Psychotic/Neurotic

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PSYCHOTIC/NEUROTIC

The relationship between the neuroses and the psychoses, or between the neurotic sphere and the psychotic one, cannot be studied from a psychoanalytical point of view without clarifying the meaning of the two terms, considering their reciprocal ties as described in the work of Sigmund Freud and Karl Abraham, and, lastly, reviewing their status today.

With regard to the term neurosis, the idea that medicine ought to set aside a nosological and etiopathogenic category to cover conditions presenting functional impairments, in the absence of manifest lesions, which affected the nervous system but not the brain or any other organ, arose in the classical period in the work of Thomas Willis (1622-1675) and Thomas Sydenham (1624-1689). These authors included as neuroses hysteria, to which they denied a uterine origin, and hypochondria, to which they denied the hepatic genesis attributed to it since antiquity. The word neurosis itself was coined in 1777 by William Cullen (1710-1790) to identify a class of generalized as distinct from localized disease which along with the neuroses included fevers and cachexies. Defined as sensory and motor attacks without fever or local disorder, Cullen's "neuroses" encompassed comas, adynamias (to which he assigned hypochondria), spasms (including hysteria), and vesanias.

Nineteenth-century usage veered back and forth between a narrow definition of neurosis limited to hysteria and hypochondria and a broader meaning that embraced syncopes, tetanus, epilepsy, chorea, paralysis agitans, and neuralgias. During the last quarter of the century, however, in part due to the advent of dynamic psychology (Pierre Janet, Sigmund Freud) and of semiological neurology (Jules Déjerine, Joseph Babinski, Gordon Holmes), a new system of classification began to take form. Matters were helped, too, by the new discipline of clinical neurology, which laid claim to epilepsy, chorea, Parkinson's disease, and cerebellar syndromes while recognizing psychiatry as the sole proprietor of the neuroses (with the exception of hysterical paralyses, which called for cooperation between the two specialties). Thenceforward the neuroses were understood either in a simple way, as by Pierre Janet, who distinguished only between hysteria and psychasthenia, or in the more elaborate manner of Freud, who contrasted the actual neuroses (anxiety neurosis, neurasthenia, hypochondria) with the so-called defense or transference neuroses (conversion hysteria, phobic neurosis, obsessional neurosis), using criteria that were certainly descriptive but also psycho-pathological in character.

The term psychosis appeared later. Introduced in 1845 by Ernst von Feuchtersleben (1806-1849), it was at first a very general designation for illnesses of the mind ("Geisteskrankheiten ") as opposed to the neuroses, attributed at the time to malfunctions of the peripheral nervous system. Psychosis thus became synonymous with mental alienation in the most general sense. During the last quarter of the nineteenth century and the first half of the twentieth, when psychiatry started emphasizing the irreducible variety of mental illnesses, psychosis covered all cases within that domain which were clearly not of the nature of neurosis, of dementia, or of mental retardation—in other words, the label was applied to almost all institutionalized mental patients. Psychoses were considered either acute (confusional states, delusional episodes, mania, melancholia) or chronic (schizophrenia, paraphrenias, paranoia), but no answer was offered to the question whether these categories were discrete or whether they were variations expressing a single underlying (psychotic) disease process. (Not to mention issues of etiology or the inflated role assigned to general paralysis.)

In the development of psychoanalysis, the relationship between the psychotic and the neurotic was at first considered a relationship of exclusion, a veritable gulf separating the one from the other, just as, in zoology, vertebrates were radically separated from invertebrates. Little by little, however, a more nuanced view prevailed: for one thing, the two realms were brought much closer together; for another, the question was raised whether a particular place should not be set aside for perversions. Even greater difficulty was met with later, when a pigeonhole had to be found for the borderline states identified in apparently neurotic subjects who, after being accepted as such for psychoanalysis, decompensated during the treatment in a psychotic manner (Kernberg, 1975).

In Freud's early works, those collected in the first two volumes of the Gesammelte Werke, a radical distinction between neurosis and psychosis was of a piece with his inaugural discoveries: the neuroses were said to reflect conflicts within the subject whose original sense escaped him, conflicts echoing others in earliest childhood, repressed but accessible in general through a transference relationship and hence accessible to psychoanalysis; the psychoses, by contrast, were related to conflicts between the subject and the outside world, hardly or not at all accessible via a transference relationship, and for that very reason contraindicating psychoanalytic treatment, even though the discourse of psychotic patients might bring directly to light aspects of the unconscious that emerged in neurotics only after many psychoanalytic sessions.

Freud continued to maintain this point of view a little later, in the third part of his commentary on Daniel Paul Schreber's Memoirs (Freud, 1911c [1910]), when he put forward the idea that the pathological process common to the various chronic delusional conditions was denial of homosexual wishes—a mechanism very different from those met with in neurosis.

The work of Karl Abraham presents what is probably the most careful psychoanalytical account not only of the relationship between the neuroses and the psychoses, but also of the relationships between each of them and libidinal fixations and regressions, as well as those of individual neuroses and psychoses to one another (1927 [1924]). Abraham showed in the clearest way, albeit in a nuanced and quite unschematic way, how the received clinical distinctions between schizophrenia, paranoia, mania, and depression might be seen as corresponding to the subdivisions of the oral and anal stages, and how likewise the neuroses related, each after its own fashion, to the genital stage; thus the empirical level of clinical experience could find theoretical support in the psychoanalytic knowledge of libidinal development. This standpoint tended therefore to buttress the view that the neurotic and psychotic spheres should continue be treated as separate, because their respective connections with the libidinal stages were quite distinct. At the same time, as Abraham noted, especially with respect to melancholia and obsessional neurosis, links had to be recognized between particular psychoses and particular neuroses, as for instance the link between schizophrenia and hysteria.

Later on, both the relative simplicity of the neurosis/psychosis distinction and its tendency to become absolute were contested, and the dividing-line was once more brought into question. This clear-cut division had long served a didactic purpose in the professional training of analysts, but even for the most vociferous partisans of the primacy of the totality—of the Germanic Ganzheit —training could hardly be founded on a complete absence of distinctions; indeed it was arguable that the usefulness of this clear opposition resided solely in its educational value, and that it should therefore be discarded once training was successfully completed.

The development of his conception of the perversions led Freud to abandon the idea of the primacy of fixation to infantile sexuality (1905d), along with the corresponding view of perversion as the reverse of neurosis, and to assign a major role to the disavowal of reality and the splitting of the ego (1940a [1938]). Since these processes were closely akin to those in play in the psychotic realm, this meant the end of the tidy arrangement that had prevailed hitherto. A difficult choice remained between two possible revisions: to reincorporate the perversions into the psychoses, or else to abandon the neurosis/psychosis dichotomy by giving the perversions their own category between the other two. The latter course was liable to jeopardize any strict distinction, for it is well known that the only good opposition is a binary one.

Georges LantÉri-Laura

See also: Abraham, Karl; Acute psychoses; Blank/nondelusional psychoses; "Claims of Psycho-Analysis to Scientific Interest"; Indications and counterindications for psychoanalysis for an adult; Infantile psychosis; Neurosis; Neurotic defenses; Paranoid psychosis; Psychic causality; Psychoanalytical nosography; Psychoses, chronic and delusional.

Bibliography

Abraham, Karl. (1927 [1924). A short study of the development of the libido, viewed in the light of mental disorders. In his Selected papers on psycho-analysis. London: Hogarth.

Freud, Sigmund. (1905d). Three essays on the theory of sexuality. SE, 7: 123-243.

——. (1911c [1910]). Psycho-analytic notes on an autobiographical account of a case of paranoia (dementia paranoides). SE, 12: 1-82.

——. (1924c). The economic problem of masochism. SE, 19: 155-170.

——. (1940a [1938]). An outline of psycho-analysis. SE, 23: 139-207.

Kernberg, Otto F. (1975). Borderine conditions and pathological narcissism. New York: Jason Aronson.