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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 ONE. Paranoid schizophrenia: ‘the radio loves me”

Murray Jackson Karnac Books ePub

SALLY

Sally, a very disturbed 30-year-old woman, is the second child and eldest daughter of a large Catholic family of eight children. The family lived in a council house in a small town in the Midlands. The parents’ marriage was unhappy, and the father left to live in another country when the patient was 12. Sally’s relationship with her mother seems to have been highly ambivalent: however, she made close relationships with several siblings. She survived well until adolescence, at which point her schoolwork disintegrated and paranoid ideation began to colonize her mind. By 21 she was convinced that when she masturbated, the whole of the town was watching her; subsequently, she believed she was being filmed. She suffered extreme persecutory guilt feelings, which seemed to be linked to her past sexual activity. After careful investigation, it became apparent (beyond reasonable doubt) that she had had an incestuous relationship with her father from the age of 11, before his departure. It seemed likely that several of the children had been sexually interfered with in one way or another. Sally felt that her mother had abandoned her and had handed her over to her father, and she hated her mother for it. These feelings may also have had their origin earlier in her life, when she was displaced by six siblings at close intervals. She felt her mother had forced her into the role of being a mother to her younger siblings, which had prompted her to turn to father for affection. She viewed him in many ways as a mother. At the same time, it seems that Sally’s father also viewed Sally to some extent as a maternal figure, thus adding to the confusion. Her longing for intimacy with her mother drew her into relationships with women, not overtly sexual but sufficient to make her feel sometimes that she was homosexual. At other times, she was afraid that she was masculine in her orientation. This was expressed concretely in moments of psychotic dread that she was turning into a man—a fear that may have partly been the expression of a wish to be in her father’s place in order to have possession of the mother for whom she longed. It was interesting to observe that, when the theme of her longing and despair in relation to her mother emerged openly during treatment, she became quite sane and coherent for the duration of the conversation about that theme.

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3. Obsessions in schizophrenia: “Alec7’

Murray Jackson Karnac Books ePub

The relation between obsessive-compulsive symptoms and depressive illness has long been recognized, but the relationship with schizophrenia is less common and less understood in psychiatry. There is some evidence that long-standing obsessional symptoms may serve to protect against the emergence of a schizophrenic illness (Bychowski, 1966) or may result in a more benign psychosis.

The descriptive psychopathology and phenomenological studies of psychiatry can be complemented by psychodynamic formulation, which is a tool of psychoanalysis. The concepts of unconscious conflict between impulse and defence, involving such mental mechanisms as displacement and symbolic transformations, provide meaning and detailed understanding of the mental forces involved in obsessional and schizophrenic states, and of the relationship between them.

Alec

Alec, aged 40, had recently begun twice-weekly psychotherapy when his therapist brought his case for discussion in a small group. After this initial consultation, he was discussed at intervals of several months until the termination of treatment four years later.

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APPENDIX A: Characteristics of schizoid thinking

Murray Jackson Karnac Books ePub

I have frequently referred to the writings of Henri Rey, which have been collected in his book Universals of Psychoanalysis in the Treatment of Psychotic and Borderline States (1994). Rey uses the term “universal” in the sense of the primitive mental structures and mechanisms that have their deepest roots in antenatal, perinatal, and postnatal mother-baby relationships and are the substance of the paranoid-schizoid level of development as elaborated by Klein. These universals find expression in different contemporary diagnostic groupings such as borderline, schizoid, or narcissistic personality disorder, and in the psychiatric classification of schizotypal personality disorder. The following is a distillate of Rey’s views on the “schizoid mode of being”, a pure culture of features that are found in varying degrees in individuals who have not reached the level of the depressive position.

•  The schizoid individual finds great difficulty in making contact with others and finds it impossible to maintain any warm and steady relationship. If he actually manages to enter into a relationship, it rapidly becomes intensely dependent and results in disorders of identity.

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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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