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Psychotic States

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Psychotic States brings together a number of Herbert Rosenfeld's papers written between 1946 and 1964 dealing with the psychopathology and treatment of various psychotic and borderline conditions from a psychoanalytic viewpoint. Taking the theories and techniques developed by Melanie Klein in her work with infants and young children, Dr Rosenfeld investigated their application to a range of psychotic syndromes, including chronic and acute schizophrenia, severe hypochondriasis, drug addiction, severe depression and manic depression, both to determine their possible therapeutic efficacy and to see what light they might shed on the etiology of the psychosis.

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1: ANALYSIS OF A SCHIZOPHRENIC STATE WITH DEPERSONALIZATION

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THE patient I shall now discuss was sent to me for a variety of physical complaints of a functional origin. In the course of treatment it became apparent that I was dealing with a psychosis of the schizophrenic type. In this paper I shall concentrate only on certain aspects of the case; namely, the schizoid symptomatology and some of the schizoid mechanisms encountered. An additional aim will be to throw some light on depersonalization, and I will try to show the connexion between processes of ego disintegration and depersonalization.

Short History of the Case

My patient, Mildred, is a young woman who was twenty-nine when the treatment started in March 1944. She is of average height and build, with straight fair hair. Her face is not exactly plain, but it usually appeared so because of its lack of expression. During the latter part of the treatment her expression became more alive and she sometimes smiled. She had her first breakdown in health when she was seventeen. Her second breakdown occurred at the age of twenty-five, in the early part of the war, while she was serving in the Auxiliary Territorial Service. She developed one physical illness after another, e.g. influenza and sore throats, until she had to be invalided from the Service. After some time she recovered and made another attempt to defeat the recurring illnesses by joining the Land Army, but again the physical disturbances prevented her from continuing. When I saw her in March 1944 for consultation she had been suffering from a so-called influenza for about four or five months. She agreed to analysis; but we soon realized that she had no desire to come for treatment, and this was in the main due to a deep-seated hopelessness about any recovery.

 

2: REMARKS ON THE RELATION OF MALE HOMOSEXUALITY TO PARANOIA, PARANOID ANXIETY AND NARCISSISM

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Psycho-analytical Theories of Paranoia

THE problems I wish to discuss concern the interrelations between homosexuality and paranoia, paranoid anxiety and narcissism. As early as 1908, Freud discussed with some prominent analysts of that time, particularly Ferenczi and Jung, the intimate relationship which he felt invariably existed between paranoia and latent homosexuality; and since then many papers on paranoia have appeared in the analytic literature. Most of the earlier and some of the later authors think that the projection of latent homosexuality is the most important factor in this disease. Ferenczi (1911a) went so far as to suggest that paranoia may be simply a distorted form of homosexuality. Freud (1911) stated his views on paranoia in his Schreber case, There he put forward his famous formula for paranoia, of how the consciously unbearable homosexual feelings are changed into hostile ones for defensive purposes, and then projected. At the same time he demonstrated that the projective mechanism could be used for other purposes: ‘In the beginning of the disease (dementia paranoides), all object cathexis is withdrawn from the objects of the environment and regression to narcissism takes place. In the process of recovery, the libido is brought back to the people it had abandoned. In paranoia, this process is carried out by the method of projection.'

 

3: NOTE ON THE PSYCHGPATHOLOGY OF GONFUSIONAL STATES IN CHRONIC SCHIZOPHRENIAS (1950)

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DURING the last ten years I have been treating by psychoanalysis a number of schizophrenics, some of very long standing. My aim was not only to achieve a therapeutic result, but to find out more about the psychopathology of this disease group. To achieve this aim I adhered to the regular analytic situation and deviated as litde as possible from the established technique employed in treating neurotics, because I felt, and still feel, that only thus may it be possible to increase our knowledge of the psycho-pathology of schizophrenia.

This paper deals with the psychopathology of confusions! states which I was able to investigate during the analyses of chronic schizophrenic patients. Feelings of confusion are part of normal development and they are a common feature in many pathological conditions. But in the schizophrenic process severe states of confusion seem to play an important part; I also noticed that following the confusional state there was either an improvement or a deterioration in the condition of my patients.

 

4: NOTES ON THE PSYCHO-ANALYSIS OF THE SUPEREGO CONFLICT IN AN ACUTE SCHIZOPHRENIC PATIENT

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IN analysing a number of acute and chronic schizophrenic patients during the last ten years, I have become increasingly aware of the importance of the superego in schizophrenia. In this paper I shall present details of the psycho-analysis of one acute catatonic patient in order to throw some light on the structure of the schizophrenic superego and its relation to schizophrenic ego-disturbances. I also wish to discuss the controversy about methods of approach to acute schizophrenic patients

The Controversy concerning the approach to Schizophrenic Patients
by Psycho-analysis

In discussing the value of the psycho-analytic approach to schizophrenia, we have to remember that psychotherapists with widely different theories and equally different techniques claim success in helping the schizophrenic in the acute states of the disease. The attempt to concentrate on producing a quick therapeutic result in the acute schizophrenic state, irrespective of the method of approach, may be temporarily valuable to the individual patient and gratifying to the therapist; but these” cures’ are generally not lasting and the therapists often neglect the importance of continuing the treatment during the chronic mute phase of the disease which follows the acute state. The psycho-analytic method can be used for both the acute and the chronic phase of the disease. I have found that when used in the acute phase it can be carried on in the chronic phase without any fundamental change in technique; in fact, the use of the analytic technique in the acute phase prepare and assists the psycho-analytic treatment of the mute phase. The ultimate success of the treatment seems to depend on the handling of the mute phase. But, if a non-analytic method of forcible suggestion or of reassurance is used in the acute phase, psycho-analysis has been found to be exceedingly difficult in the chronic phase and its ultimate success may be prejudiced. Therefore if analysis is to be used at all in the treatment of schizophrenia, it is advisable to start with it in the acute phase.

 

5: TRANSFERENCE-PHENOMENA AND TRANSFERENCE-ANALYSIS IN AN ACUTE CATATONIC SCHIZOPHRENIC PATIENT

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MOST analysts have until recently refrained from treating schizophrenic patients, in the belief that the schizophrenic is incapable of forming a transference. My own experience has shown me that we are dealing here not with an absence of transference, but with the difficult problem of recognizing and interpreting schizophrenic transference-phenomena. It may be valuable to examine first the findings of other analysts,

Both Freud (1911 and 1914b) and Abraham (1908a) made it quite clear that in their opinion the schizophrenic is incapable of forming a transference, owing to his regression to the auto-erotic level of development. They explained this by stating that on the earliest infantile level, which they called the auto-erotic phase, there was as yet no awareness of an object. But there are several statements of Freud's which seem to contradict the concept of an auto-erotic phase, in which there is no relation to an object, such as that in The Ego and the Id (1923) where Freud says: tfAt the very beginning, in the individual's primitive oral phase, object cathexis and identification are no doubt indistinguishable from each other/ From this later opinion of his we may conclude that he recognized the existence of object cathexis in earliest infancy. Freud however never gave any indication that he changed his view about the lack of transference in schizophrenia (perhaps because he had no later experience with such patients).

 

6: CONSIDERATIONS REGARDING THE PSYCHO-ANALYTIC APPROACH TO ACUTE AND CHRONIC SCHIZOPHRENIA

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I PROPOSE to discuss the psycho-analytic approach to the treatment of schizophrenia, as it is being developed by a number of psycho-analysts in England, including myself. This work derives from Melanie Klein's researches into the early stages of infantile development and from the technique she uses, both in adult neurotic and borderline psychotic patients and in the analysis of children.

In our approach to schizophrenia we retain the essential features of psycho-analysis: namely, detailed interpretations of the positive and negative transference without the use of reassurance or educative measures; the recognition and interpretation of the patient's unconscious material; and, above all, the focusing of interpretations on the patient's manifest and latent anxieties. It has been found that the psychotic manifestations attach themselves to the transference in both acute and chronic conditions, so that what one may call a ‘transference-psychosis’ develops. The analyst's main task in both acute and chronic schizophrenias is the recognition of the relevant transference phenomena and its communication to the patient. Particularly in the analysis of acute schizophrenia, certain practical problems arise as to the management of the patient in the consulting-room; these will be described later.

 

7: ON DRUG ADDICTION

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IN scrutinising the literature of drug addiction and alcoholism it becomes apparent that the great majority of psycho-analytic papers on that subject were written before 1945. One of the reasons for the scarcity of psycho-analytic contributions during the last twenty years may be the recognition that the treatment of drug addiction in psycho-analytic practice is a very difficult problem.

The Management of the Addict

I suggest that the drug addict is a particularly difficult patient to manage because the analyst has not only to deal with a psychologically determined state but is confronted with the combination of a mental state and the intoxication and confusion caused by drugs. As a severely intoxicated patient is not accessible to analysis, an attempt has to be made from the beginning of the treatment, or when the drug addiction is diagnosed while the patient is under analysis, to get the severe drugging under control, and the patient has to accept either private nursing or residence in a nursing home or hospital. If the patient accepts the condition of control of the drugging, analysis can proceed. Nevertheless, excessive acting out, which can lead to crises in the treatment, occurs when the patient periodically breaks through the control. The control cannot be too severe and absolute because this would amount virtually to imprisonment of the patient, a situation which he would experience as punishment and not as help in his attempt to give up the drugs. The difficulties in treating these patients have been stressed by Bychowski (1952) who warned every therapeutic enthusiast against the treatment of any drug addict in private practice. He adds: ‘This is possible only in exceptional cases and puts an extraordinary strain on the psychiatrist and the patient's environment.’ My own psycho-analytic investigation of drug addicts has been limited to a few patients, but I found it unnecessary to modify my usual psycho-analytic approach. As in my earlier experiences in investigating psychotic conditions, like schizophrenia and manic-depressive states, I feel that progress in understanding the specific psychopathology of drug addiction must come through the understanding of the transference neurosis or the transference psychosis, however difficult this may be, but not by giving up the psycho-analytic approach.

 

8: THE SUPEREGO AND THE EGO-IDEAL

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SINCE the aim of this symposium is to discuss both the ego-ideal and the superego, I shall first attempt to clarify the way in which these terms have been employed by Freud, and then discuss my own understanding of the terminology and how it is used in this paper. The term ‘superego’ was introduced as an alternative to the term ‘ego-ideaP by Freud in 1923 with the implication that the ego-ideal and the superego were identical. On the other hand, the term ‘ego-ideal’ which Freud originally introduced (1914b) had an entirely different meaning. At that time he differentiated the ego-ideal from a special psychical agency, the conscience, relating the ego-ideal to the ‘narcissistic perfection of childhood and suggesting that this ideal was a substitute for the lost narcissism in which we were our own ideal. This explanation would suggest a connexion between the ego-ideal and omnipotent fantasies of early infancy when the baby fantasies himself in the role of an omnipotent ideal figure, or as possessing an ideal object or part-object, often the breast or the penis. We frequently find that narcissistic patients have a highly idealized omnipotent picture of themselves which is in contrast to their real self. I am not in favour of using the term ‘ego-ideal’ for these specific narcissistic idealized fantasies.

 

9: NOTES ON THE PSYGHOPATHOLOGY AND PSYCHO-ANALYTIC TREATMENT OF SCHIZOPHRENIA

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MY interest in the psychological approach to schizophrenia goes back more than twenty-five years. At that time I had the opportunity of interviewing a large number of schizophrenic patients in the Maudsley Hospital and I noticed that some of them regarded psychological problems as the cause of their illness. I remember a young catatonic schizophrenic girl of sixteen who explained to me that she became ill after she had discovered the facts of life. She found it unbearable to think about the details of her birth from the inside of her mother. She explained that this was the reason why she did not want to have anything to do with her mother or anybody else. She did not want to read any more because she was afraid of having to visualize again something which was similarly unbearable. In fact it seemed as if this girl had, as a result of this experience, turned away from the outer world and from all her interests which were related to it. My observations at that time had the effect of making me increasingly doubtful about the prevalent contemporary teaching, which suggested that schizophrenia should be regarded as an endogenous problem which became manifest completely uninfluenced by external circumstances. At a later time I had the opportunity of trying some psychotherapy with schizophrenics in various hospitals and was astonished that I succeeded in making good contact with some very ill schizophrenic patients and that they could be helped by simple psychotherapeutic talks. In other cases, however, I felt completely helpless, especially when I realized that, after some initial improvement, the patients became very much worse.

 

10: ON THE PSYCHGPATHOLOGY OF NARCISSISM: A CLINICAL APPROACH

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FREUD was pessimistic about the psycho-analytic approach to the narcissistic neuroses. He felt that people suffering from these diseases had no capacity for transference, or only insufficient remnants of one. He described the resistance of these patients as a stone wall which cannot be got over, and said that they turn from the physician not in hostility but in indifference. Many analysts have tried to develop methods of analysis which would deal with narcissistic patients-1 am thinking of Waelder (1925), Clark (1933), and later Fromm-Reichmann (1943,1947)5 Bion (1962), Rosenfeld, and others. The majority of analysts who have treated narcissistic patients have disagreed with Freud's view that there was no transference. As the transference is the main vehicle for any analytic investigation, it seems essential for the understanding of narcissism that the behaviour of the narcissist in the analytic transference situation should be minutely observed.

Franz Cohn (1940) suggested that the sharp distinction between transference neurosis and narcissistic neurosis should be disregarded. He felt that the transference in the narcissistic neurosis is of a primitive or rudimentary type-for example, there are often serious difficulties in distinguishing between subject and object-and he stresses the introjection and projection of destructive tendencies in oral and anal terms in relation to the analyst. Stone (1954) described transferences which are ‘literally narcissistic’, where the analyst is confused with the self or is like the self in all respects: the therapist and the patient alternately seem to be parts of each other. He stresses both the primitive destructiveness and the need to experience the analyst as an omnipotent, godlike figure, and suggests that, in the patient's fantasy about the analyst's omnipotence, guilt about primitive destructive aggression plays an important part.

 

11: THE PSYGHOPATHOLOGY OF HYPOCHONDRIASIS (1964)

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KNOWLEDGE about a disease called ‘Hypochondriasis’ dates from the time of Hippocrates, and ever since then it appears to have been a common illness, judging from the literature throughout the ages. At the time of Boswell, who himself suffered from it, hypochondriasis in England was so common as to be called the ‘English Malady’. There is a large psychiatric literature on the question as to whether hypochondriasis ever existed as a separate disease entity. Bleuler thought that all patients suffering from chronic hypochondriasis were schizophrenics. Raeke, Westphal, Sommer, Wolfsohn and later Schilder were all in favour of regarding severe chronic hypochondriasis as a ‘psychotic disease entity. Bleuler defined hypochondriasis as a condition consisting in ‘continuous attention to one's own state of health, with a tendency to ascribe disease to oneself from insignificant signs and even without such’. The severity of hypochondriasis varies a great deal and it may be valuable to differentiate the disease entity ‘hypochondriasis’, which is a very chronic psychosis, generally believed to be of bad prognosis, from ‘hypochrondriacal states’, which are more temporary: they may be psychotic or neurotic in origin. Hypochondriacal states are found in the neuroses and psychoses, as in hysteria and obsessional neurosis; in depressive and neurasthenic conditions; in schizophrenia; and also in the initial states of organic psychosis. They are common in adolescence and in middle age. Temporary hypochondriacal anxieties, for example, may arise when early infantile psychotic, particularly paranoid, anxieties are stimulated and have to be worked over again by the individual. This would explain why hypochondriacal anxieties frequently arise in phases of readjustment, for example at puberty or in middle age. The meaning of these hypochondriacal phases would be similar to the function which Melanie Klein attributes to the infantile neurosis, which she connects with the working over again of early psychotic anxieties.

 

12: AN INVESTIGATION INTO THE NEED OF NEUROTIC AND PSYCHOTIC PATIENTS TO ACT OUT DURING ANALYSIS (1964)

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Iw investigating the need of patients to act out during analysis, I have come to understand that some acting out occurs in every analysis, and that one might well be justified in saying that partial acting out is not only inevitable but is in fact an essential part of an effective analysis. It is only when this partial acting out increases and becomes excessive, that both the analysis and the patient are endangered.

As far back as 1914 Freud discussed the question of acting out. In explaining the process of analysis he says: We may say that the patient does not remember anything of what he has forgotten and repressed but acts it out (Freud, 1914a). Freud then relates the acting to the repetition compulsion and continues: As long as the patient is in the treatment he cannot escape from this compulsion to repeat; at last one understands that it is his way of remembering/ Later on he says: ‘We soon perceive that the transference is itself only a piece of repetition and that the repetition is a transference of the forgotten past not only on to the doctor, but also on to all the other aspects of the current situation. We must be prepared to find, therefore, that the patient abandons himself to the compulsion to repeat, which now replaces the impulsion to remember, not only in his personal attitude to his doctor but also in every other activity and relationship which may occupy his life at the time/

 

13: THE PSYGHOPATHOLOGY OF DRUG ADDICTION AND ALCOHOLISM

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ALCOHOLISM and drug addiction have always presented a difficult psychiatric and social problem. Psycho-analysts, along with many others, have from early on been interested in the treatment of these disorders, and have attempted to investigate and understand their underlying psychopathology. A large psycho-analytic literature has developed and many analysts have made several contributions to the subject over die years. This paper aims to give a picture of the psycho-analytic literature on alcoholism and drug addiction and to correlate the psychoanalytic findings. An attempt will be made to see whether, on the basis of the ideas on which there is a consensus of opinion among the authors of this literature, one can speak of the psychoanalytic theory of drug addiction or alcoholism,,

Freud never wrote a detailed essay on alcoholism or drug addiction, but there are many isolated remarks or suggestions in his writings which throw some light on the psychopathology of addiction. In 1897 in a letter to Fliess (Freud, 1950) he suggests that masturbation is the primary addiction and that the other addictions, such as alcohol, morphine, tobacco, etc., only enter into life as substitutes or replacements for it. In another letter to Fliess he discusses the relation of dipsomania to repressed sexuality and thinks that in this condition there is a substitution of one impulse for an associated sexual one. In the Three Essays on Sexuality (1905) he says that there is in some children a constitutional intensification of the erotogenic significance of the labial region. If that significance persists, these same children when they are grown up —will have a powerful motive for drinking and smoking.’ In Jokes and Their Relation to the Umon seimss (2904) he writes: A cheerful mood, whether it is produced endogenously or toxically, reduces the inhibiting forces, criticism among them, and makes accessible once again sources of pleasure which were under the weight of suppression. Under the influence of alcohol the grown man once more becomes a child who finds pleasure in having the course of his thoughts freely at his disposal without paying regard to the compulsion of logic.’ In his ‘Contributions to the Psychology of Love (1910) Freud contrasted the relation of the lover to the sexual object with that of the wine drinker to wine. Whereas the lover may pursue an endless series of substitute objects, none of which ever gives full satisfaction, the drinker is more or less bound to his favourite drink and the repeated gratification does not affect the recurrence of his strong desire. The great lovers of alcohol describe their attitude to wine as the most perfect harmony, a model of a happy marriage. In 1911 he refers to the part played by alcohol in alcoholic delusions of jealousy and suggests that drink removes inhibitions and undoes the work of sublimation. As the result of this, homosexual libido is freed and the drinker suspects the woman he is jealous of in relationship to all the men whom he himself is tempted to love. In 1917 he compares toxic hallucinations, such as alcoholic delusions, with the wishful psychosis of'amentia’ (Freud, 1917a). He believes that alcoholic delirium arises when alcohol is withdrawn, which implies that it is a reaction to the loss of alcohol which is experienced as unbearable. In ‘Mourning and Melancholia’ (1917b) he expresses the view that alcoholic intoxication, in so far as it consists in a state of elation, belongs to the manic group of mental conditions. In mania there is a relaxation in the expenditure of energy on repression. In alcoholism the freeing of impulses from repression is made possible by the toxin. In 1928 in a paper on ‘Humour’, Freud (1927) again refers to intoxication. He compares humour with elation and suggests that it signifies the triumph not only of the ego but also of the pleasure principle. He writes ‘(The) rejection of the claims of reality and the putting through of the pleasure principle bring humour near to the regressive or reactionary processes which engage our attention so extensively in psychopathology. Its fending off of the possibility of suffering places it among the great series of methods which the human mind has constructed in order to evade the compulsion to suffer-a series which begins with neurosis and culminates in madness and which includes intoxication, self-absorption and ecstasy/ From these quotations of Freud's views it is clear that he realized that the root of addiction goes back to the oral phase of development, but he also saw that there was a connexion between addiction and infantile masturbation. He also makes it clear that he believes that the drinker often regards alcohol as an ideal object, which would explain why the drinker becomes so deeply attached to alcohol-representing this object By connecting the psychopathology of mania and humour with alcoholism and intoxication Freud laid the foundation for a deeper understanding of the addictions.

 

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