The psychotic wavelength

In this paper I have endeavoured to draw attention to what is meant when we refer to a patient as psychotic. It is argued that it is not enough just to be ordinarily sensitive to our patients; we need to tune into the psychotic wavelength with all its implications for understanding and management. Illustrative case-histories are presented from everyday psychiatric work.     

Psychic skin: psychotic defences, borderline process and delusions

In this paper, I apply the concept of psychic skin to analytic work with people suffering from personality disorders and psychoses. When psychoses emerge, the defensive skin which protects the ego is breached and violent unconscious forces rip through the personality. Some of the patients diagnosed as schizophrenic with whom I work have identified with archetypal characters such as Christ, Satan, John Lennon and the Queen. I attempt to show how the adoption of these inflated personas can serve as secondary psychic skins. Such delusional identifications can provide a protective shield to hide the denuded self and prevent intrusion from the external world. Through clinical example, I try to demonstrate how these archetypal 'second skins' can preserve life until internal and external conditions make it possible for the self to emerge. I contrast such psychotic identifications with 'thin-skinned' and 'thick-skinned' narcissism as well as 'defences of the self' in borderline states where the psychic skin may be damaged but does not disintegrate. I also look at the ways in which Jung's own personal experience was different from this and how he managed to avert psychotic breakdown.     

The relationship between cognitive inhibition and psychotic symptoms

Cognitive models of schizophrenia have highlighted deficits of inhibitory attentional processes as central to the disorder. This has been investigated using "negative priming" (S. P. Tipper, 1985), with schizophrenia patients showing a reduction of negative priming in a number of studies. This study attempted to replicate these findings, but studied psychotic symptoms rather than the broad diagnostic category of schizophrenia. Psychotic individuals exhibiting positive symptoms were compared with asymptomatic psychiatric patients and with a normal control group. As predicted, the symptomatic group failed to show the usual negative priming effect, which was present in the asymptomatic and normal groups. A modest but significant correlation was found between negative priming and delusions. Neither diagnosis, nor affective or negative symptoms, nor chronicity, nor medication, was related to negative priming. These data replicate previous findings that positive symptoms are related to a reduction in cognitive inhibition, although considerable variability was observed among the psychotic patients.     

Eros and psychotic despair

The author suggests that Freud's theory of sexuality is not adequate to explain the issue of psychosis. The sexual drive presupposes construction of the unity of the subject, whereas psychosis takes root in a period of life when the ego is not yet integrated. In a neurotic subject, suffering is always an expression of sexuality. By contrast, in a psychotic person, even aspects explicitly connected with sexuality represent an attempt to escape from despair. In the former it is a question of pleasure, and in the latter of relief In light of these considerations, the author discusses the problem of erotomania.     

The functional significance of autistic behaviors for the psychotic child

Physiological, cognitive, and emotional factors were examined throughout the treatment of a psychotic child. Heart rate, latency and accuracy in task performance, behavioral indices of stress (e.g., muscular tension, facial expression), and frequency of autistic mannerisms were measured concurrently. Both contemporaneous relationships and patterns of change suggested that autistic behaviors were organized and psychologically meaningful. Self-stimulation, conflict, and negativism (deliberate erroneous performance) occurred predictably, were intimately related, and were associated with specific patterns of heart-rate change. The changing function of self-stimulation across treatment and the centrality of negativism in this child's disturbance were discussed.This research was supported in part by a Program Project Grant from the National Institute of Child Health and Human Development to the Institute of Child Development, University of Minnesota (1 PO1 IID05027).     

Object loss and psychotic regression

The author explores the structures and dynamics of a case of acute schizophrenic decompensation, which is shown to be a pathological grief reaction. How the patient comes to terms with the loss of the object can be traced through the various stages of the illness. The nature and fundamental disturbance of object relations becomes especially clear. The psychotic regression serves to deny the loss and simultaneously constitutes repeated attempts--and their failures--to introject a good object and thereby achieve a belated primary identification. The latter would be a basic precondition for the capacity to mourn a loss adequately.     

On psychotic transference and countertransference

Following a brief discussion of the primary types of psychotic transferences, viewed from a theoretical position combining ego psychology with an object relations approach, the author presents detailed clinical material illustrating these transferences. The analyst's countertransference in work with such patients is also discussed in depth, including its use as a unique window into the patient's inner world.     

The Significance of Ferenczi's clinical contributions for working with psychotic patients

This paper tries to show that Ferenczi's contributions in “The Development of Psychoanalysis” (with Otto Rank) and in his “Clinical Diary” are pivotal for the development of modern psychotherapy with severely disturbed patients. In addition, the question of whether a psychotherapeutic technique should or could be communicated to others is discussed.     

The relation of delusional content in psychotic depression to life-threatening behavior

A retrospective analysis of all medically serious suicide attempts made by 45 patients hospitalized consecutively at the Payne Whitney Clinic with the DSM-III discharge diagnosis of Unipolar Major Depression, Recurrent, With Psychotic Features was undertaken. Patients with delusions of bodily disease, damage, and malfunction were significantly less likely to make medically serious suicide attempts than patients with delusions of sinfulness, guilt, deserved punishment, or persecution.