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13. Phobia, hysteria, psychosis: “Grace”

Murray Jackson Karnac Books ePub

In psychiatric practice, phobias present as a group of disorders of varying degrees of severity. At one extreme lie “simple “phobias, which may respond to behavioural methods of treatment (Marks, 1987); at the other, more complex conditions that may prove unresponsive to all psychiatric treatment. Some of these conditions may be found to overlie a latent schizophrenic psychosis.

In psychoanalytic theory, the dynamic relationship between hysteria, obsessions, and phobias has long been debated (Frosch, 1990, pp. 341-347), and the variety of clinical courses that a phobia may take is well known to sometimes include schizophrenia. Fairbairn (1952) pointed out that conditions usually regarded as neurotic—such as obsessions, hysteria, paranoid states, and phobias—may function as defences against underlying schizoid or schizophrenic pathology (Grotstein & Rinsley, 1994).

Klein believed that neurotic disorders represented the attempt to work through the unresolved psychotic anxieties of infancy. In a seminal paper, Segal (1981e) demonstrated how schizoid mechanisms were involved in forming the phobic symptoms of a borderline patient, and she concluded that these phobias served the purpose of averting an acute schizophrenic illness.

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10. Schizophrenia—psychotherapy, termination, reparation: “Florence”

Murray Jackson Karnac Books ePub

Since Freud’s essay “Analysis Terminable and Interminable’’ (1937c), much attention has focused on the difficulties in concluding a course of psychotherapy that has been relatively successful. Klein’s concept of reparation helps to explain why some patients, psychotic and non-psychotic, do not feel able to terminate psychotherapy until they have made good the damage they believe they have done to other people, either in reality or imagination, a theme that has been elaborated by Rey (1994).

Psychotherapy with a psychotic patient may need to go on for a long time if the patient is to be able to live independently without the help of the therapist (Holmes, 1997). It may be difficult to assess the quality of prolonged therapy because the therapist may believe that continuation is essential to prevent the patient from deteriorating, a doubt that may be difficult to resolve. Terminating therapy before the conflicts aroused by the process of separation have been sufficiently worked through may represent an impressive outcome for a severely ill psychotic patient, and an indication of chronic disabling dependency in another. Deficiencies in the therapist or the setting are likely to lead to the undue prolongation of treatment. Problems in the therapist’s countertransference can account for the development of an impasse where little or nothing is actually being achieved (Rosenfeld, 1987).

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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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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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16. Vignettes

Murray Jackson Karnac Books ePub

This chapter may perhaps be of limited interest to psychoanalysts, for whom sufficient detail of the context of the observations, the history of the patient, the depth of therapist involvement, and transference-countertransference matters are the essential prerequisites for the “decoding” of symbolic expressions and for serious consideration of their meanings for the patient. It is directed primarily to non-analysts who are interested in learning more about the manifold ways in which psychotic processes may find expression and exploring ways of thinking about them.

The fifteen brief clinical examples illustrate many of the specific characteristics of psychotic thinking and their various possible meanings. I hope that digesting the previous chapters will make it easier for the reader to begin to think about these further examples of gross psychopathology and bizarre psychotic thinking. The cases illustrate a range of psychotic mechanisms grouped very roughly according to their most prominent features. All the cases (with the sole exception of Patient L) were involved in psychoanalytically based psychotherapy, usually of long term, and four were in formal four-times weekly psychoanalysis with experienced psychoanalysts. Some of the cases are taken from my own psychiatric and psychoanalytic practice, where detailed and intensive psychotherapy of disturbed schizophrenic patients, in a secure and “containing” psychodynamic environment, was possible (Jackson & Williams, 1994). “Code-breaking” has no place in psychotherapy, since all symbols have personal meaning for each individual. Just as in the case of dreams, the therapist needs to have the patient’s associations to and reflections on the material before he offers his own ideas. In psychotic states, however, this is likely to prove impossible until the patient has become relatively stable and capable of cooperating with the therapist.

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