and in more recent debates concerning stabilisation (Skriabine, 2004a; Stevens, 2002). Lacan’s reading of the ‘as-if’ phenomena in terms of untriggered psychosis is instructive because he maintains the integrity of the neurosis/psychosis distinction, despite the absence of obvious psychotic phenomena. In doing so, he preserves the notion of psychotic structure, and is unequivocal in proposing that psychosis has no necessary connection with symptom severity. For Lacan (1993), the tendency for imitation in ‘as-if’ personalities, evident in narcissistic identification between individuals who share similar traits, constitutes a ‘mechanism of imaginary compensation’ that stabilises the psychotic subject. He suggested that in certain cases of schizophrenia, imaginary identification functions to stave off psychotic decompensation and used the term ‘untriggered psychosis’ in such cases. An untriggered psychosis is like a broken stool; although minus one leg, a three-legged stool may still function to support a person, depending on their weight distribution. However, once the person’s weight shifts to the missing leg, it will collapse, person in tow. Similarly, although imaginary identification functions to keep the person ‘upright’, psychosis may be triggered, which leads to the collapse of this supportive function. Thus, Lacan’s discussion of the ‘as-if’ phenomena as an untriggered psychosis contrasts markedly with the borderline concept; rather than moving away from psychosis, a specific mechanism of ego identification is used to discern stabilisation in psychosis. Lacan’s (1993) statement that a neurotic symptomatology can be very hard to distinguish from a pre-psychotic symptomatology aims, in part, at severing symptom severity from diagnostic decision making. Thus, although untriggered psychosis is thought about in terms of the imaginary, it is not to the detriment of the symbolic and the subject’s position concerning the Name-of-the-Father. Moreover, the ‘as-if’ phenomena and, more generally, imaginary identification in psychosis, continue to inform debates concerning psychotic triggering and stabilisation in the field of ordinary psychosis. I return to these themes throughout the book. I now focus on body phenomena in mild psychosis and show how this has been systematically minimised in contemporary psychiatric nosology.

1.2 The marginal status of body disturbances in mild psychosis

Lacanian psychoanalytic theory and contemporary psychiatry utilise diverging and incompatible philosophical approaches to nosology. The diverging epistemological positions means that there is no shared ‘construct validity’ underlying the idea of psychosis used in each discourse. Consequently, when Lacanians talk about psychosis in a clinical and theoretical sense, the idea of psychosis has next to nothing in common with the contemporary psychiatric idea of psychosis. In Lacanian theory, the approach to nosology and the idea of psychosis that I focus on throughout this book is based on the classical theory of the 1950s. It was during this time that Lacan articulated a series of precise clinical distinctions between neurosis, psychosis and perversion based on a modified structuralism (Vanheule, 2011b). Although this nosological triad replicates the core Freudian nosological system, Lacan’s distinctions are based on the subject’s position in the unconscious and their relation to social discourse. Moreover, neurosis, psychosis and perversion are considered to be both clinical and subjective structures; as such, there is no ‘normal’ and each subject will, more or less, occupy one of these positions. In contrast, the DSM draws on a medical, scientific and biological epistemology. Therefore, psychosis is considered an illness with a biological basis (Sadock and Sadock, 2007). The diverging approaches to nosology and clinical problems raised by psychosis are, strictly speaking, incompatible. The disjunction between the Lacanian and contemporary psychiatric approach to psychosis has theoretical, clinical, political and social implications.

In fact, the recent backlash against the publication of the DSM-5 demonstrates how political issues infuse the discourse on mental health. The opposition to the DSM-5—on ethical, political, clinical and scientific grounds—indicates that public and professional interest groups will no longer accept the idea that a small panel of experts will have the ‘final word’ on mental suffering through a doctrinaire discourse of ‘mental health’ (Belluck and Benedict, 2013). It is not surprising that consumer-driven organisations such as The International Society for the Psychological Treatment of Psychosis and the Hearing Voices Network, that are profoundly critical of the medicalisation of psychosis, aim to de-pathologise and normalise psychotic states in an attempt to reclaim the ‘right’ to be psychotic without stigma and pathologisation. Lacanian ideas on psychosis, while derived from classical psychiatric knowledge and Freudian theory, also present a non-medicalised view of psychotic subjectivity. What ordinary psychosis adds is greater sensitivity to psychosis in its multitude of milder forms and to the factors leading to the onset, triggering and stabilisation of psychosis. By building on Freud’s views that certain symptoms in psychosis constitute an attempt at recovery, Lacan...