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Psychosis (Madness)

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In this volume a number of British psychoanalysts introduce us to psychoanlaytic definitions of intra-psychic and subjective meaning in patients suffering psychotic conditions. Irrespective of the particular type of psychotic illness under consideration of the context or treatment, each paper illustrates how the psychoanalytic clinician searches to establish meaning from events which are highly complex and often overwhelmingly confusing.Contributors:"Psychosis and violence" Leslie Sohn; "Sorrow, Vulnerability and Madness", Michael Conran; "How Can You Keep Your Hair On?", Michael Sinason; "The Delusions of the Non-Remitting Schizophrenias - Parallels with Childhood Phantasies", Thomas Freeman; "Managing Psychotic Patients in a Day Hospital Setting", Richard Lucas; "Desctructive Narcissism" and "The Singing Detective", David Bell.

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1. Leslie Sohn. Psychosis and violence

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Leslie Sohn

Previously, in another place, I presented a paper on unprovoked assaults, and discussed some patients, one of whom will appear in this paper. From that I wrote a paper which appeared in the International Journal of Psychoanalysis (Sohn 1995).

I want to take a further look at the patient I described in order to emphasise the relationship of his psychotic state to the events of violence which brought him to our attention. And then, in contrast, I want to talk about a young psychotic woman who never resorted to physical violence, although she had had delusional ideas of having murdered - or somebody having been murdered, or somebody having murdered somebody - and she felt that she’d seen the dead body. Then I want to talk about two other men; one a borderline case with almost delusional belief in his sanity, whose violence was solely directed unwittingly to his own mind and its contents, and to the mind of others who were exposed to him, and we were expected to believe implicitly in his conclusions. To do so, and to believe that, would mean that the listener’s mind would have totally given up its own scepticism and independent thinking. In other words, that the listener’s mind would have felt murdered, or dead. This man deigned physical assault; he was above it, and I think he even deigned physical contact as well.

 

2. Michael Conran. Sorrow, vulnerability and madness

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Michael Conran

You think I’ll weep;
No, I’ll not weep:
I have full cause of weeping, but this heart
Shall break into a hundred thousand flaws
Or ere I’ll weep. 0 Fool! I shall go mad.

William Shakespeare, King Lear Act II Scene iv

The paper I am about to read is one I have given before and it presents me with a dilemma which I shall now explain. It is in fact part of a chapter of a doctoral thesis written more than a quarter of a century ago; and it is my intention to read it in its original, that is to say, unrevised form. To be sure, I could not, or should not, have written it in this form now. Which is to say it is scarcely to be judged now as a case history, even less as a scientific paper. I now like to think of it as a story, though if anyone had suggested that to me when I wrote it I should have bristled with indignation. This was written before I trained as a psychoanalyst and I did not then appreciate the everlasting importance and strength of the story. Modern medicine came to abjure the story generally under the contemptuous and dismissive epithet, ‘anecdotal evidence’, which, however statistically justified, diverts attention away from the central importance to everyone of us, as to every patient, of his own story. Much of the business of psychoanalysis is to help the patient to find a story in the first place, and then one with which he can live. Pirandello’s most celebrated play, Six characters in search of an author, does, in some sense, illustrate this; but the quotation I most cherish is that of Isaac Bashevis Singer who said, “The story is everything. If the Iliad had come to us a commentary by Marx or as an interpretation by Freud, nobody would read it.’ In another context he said, ‘A story must be a love story. Many writers have attempted to write a story which is not a love story and they have always failed.’

 

3. Michael Sinason. How can you keep your hair on?

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Michael Sinason

In common speech, ‘keep your hair on’ is said to someone when he or she is felt to be in danger of getting into an uncontrolled state of rage. When someone hasn’t ‘kept their hair on’ and there has been an eruption of destructiveness they are often referred to as having gone ‘absolutely mad’, which recognises how out of contact with reality they are. During the breakdown, the hate, rage and damage is often directed at things that are otherwise particularly cared for and valued. The scale of damage is variable but what is so painful about these situations is that when the individual ‘recovers himself he is usually appalled by what has happened. That is why friends of the individual try to prevent the situation from worsening by saying ‘keep your hair on’ when they see the early warning signs. They know that the person will regret what they will do if they are taken over by the rage.

These commonplace ways of referring to the nature of a breaking down of mental functioning and its consequences can carry a great wealth of experience of the actual dynamic nature of the processes involved. I think this occurs because people learn an emotional grammar from their interactions with others, which parallels the way they learn to speak. They learn the grammar of mental states from the way that facial expressions and tones of voice change and from the way smaller actions of threatening and gesturing can lead to escalating violence.

 

4. Thomas Freeman. The delusions of the non-remitting schizophrenias: parallels with childhood phantasies

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Thomas Freeman

M Bleuler’s (1978) follow-up studies have confirmed the clinical observation that the course of the illness in non-remitting schizophrenias is towards the establishment of relatively stable ‘end states’. The term ‘end state’ as used by M Bleuler (1978) does not mean that the process of illness has come to an end, is incapable of further development for good or ill, or that further changes may not affect the personality. Only when the illness has continued in this relatively steady condition for five years can it be designated an ‘end state’. Although acute attacks may occur during ‘end states’ they are ephemeral and there is a return to the quiescent condition. M Bleuler distinguishes three types of’end state’: severe, moderately severe and mild. Dementia and defect state were the terms used in past times to describe the first two. The third type consists of those patients whose illness is not immediately obvious, who can conduct a rational conversation without the intrusion of delusional and hallucinatory experiences and can undertake useful work. The delusions which occur during the initial, acute attack of a schizophrenic psychosis are inclined to disappear along with other acute manifestations (E Bleuler 1911). In contrast the delusions which make their appearance when the illness follows a chronic course (non-remitting) tend to persist unchanged over many years (E Bleuler 1911). The introduction of drug therapy has not altered this apart from causing a transient disappearance of the delusions. The long-term observation of schizophrenic patients whose illnesses have reached ‘end states’ suggests that the content of the delusions is different from that present during the initial attack. The delusions to be described here are drawn from 12 cases, four of which had reached a severe ‘end state’ (three women and one man), six had reached a moderately severe ‘end state’ (four women and two men), and two, a mild ‘end state’ (one man and one woman). The retrieval of the delusions was sometimes easy, but occasionally very arduous. The greatest difficulty was encountered when there was inattention, withdrawal and cognitive disorganisation. The presence of thought-blocking, derailment of speech, the inappropriate use of words (loss of the symbolic, function), aberrant concepts (Schilder 1923) and neologisms combined to conceal the content of delusions (Freeman 1969). Perseverations, transitivistic phenomena and apper-sonations expressed in speech contributed to the confusion caused by the breakdown of syntax. The recovery of delusions in such severe ‘end states’ can therefore only be accomplished piecemeal. Fortunately there are occasions, however brief, when speech regains its communicative function and a detail of the patient’s delusional reality makes its appearance. These are occasions when the patient has a pressing need or is angry because of a disappointment (Freeman 1969). Although patients whose illness has reached a mild ‘end state’ can communicate verbally when they so desire, it is unusual for them immediately to reveal the details of their delusions. The reticence tends to disappear when they discern that an interest is being taken in their circumstances. After some weeks, however, a reluctance to continue with daily sessions begins to appear. Patients fear that they are wasting the psychiatrist’s time. Then they either stop attendance or become increasingly withdrawn. The psychiatrist may be accused of exerting a malevolent influence. Such a sequence of events occurs despite the chemotherapy. After a few weeks it is sometimes possible to re-engage patients in further meetings. However, after a short while the reluctance and withdrawal appear once more.

 

5. Richard Lucas. Managing psychotic patients in a day hospital setting

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Richard Lucas

The psychiatric day hospital can be regarded as one form of a therapeutic community. Maxwell Jones, a pioneer of the therapeutic community, described this as being a ‘living/learning’ situation, both for staff and patients (Jones 1952). However, there is nothing magical about a therapeutic community; it is only as effective as the sum of its input - by both staff and patients. In this paper I want to concentrate on the role of the day hospital in the management of psychotic patients, especially in attempting to make emotional contact with those in seemingly inaccessible states, through the utilisation of analytic insights. Illustrative clinical examples will be given, related to the day hospital setting

The general psychiatric approach to psychosis does not usually incorporate a space for analytic thinking. General psychiatrists look on schizophrenia in terms of an organic disorder for which we have not as yet fully identified the cause, but which drugs (major tranquillisers) help. For example, in a review on the current management of schizophrenia, on the role of psychotherapeutic input, Fahy and David write ‘Psychotherapy, both individual and family, continues to fight a rearguard action against exclusively pharmacological treatment of schizophrenia’ (Fahy & David 1993). Diagnosis is made by trying to be objective about describing subjective experiences (Jaspers phenomeno-logical approach). Some symptoms are said to be more important in making the diagnosis: first rank symptoms, eg hearing voices commenting in the third person, and primary delusions. These features are elicited by the mental state examination. A social history is taken, including when the patient last worked, and whether they have been able to mix with others or have always been withdrawn - the so-called schizoid personality. Also the family atmosphere is assessed. It is known that, apart from stopping medication, an over-pressuring home atmosphere with unrealistic high expectations (high expressed emotion) is a major cause of relapse (Gelder et al 1990). However, while all this is relevant in making a diagnosis and assessing social and family stresses linked with relapses, in my view we then need to make a further mental state assessment - a psychoanalytic one of the individual.

 

6. David Bell. Destructive narcissism and The Singing Detective

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David Bell

The great neurologist, Hughlings Jackson, who much impressed Freud, once said: ‘…Find out all about dreams and you’ll find out all about psychosis’. The world of our dreams is also, of course, the territory of artists. Works of art grip us in a profound way because they deal with unconscious concerns that are fundamental to us.

The television drama The Singing Detective, by Dennis Potter, is one such work. It deals with the tyranny of arrogance and cynicism, the terror of dependency, humiliation and shame. These are issues for all of us, but it is, I believe, in the psychotic patient that they reach their greatest intensity and become literally matters of life and death. Potter’s narrative is striking in its explicitness and in its understanding of the internal world with its interweaving of memory, fantasy and reality. In this paper I will offer one way of understanding Potter’s drama and I will compare it with some clinical illustrations from psychotic and non-psychotic patients.

 

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