Is there a psychoanalytic nosography in the etymological sense of a rewriting and reorganization of psychopathology on the basis of psychoanalysis? And if so, is that nosography restricted, in its form and boundaries, to the sphere of psychoanalytic thinking and practice; that is, is there a psychoanalytical symptomatology for internal use only that does not coincide exactly with that of psychiatry? In answer to these questions, it is arguable that dynamic psychology sought at first to dismantle several established clinical pictures and to erode the boundaries between the normal and the pathological, but that then, having exhausted the possibilities of this approach, it abandoned the efforts.
Alternatively, can psychoanalytic theory, or more precisely, metapsychology, perhaps be said in a more ambitious way to have revised the whole of psycho-pathology and placed it in a perspective where, reordered, it attained a new coherence? Indeed, psychoanalysis grew out of a questioning of psychiatry, and in particular, the neurological or mental nature of hysteria. Also, before writing Studies on Hysteria (1895d), Freud thoroughly scrutinized the normal clinical treatment of patients at that time.
Freud's study of dreams, his study of the development of sexuality, his model of the mental apparatus, and his positing of the unconscious all implied a broad transcendence of the clinical data from which he set out. Yet his quest for a new understanding of the neuroses nevertheless led him back to familiar categories: conversion, phobia, obsession, and anxiety. Freud found that, in the context of the interaction between affects and ideas, the mechanisms of defense could be most effectively differentiated on the level of symptoms, for this level yielded the greatest degree of explanation.
Yet even on this level, the level of Freud's first topography, the classical syndromes tended to reassume their old forms rather than to break down as their outlines came into clear view. A specific set of conflicts could be confidently aligned with parapraxes, with phobias, or with confused or delusional states. These diverse conditions were explicable by reference to a dynamic that the earlier categories of traumatic neurosis, transference neurosis, and actual neurosis had initially tended to define too narrowly—in terms that for this very reason have fallen out of use. All the same, Freud failed sufficiently to explore the vicissitudes of the interaction between primary and secondary processes (the affective and thought processes) in trying to better understand, on the basis of conflict, the various disturbances of consciousness that challenged the existence of the object. Accordingly, what Freud called "reality-testing" and described as an "institution of the ego" (1916-1917f , p. 233) became an object of study alongside the still relevant material addressed in the clinical treatment of acute mental disorders.
Other questions had already arisen for Freud when he found it necessary to introduce narcissism into his theory (1914c). These questions obliged him to consider the withdrawal of libido from the object and redirection toward the ego, as well as its restitution. This consideration brought in, in different ways, the notions of depression, psychosis, and delusion. Clinical and therapeutic experience with such pathology demonstrated that its organization was too complicated to be adequately explained by its unconscious meanings alone. Here too the idea of narcissistic neurosis was not up to the task of circumscribing nuances and distinctions, and this remained true even after the category of narcissistic neurosis was subsequently limited to depression alone. At this point Freud focused on hypochondria as the main decompensatory tendency: "The relation of hypochondria to paraphrenia is similar to that of the other 'actual' neuroses to hysteria and obsessional neurosis" (p. 84).
To go more deeply into what, in 1895 in Draft G of the Fliess Papers (1950c), he had had to say about the essential nature of depression, Freud took classical melancholia as the basis for what he characterized as the withdrawal of the conflict into the ego (1916-1917g). Such narcissistic identification with the lost object already implied a second topography that would overturn earlier mental agencies and offer even the most "endogenous" psychiatry a vast range of possible dynamic explanations.
Furthermore, the heterogeneous borderline states, which have since achieved so much importance in clinical practice, can perhaps be unified only within the psychoanalytical perspective of seeing them as a narcissistic failure in dealing with conflict and avoiding depression by mobilizing a set of defenses against reality: negation, splitting, idealization, and so on.
As for psychosis, beginning with his discussion of the Schreber case (1911c ), Freud suggested that it had roots deeper than merely the various projective modalities of the homosexual drive, deeper than merely the repression of reality (1924b, 1924e). Though loath to challenge the established German-language nosography of the day with regard to what he would have preferred to call "paraphrenia," Freud felt that the subject's the return to autoeroticism short of narcissism, the failure of thing presentations, and the opacity of the symbol in instances of "organ-speech" (1915e, p. 198) raised questions about what was at stake in psychosis, namely the integrity of the ego and the objects that were incompatible with it.
Consideration of the psychic context of breakdowns of mental life, of Freud's earliest questions concerning the actual neuroses, and of the development of psychosomatic medicine support the idea that, even though psychoanalysis has not invented a new nosography, it has nevertheless cast an incomparably clear light across the whole field of psychopathology and has provided a firm foothold to understand the field.
See also: Actual neurosis/defense neurosis; Alcoholism; Alienation; Character; Conflict; Narcissistic neurosis; "Psycho-Analytic Notes on an Autobiographical Account of a Case of Paranoia (Dementia Paranoides)."
Freud, Sigmund. (1911c ). 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: 81-105.
——. (1915e). The unconscious. SE, 14: 159-204.
——. (1916-1917f ). A metapsychological supplement to the theory of dreams. SE, 14: 237-258.
——. (1916-1917g ). Mourning and melancholia. SE, 14: 237-258.
——. (1924b). Neurosis and psychosis. SE, 19: 147-153.
——. (1924e). The loss of reality in neurosis and psychosis. SE, 19: 180-187.
——. (1950c ). Draft G. In his The origins of psycho-analysis: Letters to Wilhelm Fliess, drafts, and notes, 1887-1902 (Eric Mosbacher and James Strachey, Trans.). London: Imago, 1954. (Revised translation in SE, 1: 200-206)
Freud, Sigmund, and Breuer, Joseph. (1895d). Studies on hysteria. SE, 2: 48-106.