Fragmented attachments: the paranoid-schizoid experience of loss and persecution

The author discusses paranoid-schizoid patients who have yet to deal with whole-object depressive fears of harming one's object. Their paranoid-schizoid anxiety is more a combination of dread, paranoia, and fear of destroying one's object with neediness, envy, and other oral desires. In this part-self and part-object world, destruction is absolute. Ego functions and object relational capacities such as guilt and grief are not yet fully consolidated. The part-object is not only destroyed but is also equally capable of magically resurrecting itself to seek revenge. Fear of annihilation of the self and object, as well as desperate attempts at keeping each other alive, are the primary focus of this early anxiety state. These infantile fears are at the root of certain difficult treatment situations. Within the transition from paranoid-schizoid to depressive, the ego struggles with highly exaggerated and distorted fantasies of persecution, loss, and primitive guilt by resorting to crude and often self-destructive mechanisms. These include splitting, projective identification, and idealization. During the course of analytic treatment, three overlapping phases are distinguishable. Acting out is the main theme of early treatment. As this externalization of internal conflict is analyzed and contained, a second phase of intrapsychic struggle emerges. The patient exhibits a paralyzing battle between certain ego-object ties and the striving of a defensive death instinct. If the analytic relationship is able to withstand passage through these difficult phases, the patient begins to work through more core issues of persecutory loss and annihilation. Case material is used for illustration.     

Erotomania or de Clérambault syndrome.

De Clérambault focused attention on a syndrome in which a woman has the delusional belief that a man, usually of higher social status and considerably older, is much in love with her. If the patient's romantic ideas shaped private fantasies instead of determined public behavior, there would be little cause for concern. The situation becomes critical when the fantasies are dramatized in real life with an unsuspecting and usually unwilling man cast in the role of the lover. The woman dwells on the feelings she ascribes to her "suitor." Such delusional thinking, resulting from an ego defect and producting bizarre actions, may be shaped largely by feelings of being unloved or even unloveable; a narcissistic blow is overcome by a grandiose fantasy. Cases in which erotomania is prominent are usually diagnosed as paranoid state or paranoid schizophrenia.     

Psychoanalytic psychotherapy and the ADHD-triad (impulsivity, hyperactivity and attention deficit disorder)

A brief survey of the psychoanalytically oriented literature regarding the symptom triad of ADHD is followed by the discussion of frequently found disturbances in infantile development, attachment, object relations (regulation of drives and affects, ego functions) of the role of infantile trauma (object loss) and psychic conflict. In the analytic-psychotherapeutic process with a child, the ADHD-symptom-triad may manifest itself e.g. as intrapsychic conflict on the level of the self-representation or of the representation of central self-object-relations (characterized by an insufficient containing-/holding-function), as impairment of self-regulative functions, as inconsistent symbolizing capacity or as deficient regulating and controlling capacity of the ego. The multitude of factors involved does not allow a generalisation of neither the etiology or the pathogenesis of this symptom triad. This is particularly evident in a therapeutic procedure which is relation oriented. In a first interview the authors illustrate the capacity of a ten year old boy (diagnosed as ADHD patient) to make use of the analytic therapeutic dialogue and to present his intrapsychic experiences and problems in a figurative and narrative performance. Finally some specific technical features of low or high frequent analytic psychotherapy with ADHD children are shown: according to the foremost pregenital form of relations--manifested mostly by intensive self esteem problems, narcissistic aggressiveness and motor impulsivity--the transference and counter-transference movements proceed predominantly by projective and introjective identifications. Containment of the difficulties by the therapist is often paralleled for a long period of time by assistance in regulation and by limit setting for the child. Translation of action into language and transformation of intrapsychic processes within the psyche of the therapist into helpful interventions for the child require a continuous adjustment to the inconsistent ego functions and the fragile self esteem of the child. The additional use of stimulant drugs, the work within the family and/or the social context and the high need for research in the analytical field are briefly discussed at the end.     

Psychosis and adolescence. The relation of intrapsychic structure formation and change to action and task

This article is an exploration of intrapsychic structure formation and change from the point of view of a psychoanalytic concept of action. It compares the normal development of intrapsychic structure with that involved in psychotic disorganization as individuals encounter adolescence and its developmental tasks and requirements for action. The flexible complexity of intrapsychic structure and available action in a normally developing adolescent and the contrasting fixed simplicity of intrapsychic structure and its repertory of action in psychotic patients are highlighted. Four different environmental life occasions, all of which are associated with intrapsychic change, are examined against this background. The first of these involves little initial action on the part of the ego, although lasting change does occur. The last three involve both inner and outer developmental actions that can be central to growth and may be the occasion of psychosis. The first environmental life occasion is "trauma," in which the person's action, potentialities, and intrapsychic structure are disrupted by the world's destructive action and are thereby changed. The second is "intimacy," in which newly evolved actions and interaction are sought, often with little regard for or knowledge of the accompanying necessities of intrapsychic change. In the third --"success"--new intrapsychic change and altered necessities of action can surprisingly affect both the sense of continuity within one's inner world and the nature of one's relationship to the action of the outer world. The fourth occasion is "analytic" therapy, in which the regularities of one's intrapsychic structure and its stereotypies of action are often disrupted by the very "therapeutic" processes that allow these to be observed and examined in the course of promoting progressive development. All of these exciting and dangerous occasions mark out a separate, autonomous, individual, chosen act. The attempt to explicate the role of action in intrapsychic structural change during analytic work with a psychotic patient defines the analyst's actions as interferences and disruptions of that inner structure. His actions are noted, felt, represented, and organized into a part of that reformed, newly organized inner structure. Those analytic actions are represented by the patient as "having an impact" upon the patient and do indeed affect the patient. In that regard it is asserted that for a full, psychoanalytic conception of the ego, what is required is not only a central "body ego," but the integration of action in the formation and function of that ego's intrapsychic structure--an "action ego." Clarification of the complex relationship of conceptions of "fantasy" and action are re-examined in this context.(ABSTRACT TRUNCATED AT 400 WORDS)     

On conscious primal scene fantasies

Pertinent literature concerning the pathogenicity of the primal scene is reviewed. Two psychoanalytic cases, both of whom had conscious primal scene fantasies prior to beginning psychoanalysis, are discussed. These fantasies did not represent significant ego or superego deficits. The authors suggest that conscious primal scene fantasies, in these patients, represented screen memories. Both patients were successfully analyzed.     

Object relation with drug--case report

Psychoanalytic exploration of the action of psychotropic drugs has a long tradition which begins in the pioneer days of contemporary psychopharmacotherapy in 1950-ties. This exploration and publications based on them theorized about influence of neuroleptics on ego defences, id drives and intrapsychic conflicts and decrease in symptomatology as a result of action of the medication on all listed above. The paper presented is the case story about psychodynamic meaning of medication with a neuroleptic drug in a new context. The patient after a psychotic episode (paranoid type) was treated with quetiapine 600 mg per day and in the same time had an individual psychotherapy. During psychotherapy her inability to establish object stability was disclosed. In that particular intrapsychic situation the patient established a relation with an omnipotent and idealized representation of the drug. Medication was an absolutely idealized object for her one that was controllable and stabile and could not abandon her. The quality of relation with the drug was based on a primary defence mechanism like splitting, idealization and omnipotence and denial.     

Clinical observations of suicidal behavior in a neurotic,a borderline,and a psychotic child: Common processes of symptom formation

This paper illustrates the characteristics of suicidal behavior in three psychiatrically hospitalized children, ages six to 12 years, with neurotic, borderline, and psychotic disorders. The author proposes that the nature of suicidal fantasies and the mode of ego functioning associated with suicidal behavior in these disorders are similar. However, it is emphasized that other differences in the fantasies and ego functioning exist for these distinct disorders. The paper presents a hypothetical model of how suicidal behavior of children develops. The clinical implications of this model for neurotic, borderline and psychotic disorders are discussed.This paper was presented at the Fifty-Eighth Meeting of the American Orthopsychiatric Association, March, 1981, New York, New York.     

Emotional and cognitive factors in the borderline profile

Profiles of ego functions of borderline patients are studied. Three ego functions were found to be significantly more disturbed: reality testing, object relations, and defense mechanisms. Further analysis of these and their subfunctions reveals a significant difference between emotional and cognitive factors. Emotional-internal functions are the more disturbed. This consistent difference illuminates the style of functioning of borderline patients.     

Revolution and evolution. A brief intellectual history of American psychoanalysis during the past two decades

The past twenty years have witnessed revolutionary changes in the theory and practice of psychoanalysis in the United States. The previously dominant clinical model of ego psychology with its emphasis on ubiquitous unconscious conflict between instinctual drives and the demands of reality and conscience, all mediated by the ego, is now but one of an array of differing theoretical views vying for attention. The alternative competing theoretical and clinical domains can be loosely categorized under the rubrics of object relations, self psychology, and the off-shoots of these which include the relational and intersubjective frames. These insurgent models of mental functioning and development, all of which grow out of object relations theory and thus overlap conceptually, have significant implications for psychoanalytic technique. It is the purpose of this article to review aspects of these models and the historic and revolutionary changes that their appearance have effected in the psychoanalytic landscape. A brief summary will also be made of the more evolutionary advances that have occurred in ego psychology during the past two decades. The extant literature on these issues is complex and voluminous, not to say vast. In advance, I apologize for the necessarily selective and even idiosyncratic nature of this paper. Inevitably, many original and important contributions to the evolving mosaic that makes up contemporary psychoanalysis are ignored or short-changed.     

Meeting of the minds: ego reintegration after traumatic brain injury

Many symptoms of brain injury (e.g, difficulties with speech, intellectual functions, concentration, flatness or lability, distractibility) bear a close resemblance to inhibitions and compromise formations evident in problematic intrapsychic development. Disturbances in intrapsychic function can have an organic basis, and errors in differential diagnosis can result when therapists do not consider intrapsychic and organic damage in combination. Brain-injured individuals need others who are comfortable providing auxiliary functions, particularly as an aid in managing anxiety. Understanding the operation of anxiety after brain injury can further the capacity of these individuals to attain and maintain more gratifying interpersonal relationships.     

Psychodynamics of spirit possession among the Inuit

Three cases of spirit possession were studied to determine common underlying psychodynamic factors. The spirits were believed to represent culture bound defense mechanisms, and attempts at problem solving in individuals suffering from unresolved conflicts. These being anomic anxiety, dependency, sexual identity and aggression. The symptoms, therefore, were considered to be attempts at conflict resolution. Furthermore the psychodynamic process is described as a transition phase in psychic development between externalization and internalization of intrapsychic distress or collective versus individual ego solutions to life stress. As such, therapy will be facilitated by knowledge of myths and customs and culturally significant methods of healing.     

Actualité de l’hystérie. Le féminin chez l’homme et la femme

What is hysteria today, since its paradigmatic definition that allowed S. Freud to conceptualize the psychoanalytic theory and method, until its withdrawal in current trends with the objective of rejecting sexual and sex differences? We illustrate the durability of hysteria neurosis with two case studies of both sexes that combine anxiety hysteria elements and conversion hysteria elements. The intrapsychic functioning has been explored with projective methods. Neurotic features and sexual representations are prevalent. They show that feminine within psychic bisexuality is a crucial problematic for these patients. The female patient is investing activity against passivity and seduction fantasies are lively in both active and passive positions. The male patient summons up his aggressive instinct and narcissist mechanisms of defence when confronted to passive position. For all that, can we say it is a refusal of feminine in both sexes?     

Family studies and changing concepts of personality development

Many of the most significant changes in concepts of personality development and maldevelopment derive simply from belated appreciation that the child grows up in a family; and that the child requires considerable positive input from those who raise him to grow into a reasonably integrated person. Only recently have psychiatrists and psychoanalysts begun to focus on the influence of the family transactions throughout the formative years. The paper briefly presents the requisites a family must provide to assure the integrated development of its offspring and groups them under four headings: the parental nurturant functions that change with each phase of the offspring's development; the influence of the dynamic organization of the family on the offspring's intrapsychic structure, affecting self-boundaries, gender identity, superego directives, and so forth; conveying through family transactions the basic social roles and societal institutions to the child; transmitting the instrumental techniques of the culture, and particularly its language with its system of meanings and logic upon which virtually all ego functioning depends. The paper considers the evidence that the "choice of the neurosis" -- or more correctly, the choice of the psychiatric syndrome -- does not depend only upon fixation at various phases of pre-genital development, but also, and perhaps primarily, upon the panphasic influence of the intrafamilial environment. It is of particular importance to recognize that there is a very direct relationship between the family transactions, the separation-individuation process, bounary formation, the attainment of various degrees of object constancy, problems of splitting, superego directives, and what can be conscious and what need be repressed into the unconscious. The failure to recognize the import of the family has interfered with the formation of an integrated developmental theory that can unite various aspects of the developmental process that have remained more or less isolated from one another -- drive theory, object relations, ego psychology, separation-individuation, and cognitive development. Finally the question is raised if in providing guidance to parents we have been amiss in not focusing on such matters as who the parents are, how they relate to one another as well as to the child, the values they communicate by their behaviour -- matters that are fundamental and to which almost all else is secondary, but about which relatively little has been said or taught.     

The depressive character.

The depressive character is characterized by perpetual and unsuccessful efforts to maintain self-esteem and to avoid a sense of helplessness. Such individuals suffer from chronic depression which may or may not be masked, but which permeates their character. Although the condition is among the commonest seen in many of our clinics and practices, it remains without a generally accepted diagnostic form. It is suggested that the essential, clinical, dynamic, and structural features of the depressive character are: (1) consistently low self-esteem and a sense of helplessness, dependent object relations and chronic guilt; (2) self-directed aggression and masochism are frequent but not invariable; (3) extensive use of the mechanism of denial is as common as the previously described obsessional defenses seen in patients subject to psychotic depression; (4) often the depressive character suffers from intense oral envy; (5) depressive character traits may help to ward off any of the basic anxieties, namely, object loss, loss of love, castration anxiety, and superego anxiety (guilt) (6) the depressive character may be similar to a number of related disorders, namely, the obsessional character, hysterical characters with a large oral component, and depressive borderline states; (7) sensitivity to loss, sadness, and fragility of self-esteem makes the depressive character especially vulnerable to regression into overt depression; (8) the persistence of oral incorporative mechanisms, ambivalent, dependent object relations, ego versus superego tension with depressive affect, and sensitivity to loss are characteristic of the ego of the depressive character.     

Regressive transferences--a manifestation of primitive personality organization

Regressive transferences are but one manifestation of dynamic infantile and frequently unconscious fantasies seen in patients with a primitive personality organization. Such transference relationships may vary from an apparent profound unrelatedness to intense symbiotic dependencies. These transferences are primarily preoedipal and may include grandiose, persecuting, somatizing and dehumanized object experiences as well as narcissistic idealizing and denigrating selfobject formations. Three types of regressive transferences in patients with primitive personalities are described: primitive libidinal, transference automatism, and somatization. All three demonstrate symbolically meaningful but primarily unconscious primitive transference reenactments. Regressive transferences not only represent impulses seeking gratification but are also restitutive attempts for earlier losses and lack of self-cohesion. Patients with a primitive personality organization often have suffered early deprivations that bring about the formation of unstable internal representations. This makes acceptance of ambivalence and mourning difficult due to fear of ego dissolution caused by the aggression toward the self and others. Identification and exploration of shared intersubjective phenomena may facilitate conscious reconstruction and eventual interpretation of these regressive transferences.     

Family treatment within a psychodynamic treatment milieu

Family therapy for acute inpatient treatment is invaluable. It serves to support the patient as well as the family through the crisis of hospitalization. On intensive treatment milieus, the family treatment augments the other modalities, furthering the reconstitution of the patient by preventing acting out and splitting, providing a holding environment for the family's anxieties, and supporting their interest and involvement in treatment while educating them about the illness and the aftercare needs. The area of inpatient family therapy is still fledgling. Despite early observations about family pathology stemming from inpatient units, the family treatment focus has shifted to outpatient treatment. This has left a vacuum for clinicians whose primary involvement is in inpatient settings. In the past decade, however, more emphasis has been placed on family-oriented units, but the focus has been primarily on the structure and generalized treatment recommendations or on specific interventions tied to illness categories, that is, schizophrenia, anorexia, substance abuse. Unfortunately, these disparate pieces of work have not led to an overall understanding of how to integrate family concepts and treatment strategies for general psychiatric populations into dynamic treatment units. In order to integrate family treatment into a dynamic milieu, an overall assessment of familial ego functioning, strengths and weaknesses, is necessary. Utilizing an ego psychological perspective renders this assessment integratable into the language and interventions of an intensive treatment unit. Identifying drive-taming capabilities, level of object relations, anxiety tolerance, defenses, and adaptive capacities of the whole family allows for the designation of appropriate interventions. These interventions are tailored toward engaging the family's strengths while limiting the destructive nature of existing pathologies. Treatment interventions are based first on the establishment of familial treatment alliances that can withstand the regressive pull of a psychotic or near-psychotic illness. From this the more traditional therapeutic interventions flow, based on the needs of the case. The focus may be purely informative, educative, and supportive or may be more insight oriented, restructuring. The particular choice of interventions, though, is designated by the strengths and weaknesses identified in the assessment. In this manner we can utilize a biopsychosocial model of treatment that is truly integrated and in which the component parts are understood conceptually by all disciplines.     

The life and music of Alexander Scriabin: megalomania revisited

OBJECTIVE: To shed more light on the relationship between the grandiosity of the Russian composer Alexander Scriabin (1872-1915) and his creative output, and discuss its implications for psychopathology. CONCLUSIONS: Scriabin was a highly original composer, who brought innovations to the idiom of music. He firmly believed that music and philosophy were inseparable and that music was only a vehicle for expressing ideas and emotional states. As Scriabin was getting more preoccupied with mysticism and as he was developing a belief that his mission was to save the world through his art, his music became more esoteric. Over the last five years of his life, he composed relatively little, as he was working on a supergrandiose project that he never completed. Scriabin's grandiosity, which had delusional qualities, might have diminished his creativity towards the end of his life and contributed to his destructive fantasies. All along, his social fa?ade was well preserved and he was not noted to exhibit overt psychotic behaviour, suggesting an encapsulated delusional megalomania. The implications of megalomania, especially in creative or otherwise influential individuals, are briefly discussed.     

Sexual Desire,Violent Death,and the True Believer

The relationship among sexual desire, violent death, and fundamentalist belief leading to acts of terrorism is explored through the psychoanalytic lens of structural and object relations theory. Using contemporary and historical cases of jihadist, ethnic nationalist, and single-issue terrorist violence, the author posits that both the fear of and desire for sexual pleasure, and its condemnation and often punishment within the strictures of fundamentalist belief systems, are often intrapsychically managed through pre-Oedipal defenses, compensatory fantasies of death of the self and object, and the promise of unlimited sexual gratification through violent obliteration. The actual targeted violence, directed toward perceived unbelievers, also advances the fantasy of ambient purification (morally cleansing the environment), and the fantasy of ushering in a destined utopia, usually vaguely defined.     

Issues of separation related to psychosis in twins

The subject of twins has been surrounded by a mystique from ancient times. The literature on twins is reviewed. A case study of a pair of schizophrenic twins is presented and issues involving separation as a precipitating factor in the decompensation of twins are identified and discussed. Feelings of ambivalence, rivalry, competition, diffusion of ego boundaries, mutual complementariness, and a sense of one being incomplete without the other are reviewed and illustrated in the clinical material. Normal unconscious fantasies in twins may become concrete and delusional in psychotic twins. The inpatient treatment of the two patients emphasizing their separateness was not effective. A change in technique in which they were permitted to resume their mutual clinging and were treated as a unit was followed by resolution of symptoms. In contrast to advice in the literature that attempts be made to separate psychotic twins in order to promote their individuation, the authors suggest that the need for fusion be reinforced in psychotic twins as a therapeutic maneuver during the acute episode.     

Applying Fairbairn's object relations theory to the dynamics of the battered woman

Fairbairn's secular object relations model of the development of the human personality emphasizes the power of the environment to form inner ego structures and the ensuing tragic results for all human infants who are faced with an unnurturing environment. Every act that children take to insure their continuing attachment to a frustrating, yet tantalizing object undermines their developing ego structure. The consequence of severely compromised ego structures is repetition compulsion in adulthood, as illustrated by the battered-woman syndrome. Each of the engorged and unrealistic part-ego structures seeks out external objects to re-enact the original relationship that created them. The consequence of a severely rejecting childhood can be endless abuse or death.