Psychoses, Chronic and Delusional

PSYCHOSES, CHRONIC AND DELUSIONAL

In psychiatry the term psychosis, first used to refer to mental illnesses in general, was later restricted to the major clinical forms: schizophrenia, chronic and delusional psychoses, and manic-depressive psychoses. Unlike the neurotic, the psychotic subject does not "criticize" the disorders of his or her thought. In 1845 Baron Ernst von Feuchtersleben used the term psychosis to refer to mental illness in his manual of medical psychology. At the end of the nineteenth century, alienists defined psychosis as the loss of reason and mental alienation.

Psychoanalysis seeks less to categorize mental illnesses than to identify their structures and mechanisms. A structural and dynamic definition of psychosis must be conceived on the basis of a primary disturbance of the libido's relationship to reality, through splitting and the reconstruction of an alternative, delusional reality. Eugen Bleuler, influenced by psychoanalysis, characterized schizophrenia as a dissociation of thought through withdrawal into the self, or autism. He posited as its basis splitting, linked to a loosening of associative texture. Skirted around by Sigmund Freud, who preferred the term paraphrenia, the notion of schizophrenia nevertheless became standard within psychiatry and psychoanalysis. A second variety of chronic psychosis, paranoia, is characterized by systematic delusions (delusions of persecution, jealous delusions, erotomania, delusions of grandeur), the predominance of interpretation, and the absence of intellectual deterioration.

In Manuscript H (1894), Freud designated three conditions as psychoses: hallucinatory confusion, paranoia, and hysterical psychosis (which he distinguished from hysterical neurosis). In his texts on the neuropsychoses of defense ("The Neuro-Psychoses of Defence" [1894a] and "Further Remarks on the Neuro-Psychoses of Defence" [1896b]), he took the distinction between neurosis and psychosis as given. From his earliest writings, he undertook to characterize the psychopathology of the psychoses through his successive theories of the psychic apparatus. His only study of a case of psychosis is his commentary on Daniel Schreber's Memoirs of My Nervous Illness. Freud's correspondence with Carl Gustav Jung illustrates the development of Freudian doctrine between 1909 and 1911, and the essays "On Narcissism: An Introduction" (1914), "Fetishism" (1927), and "The Loss of Reality in Neurosis and Psychosis" (1924) show the further elaboration of his theories.

Freud examined the individual's relationship to reality from the vantage point of a consideration of the libidinal cathexes. In the psychoses, the loss of reality—and the changed relationship to others following a radical decathexis of the objects of everyday reality ("the end of the world," for Schreber)—must necessarily be considered in a way other than descriptive, taking into account the attempted reorganization of reality by the psychotic processes.

All psychoses are characterized by the coexistence of two attitudes: one that takes reality into account, and another that "this same ego, under the influence of the id, withdraws from a piece of reality" (1924e, p. 183). Delusions affirm the subject's belief in the existence of an alternative reality that restores the primitive cathexes that archaically linked childhood awareness with an early love object. The reconstruction of reality in accordance with the "desires" of the id expresses both a defensive cancellation and a reparative force. This entails a process whose psychotic manifestation in no way excludes rearticulation in terms of the mechanisms defined by psychoanalysis. Thus, in Freud's view, hallucinatory psychosis could be considered as the expression of an imaginary maintaining of an early reality whose loss the ego finds unbearable. This theorization requires the refinement of concepts such as regression, which is above all conceived as a function of development of the ego and of the libido: In the one case, regression leads to primary narcissism, and in the other, to hallucinatory wish fulfillment.

Initially, Melanie Klein, like Karl Abraham, tended to base her clinical work on a psychopathological theory of the points of fixation and temporal regression of the libido. In addition to this temporal regression, Freud distinguished a topographical regression that made it possible to compare the mechanisms of dreams with those put into play in psychosis. "In schizophrenia, it is words that become the object of elaboration by the primary process; in the other, the dream, it is the thing-presentations: representations of things to which the words have led." In schizophrenia, circulation is cut off between the preconscious cathexis of words and unconscious thing-presentations. The fundamental mechanism of paranoia is projection. The feeling of hatred toward the object is projected outward and then turned back onto the subject in the form of persecutory hatred.

In the final stage of his work, in describing the splitting of the ego, Freud was on the way to defining an original mechanism of the repudiation of reality in psychosis: denial of the reality of castration. This notion of the Verleugnung (denial) of castration, which he opposed to repression, goes back to the primal experience of loss. Thus, Jacques Lacan, taking up the term Verwerfung (rejection) in his discussion of the "Wolf Man," translated the German Verwerfung as foreclosure and, on the basis of this notion of a primordial excision of a fundamental signifier, elaborated his conceptualization of psychosis. The phallus as the signifier of castration is not inscribed within the symbolic order. Not integrated into the psychotic's unconscious, it returns to the real, especially in the phenomenon of hallucinations. Through Lacan's paternal metaphor, it can be considered that foreclosure of the Name-of-the-Father is the hole in the symbolic that is inherent in all psychoses.

The psychoanalytic elaboration of a theory concerning chronic and delusional psychoses runs up against the difficulty and complexity of a concrete approach. It becomes diversified into a theoretical eclecticism bringing together the considerations through which each school of thought, and indeed each analyst, refines and consolidates the foundations of the transference relationship. For all the intrinsic interest of the original viewpoints of John N. Rosen, Frieda Fromm-Reichmann, Marguerite Sechehaye, Gisela Pankow, Gaetano Benedetti, or Piera Aulagnier, among others, it is impossible to recognize their particular relevance without having access to the specific techniques used in their respective therapeutic approaches.

Through a "psychotic transference" that moves from extreme avoidance to a relationship that is almost one of merging, demands are placed on the analyst that touch his or her own archaic unconscious dispositions; "falling in love-hate" and the preponderance of narcissistic investment over object investment make it difficult to manage. What place does this relationship have within the complexity of medication-based, institutional, or readaptive approaches? Analytic theory must certainly be remembered in a variegated context (families, care-givers, recipients of care) if one wants to maintain a certain structural coherence. José Bleger's notion of framework, Lacan's of historization, and the understanding of transference and counter-transference—both individual and institutional—must always be implemented when the challenge of treating the psychoses is undertaken.

Michel Demangeat

See also : Ego Psychology and Psychosis ; Foreclosure; Historical truth; Hypochondria; Indications and contraindications for psychoanalysis for an adult; Infantile psychosis; Mathilde, case of; Paranoia; Paranoid psychosis; Paraphrenia; Persecution; Psychotic/neurotic; Schreber, Daniel Paul; Symbolization, process of.

Bibliography

Freud, Sigmund. (1894a). The neuro-psychoses of defence. SE, 3: 41-61.

——. (1896b). Further remarks on the neuro-psychoses of defence. SE, 3: 157-185.

——. (1911c [1910]). Psycho-analytic notes on an autobiographical account of a case of paranoia (dementia paranoides). SE, 12: 1-82.

——. (1914c). On narcissism: An introduction. SE, 14: 67-102.

——. (1924e). The loss of reality in neurosis and psychosis. SE, 19: 180-187.

——. (1927e). Fetishism. SE, 21: 147-157.

——. (1974a [1906-13]). The Freud/Jung letters: The correspondence between Sigmund Freud and C. G. Jung (William, McGuire, Ed; Ralph Manheim and R. F. C. Hull, Trans.). Princeton, NJ: Princeton University Press.

Lacan, Jacques. (1966). On a question preliminary to any possible treatment of psychosis. InÉcrits: A Selection (Alan Sheridan, Trans.). New York and London: W. W. Norton.