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19. Conclusions

Murray Jackson Karnac Books ePub

I have presented a wide range of examples of the thinking and behaviour typical of severe psychotic illness and have offered commentaries based on the application of Kleinian concepts. I wished to demonstrate the value of these concepts as guidelines, or navigational aids, to learning and treatment by psychotherapists, psychiatrists, and others working in the field who have different perspectives and different but related special skills.

At the beginning, I pointed out that the perspective of this book is that however much later experience may promote or obstruct normal development, it is in the mother-baby relationship that the seeds of psychosis are to be found. I quoted Winnicott’s maxim that the place to study psychosis is in the nursery and Segal’s assertion that the roots of psychosis lie in the pathology of early infancy which structures the budding inner world and influences later developmental levels in an epigenetic fashion. I also remarked that it was not going to be easy to write a text that would be intelligible and do justice to both psychiatric and psychoanalytic thinking.

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CHAPTER FOUR. Catatonia 1: psychotic anorexia

Murray Jackson Karnac Books ePub

Catatonia is the term used to describe a disorder, the main feature of which is a recurrence of episodes of catalepsy. The actual term was first used in a psychiatric context by Kahlbaum in 1874 in a classic monograph entitled “The Tension Insanity” (Johnson, 1993). Catalepsy is a state of extreme physical immobility and mutism, lasting for minutes or hours at a time. A characteristic of catalepsy is the spontaneous adoption of postures, perhaps statuesque or stereotyped, and the automatic maintenance of bodily positions imposed by the examiner. Cataleptic phenomena may also include trance or stupor. The origin of catalepsy can be psychogenic (as in hypnotic suggestion), pharmacogenic (induced by certain drugs, including neuroleptics), or organic (neurological disease such as encephalitis lethargica).

The association of catalepsy with schizophrenic features led to the diagnostic category of catatonic schizophrenia (Bleuler, 1950) and later to hopes that such patients might respond to psychoanalytic psychotherapy (Rosen, 1953). Initial optimism proved unjustified, and it was found that most attacks could be cut short by electro-shock treatment, although recurrence was usual. Catatonic schizophrenia was once commonly encountered in psychiatric practice and is now relatively rare. This is probably due to the powerful symptom-reducing capability of neuroleptic drugs and an increasing preference by clinicians for more sophisticated diagnoses. Nevertheless, catatonia remains a common presenting problem and challenges the psychiatrist’s skills in evaluating organic and psychogenic factors in each individual case.

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14. Chronic schizophrenia— catatonic and spatial features: “George”

Murray Jackson Karnac Books ePub

Catatonic schizophrenia was once common among the chronically institutionalized schizophrenic patients of many mental hospitals. In its classical form, it presented as grossly disturbed behaviour and dramatic motor phenomena. Stuporose or semi-stuporose states, often with the assumption of stereotyped postures, sometimes punctuated by sudden outbursts of panicky and at times violent agitation, were characteristic.

However, the advent of anti-psychotic drugs, advances in the practice of psychiatric nursing, and improvements in the organization of traditional mental hospitals have greatly reduced its incidence. Minor forms may still be encountered in which the differentiation from obsessional states may be difficult. In the following case, the psychodynamics and meaning of such symptoms could eventually be understood, and the underlying psychological conflicts resolved.

George

When presented to the seminar, George was 24 years old and had been in twice-weekly psychotherapy in a treatment home for young schizophrenic patients for four years. He had had his first psychotic attack at the age of 16, when long-standing symptoms of depression changed to an acute hallucinatory psychosis with catatonic features. He experienced auditory hallucinations in the form of voices commanding him to kill himself. He said that he was Hitler and the Devil and at other times that he was Jesus Christ. He had a vision, which he thought might have been a dream, of Christ on the cross, which terrified him. He believed that other people had access to his thoughts and could read his mind.

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12. Paranoid delusions— sealing-over and working through a psychotic transference: “Frank”

Murray Jackson Karnac Books ePub

Some individuals make a good recovery from a first psychotic episode, and others pursue a relapsing course which may or may not lead to chronicity, In some cases, recovery from a psychotic breakdown has been achieved by the covering-up, sealing-over, or encapsulation of psychodynamic forces. Such sealing-over may sometimes confer a sufficient stability and ego strength for an indefinite period, sometimes requiring medication on a regular or occasional basis. In other cases, the adjustment breaks down under subsequent stress and the underlying unresolved psychotic process breaks through, with the return of symptoms. However, under favourable circumstances such a relapse may present an opportunity to resolve this “unfinished business” by working through the underlying pathogenic conflicts in psychotherapy. The following case illustrates the improvement that may follow such an attempt.

Frank

Frank, 34 years old, was first referred to the psychiatric services at the age of 27. He was brought from the apartment where he had been living by his parents, who had been worried by his increasing withdrawal, suspiciousness, and irritability over the previous year, a change in character that had recently led to his losing his job,

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CHAPTER SEVEN. The treatment setting

Murray Jackson Karnac Books ePub

The clinical vignettes presented in the first six chapters refer to work that took place on a small, experimental unit of 11 beds, which shared a ward with a general unit of a similar size. The units together made up an acute admission ward known within the Maudsley as Ward 6. The experimental unit made use of a psychoanalytic perspective in its treatment plans, whilst its partner functioned on more general psychiatric lines. The two units dealt with a wide range of disturbances, and since most of the nursing staff served both units, a beneficial mutual influence evolved. An increasing psychodynamic attitude developed on the ward as a whole, whilst the provision of a firm psychiatric base for work of a psychotherapeutic nature came to be appreciated.

Contexts and credos

The psychodynamic philosophy of the unit regarding the nature of functional (as opposed to provenly organic) psychoses and their treatment could be summarized using a number of theoretical and clinical observations repeatedly confirmed over time. For example, psychotic conditions and severe disorders of character with psychotic features often called “schizoid” or, more recently, “borderline” conditions, affect individuals who are predisposed by reasons of constitutional vulnerability or adverse environmental conditions in infancy and childhood, or both. Many psychotic symptoms and delusions reveal meaningful content and are an expression of profound intra-psychic conflict. An acute psychotic attack may often be understood as the final stage in a struggle—perhaps lifelong—of a vulnerable individual to adjust to the world of external reality in the face of overwhelming and unresolved emotional problems of relating to the self and to others. This struggle has its roots in infancy and early childhood and in a failure, in varying degrees and for differing reasons, to experience a sufficiently stable relationship with the mother or primary object. The development of a normal core to the structure of the personality and a capacity for making and sustaining emotional attachments have been impaired, and it is frequently the demands on the adolescent to change and grow that precipitate the first overt breakdown.

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