Prepsychosis

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PREPSYCHOSIS

Prepsychotic states are characterized by precariousness of the neurotic mechanisms, that is to say, "secondary processes" that are too readily invaded by the "primary processes" (Sigmund Freud), resulting in the sudden appearance of troubling and raw images that cause excessive anxiety and disorganization.

The notion of prepsychosis or prepsychotic states was introduced in 1969 by René Diatkine and Serge Lebovici to account for the lability of symptomatology and appearance of some worrisome clinical configurations in children; the term "prepsychosis" describes states that it would be imprecise, and also detrimental to the child, to try to situate as either neuroses or psychoses.

It was in the context of a psychoanalytic approach to the mental functioning of children that the notion of prepsychosis became necessary. In psychoanalytic clinical work with children as it developed in France between 1960 and 1980, diagnostic and prognostic assessment was not based on a collection of symptoms and behaviors but rather on a psychoanalytic exploration of the mental processes put into play in the child to ensure homeostasis in his or her mental functioning. From this point of view, "neurotic functioning," as it is observed in "infantile neurosis," is the most favorable form of psychic organization. "Infantile neurosis" (as part of the Oedipus complex) is thus opposed to "neurosis in children," which encompasses various pathological conditions.

Clinical psychoanalysis attempts to penetrate beyond manifest symptomatology as exemplified by the psychoanalytic understanding of phobias, wherein a phobia ensures that the anxiety be associated with an avoidable situation and thus that it is an effort to disengage the child's mental functioning from the risk of being flooded with an excess of anxiety that would be paralyzing. But if this attempt at fixation fails, the possibility of flooding by anxiety despite the phobia remains strong; in this situation large quantities of diffuse, unbound anxiety lead to the massive inhibitions and counterphobic behaviors that define prepsychotic states. But overwhelming anxiety inevitably restricts autonomous mental functioning. Only with difficulty can the mental structures necessary to their development be organized in such children, allowing for sublimations or pleasure in mental functioning that would enable them to ensure the regulation of their mental activity. Their current, apparent neurotic organization does not protect them from breaks in their equilibrium that may cause them to resort to psychotic or aberrant behavior.

Thus, in prepsychotic states the secondary processes are sufficiently developed to ensure, for certain periods of time or under certain environmental circumstances, a relatively adequate mode of behavior in which the child shows a neurotic type of functioning. However, this functioning can easily be overwhelmed and again flooded by extremely debilitating anxiety and by the primary processes. In the absence of reinforcement by the neurotic mechanisms, a kind of fragility of psychic functioning sets in that will make it difficult for the child as he or she approaches the critical period of adolescence.

The prognosis with such states essentially depends upon the support and reinforcement of the child's neurotic functioning that can be provided through the child's social and family environments and psychotherapy treatment. Prepsychotic childrens' vulnerability to disorganization also predisposes them to various developmental vicissitudes. Rather than evolving toward fixation in psychotic organization per se—which remains a possibility in the mid- or long term—most often such children begin to manifest behavioral disorders: perverse or psychopathic conduct, sexual behavior problems, somatization, substance abuse, and so forth. Another course of development, particularly in young children, is that of inhibited intellectual growth, where the mechanisms of isolation put into effect in an attempt to control being invaded by the primary processes result in impoverished mental functioning and restriction of developmental possibilities.

In itself, then, the term prepsychosis does not have a prognostic value relative to possible psychotic organization later on, but is instead intended to situate the functioning of these children between neurosis and psychosis. The choice of this term has thus often been criticized, and other authors faced with the same clinical reality have proposed such terms as "parapsychosis" (Jean-Louis Lang) or "developmental disharmony" (Roger Misès). The term "borderline conditions" applied to childhood, might also be suitable to describe these intermediary states.

The essential thing, more than the term itself, is the emphasis placed by Diatkine and Lebovici on the specifics of mental functioning in such children and on the need to envisage this phenomenon from a dynamic point of view and not merely from a perspective of diagnostic description.

Paul Denis

See also: Blank/nondelusional psychoses; Borderline states; Infantile psychosis.