Acute Psychoses

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ACUTE PSYCHOSES

The notion of acute psychosis as envisaged by psychiatry is situated on the border of psychoanalysis. The acute psychoses, sudden and severe disorganizations of the mind, all have in common a disturbance of the relational faculties, a loss of contact with what is commonly accepted as reality, and a diminishing or absence of critical abilities with regard to the pathological.

There are multiple different forms of acute psychosis. Among these are melancholic and manic episodes, which can clinically exist in alternation (hence the framework of manic-depressive psychosis) and which are associated with Freud's writings on the "narcissistic neuroses"; acute delusional psychoses, some of which are linked to the development of chronic psychosis; and finally, dream-confusion disorders, for which the possibility of an organic etiology must always be investigated. As varied as they are, these disorders all have in common the temporal features of an "attack": They are sudden, uncontrollable, incomprehensible, and reversible.

Since antiquity, melancholia has referred to a form of madness characterized by "black bile": dejection, sadness, spiritual pain, feelings of abjection and guilt that may be expressed in delusional form, and despair that may lead to suicide. Emil Kraepelin incorporated melancholia into manic-depressive psychosis. Karl Abraham, in his 1912 publication "Notes on the Psycho-Analytical Investigation and Treatment of Manic-Depressive Insanity and Allied Conditions," attempted to apply a psychoanalytic approach to cases that were "cyclical" (1912/1927, p. 138) in their evolution. His way of envisioning the psychogenesis of the attack, and his reference to a "hidden structure" and ambivalence stimulated the thinking of Sigmund Freud, who had been investigating melancholia as early as 1895. In a manuscript sent to Wilhelm Fliess that year, Freud compared it to "mourning—that is, longing for something lost" (Manuscript G, p. 200). In 1917 he published "Mourning and Melancholia," where he envisioned melancholia as the pathological form of mourning. In the work of mourning, the subject is able to gradually achieve detachment from the lost object; in melancholia, by contrast, the subject identifies with the lost object and believes him- or herself to be guilty of its disappearance.

The acute psychoses, and especially attacks of melancholia, owing to their frequent recurrence and possible alternation with mania, from the outset presented psychoanalysis with the problem of the relationship between attack and structure. "Structure" implies that no term of the field in question can be approached without taking into consideration the terms that are articulated together with it; no single term takes effect without the others. The three conditions that Freud posited as the origin of melancholia—loss of the object, ambivalence, and regression of the libido into the ego—provide the framework of a structure. Whatever may reactivate such a mechanism around the loss of object provokes another melancholic attack, and Freud explored this "struggle of ambivalence" (1916-1917g [1915], p. 257) in which the ego itself becomes carried away in the process of accusation of the object, or even its "condemnation to death." He posited that this process can come to an end in the unconscious, either through exhaustion or through exclusion of the object, which is thereafter deemed worthless. The ego can then revel in the satisfaction of recognizing itself as the best, as superior to the object. The accumulation of a cathexis that is at first bound, and then liberated at the end of the melancholic process—the enabling condition for possible mania—implies regression of the libido to narcissism. In The Ego and the Id (1923b), he analyzed the ego's dependency states, writing: "If we turn to melancholia first we find that the excessively strong super-ego which has obtained a hold upon consciousness rages against the ego with merciless violence" (p. 53). What dominates the superego here is "a pure culture of the death instinct" (p. 53). In "Neurosis and Psychosis" (1924b [1923]) he restricted the "narcissistic neuroses," characterized by withdrawal of the libido onto the ego, to disorders of the melancholic type.

In order to envisage acute psychoses as a whole, Melanie Klein's theoretical elaboration must be mentioned. In 1935 Klein stopped referring to "developmental stages" and instead began using the term position to differentiate psychotic anxieties in children from psychoses in adults. In this view, psychosis is seen sometimes as a temporal regression reversible to either the paranoid or the depressive position, sometimes as the "fertile moment" of a psychosis arrested in such a "position," and sometimes as a cyclical episode that can be clinically treated, even if the subject's anchorage in such a "position" remains structurally determined.

It should be noted that the various acute psychoses were the object of a clinical and psychopathological synthesis by Henri Ey (in the third volume of his Études psychiatriques ) that often challenges psychoanalysis.

Acute psychosis is an expression of the complexity of what is happing on different levels in the patient; the possibility of some severe organic dysfunction cannot be ruled out, nor can the possibility of a reactive crisis. In any event, the patient's acute state requires specific types of care, and his or her history is essentially done away with by the urgency of the circumstances. The anguish of people close to the patient and the team of caregivers in the face of madness must be taken into account. Research confirms the effectiveness of a psychotherapeutic approach based on psychoanalytic conceptions associated with traditional methods of treatment of the acute episode. In the most favorable conditions, such an approach still makes structural study possible.

Michel Demangeat

See also: Mania; Melancholic depression; Organic psychoses; Postnatal/postpartum depression; Psychotic/neurotic

Bibliography

Abraham, Karl. (1927). Notes on the psycho-analytical investigation and treatment of manic-depressive insanity and allied conditions. In Selected papers on psycho-analysis. (Douglas Bryan and Alix Strachey, Trans.). Hogarth Press: London. (Original work published 1912)

Ey, Henri. Traité de psychiatrie clinique et thérapeutique. Paris: E.M.-C., 1955.

Freud, Sigmund. (1916-17g [1915]). Mourning and melancholia. SE, 14: 237-258.

——. (1923). The ego and the id. SE, 19: 1-66.

Klein, Melanie. (1975). A contribution to the psychogenesis of manic-depressive states. In The writings of Melanie Klein (Vol. I, pp. 262-289). London: Hogarth. (Reprinted from International Journal of Psycho-Analysis, 16 (1935), 145-174.)