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8. Chronic paranoid schizophrenia— schizoid thinking: “Ellen”

Murray Jackson Karnac Books ePub

Little is known about the long-term outcome of patients who have been deprived of adequate treatment, or have failed to respond to it, and have drifted into a chronic state. Suicide is not uncommon, but violence towards others is relatively rare, despite the media reporting of dramatic, often tragic, cases. Some paranoid patients manage to achieve an adjustment in which their distress is reduced to a manageable level Their delusions may exert a protective function for them, and many have retained sufficient insight to realize that other people regard them as eccentric or mad, and they have learned thereby to keep their delusional world to themselves. The following patient illustrates some of the psychodynamic processes leading to such states and the meaning of such delusional beliefs.

Ellen

Ellen, a 57-year-old divorced mother of two children, had her first schizophrenic breakdown at the age of 28, spent a large part of the next thirty years in psychiatric care, being admitted on seventeen occasions, usually on a legal order, with the diagnosis of chronic paranoid schizophrenia. She had never been engaged in psychotherapy and was currently in a supportive contact with a social worker.

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7. Paranoid schizophrenia— space-time factors: “Conrad”

Murray Jackson Karnac Books ePub

Some psychotic conditions are characterized by the regressive revival of “sensorimotor” forms of thinking, in which some mental events are experienced in bodily terms and are tied to primitive concepts of space and time and to belief in omnipotent power. In the course of psychotherapy, such psychotic thinking may sometimes be understood as an unconscious defence against the mental pain that sane and self-reflective thinking can bring.

Conrad

Conrad was 24 years old and had been in twice-weekly psychotherapy for two years when his case was brought to the seminar. Supervisory contact was subsequently continued during the following three years.

At the age of 15, Conrad had developed an acute psychosis characterized by persecutory delusions and outbursts of violence. He believed that his food was poisoned, that the KGB were trying to murder him, and that his country was under threat of an imminent missile attack. He was admitted to a psychiatric ward for children and adolescents, where neuroleptic medication soon brought his agitation under control and his delusional thinking receded. He remained in hospital for several months, during which time he was often verbally aggressive towards the staff and other patients and occasionally made unprovoked assaults on them. Although temporary increase of medication was often needed on such occasions, his aggressive outbursts gradually subsided and it eventually proved possible to discharge him on a small maintenance dose of medication.

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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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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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CHAPTER THREE. Psychotic character: “a bit of an old rogue”

Murray Jackson Karnac Books ePub

A significant proportion of the clinician’s work is concerned with attempts to assist individuals whose behaviour and symptomatology are the expression of lifelong difficulties in forming and preserving close emotional relationships. Such patients are regarded as suffering from personality disorder. They present in many forms, often associated with diagnosable psychiatric illness such as hysteria (seen more often in women), schizoid states {seen more often in men), obsessive-compulsive disorder, or depression. They tend to lead chaotic, unhappy lives and often cause emotional damage to others. Psychoanalysts consider that such disturbances derive from failure in crucial phases of early emotional development, which leaves the individual without a coherent sense of self or a capacity to manage impulses realistically. They are often afflicted by feelings of futility, emptiness, and depression. Although at times they function psychotically, these occasions are usually responses to stress and last for no more than a few hours or days, rarely leading to a diagnosis of psychosis. Over extended periods, these patients may experience many phases of disorganization, but they do not deteriorate, hence they are designated as demonstrating “stable instability”. Since they inhabit the border between neurosis and psychosis but belong to neither, they are classified as borderline personalities, and it is widely acknowledged that they are extremely difficult to treat. In recent years a burgeoning literature, psychiatric and psychoanalytic, has accumulated about them.1

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