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Psychosis and schizophrenia: effects of changes in psychiatric classifications on clinical and theoretical approaches to mental illness. Current pathological classifications prioritize a physicalist approach. Consequently, conditions that previously were associated with neurosis and subjectivity are being medicalized, conditions previously recognized as psychotic are relocated under the heading of personality disorders, and psychosis has been reduced to schizophrenia and considered a deficit of psychic functions.
Key words: psychosis; schizophrenia; psychiatry; psychoanalysis; Diagnostic and Statistical Manual of Mental Disorders.
This article discusses the changes which have occurred in the diagnostic classification systems for mental illness, especially regarding the conceptual weakening of the psychosis category, at the same time that schizophrenia has become dominant as the only condition recognized as psychotic. This new inflection represented a paradigm shift, weakening the description of mental illnesses based on assumptions we could call psychodynamic in favor of a physicalist approach to mental pathology.
At least three major consequences of this change can be seen, in terms of disease classification and clinical application. The first is the medicalization of conditions which had previously been associated with subjectivity, such as anxiety, sadness, obsessive thoughts, phobias, sexual behaviors and others — all of which had previously been approached from the framework of the neuroses as conceived by psychoanalysis.
The second consequence is that conditions which had previously been recognized as psychotic have been relocated to fit under the heading of personality disorders. The third consequence, which we will discuss in detail, is the reduction of psychosis to schizophrenia; in other words, schizophrenia became the only condition which is currently recognized as psychotic.
We are addressing the practical field of mental health in which we work, where we notice that the proliferation of diagnoses generated by the DSM has frequently had a disorienting effect in relation to diagnosis and the clinic — mainly the effect of a lack of familiarity with psychosis where it often appears. We will attempt to indicate, within both the description of diseases and psychiatric classification, how current leanings make psychosis more difficult to recognize, except when disruptive or deficit-related symptoms occur.
In this sense, our approach lies within psychiatric doctrine and the dialog between psychoanalysis and psychiatry, although it does not neglect to consider and mention the convergence of economic and social processes which have contributed to the transformations we discuss. We know from Canguilhem that it is impossible to separate the internal reading of a scientific discourse from its external reading, since this latter creates the conditions which make the referred discourse possible, and that often the multiple processes which unfold in a particular historical, social, and economic context decisively determine the phenomena within that discipline cf.
The notion of psychosis was the category that determined psychiatry for almost two centuries. In its strong sense, it defined or defines a deep psychological structure — a specific mode of subjective constitution and functioning — as opposed to neurosis, and its expression in symptoms can vary greatly.
In this meaning, psychosis demarcated the specific field of psychiatry, its most suitable object. Along with the abandonment of this conception and the opposition between neurosis and psychosis, the categories which had expressed the terms for psychiatry in culture for a whole century were also abandoned: paranoia, melancholy, manic depression, hysteria, and obsessional neurosis.
The stated intention of these modifications was to create as much consensus as possible in psychiatric classifications, regardless of which school the psychiatrist followed. To do this, the DSM and then the ICD declared themselves to be atheoretical, excluding the categories which involved theoretical and psychodynamic assumptions and intending to base classification exclusively on symptoms that could be empirically observed and quantified.
Some works we will cite show that while this may not have been the intention, in effect these changes certainly suppressed reference to psychoanalysis. They also demonstrate how a diagnostic system exclusively based on symptoms has favored increasing emphasis on pharmacological treatment. It is not by chance that the only condition currently recognized as psychosis schizophrenia is a deficient condition which offers a biological interpretation, pharmacological action, and rehabilitation activities that can be both generous actions of social inclusion and at the same time can shift the balance toward a practice of normalization and adaptation, depending on the interpretation.
Psychoanalysis has been charged with sustaining the clinical and doctrinal validity of the psychosis category, to the point of spreading the feeling that this concept pertains more to psychoanalysis than psychiatry. At the end of the nineteenth century, the advent of neurology showed that for most mental illnesses, the previously assumed injuries did not exist, unlike in neurological diseases; the emergence of psychoanalysis explained neuroses by assigning them to certain psychological mechanisms, capable of modification through psychoanalytic treatment.
This established the terms psychosis and neurosis as antonyms, each hosting a certain group of psychological diseases. Bercherie , p. During this same period, Magnan distinguished the mixed states organic brain lesions, senile dementia, neuroses [hysteria], epilepsy, alcoholism etc. Psychosis went on to be the most suitable object of psychiatry, separating neurological diseases pertaining to neurology on the one hand, from the neuroses, which became the area where Freudian psychoanalysis excelled.
If a science or discipline is only characterized by describing its specific object, the notion of psychosis was the one which specified psychiatry from neurology, on the one hand, and psychoanalysis, on the other even if the initial meaning of the term differed from how it was to be conceived eventually.
Regarding psychoanalysis, here we refer to the situation left by Freud, who despite maintaining a theoretical and clinical interest in psychosis, considered it inaccessible for psychoanalysis.
Freud himself never had a regular practice with psychotic patients. As a neurologist, he was interested in the enigma that hysteria represented for this specialty, and the invention of psychoanalysis corresponds to the rupture that Freud introduced into the understanding of this disease hysterical neurosis.
This rupture eventually inverted the very meaning of the term neurosis, which no longer alluded to the neuronal system but instead came to designate a psychopathological state characterized by the absence of organic disease in the nervous system. Regarding psychosis, Freud placed all his hopes into the work of his colleagues Karl Abraham and Carl Jung, both psychiatrists dedicated to applying psychoanalysis to this pathology. However, despite their significant contributions — first, regarding psychosis-manic depression Abraham, , and second, with regard to schizophrenia Jung, — it can be said that only with Lacan did psychoanalysis come to develop a theory of psychosis that was not based on notions borrowed from the neurosis clinic.
In this way, the term psychosis came to be used for this group of diseases. Psychosis or psychoses was understood to mean maniac-depressive psychosis, paranoia, and schizophrenia. It can be said that throughout the twentieth century, these three disorders characterized the field of psychiatry. The nosographic structure established by Emil Kraepelin around the turn of the twentieth century guided psychiatry for the next hundred years.
By emphasizing the criteria for evolution and prognosis introducing the dimension of the course of the disease over time , Kraepelin: 1 formalized maniac-depressive insanity as a single disease; 2 isolated paranoia as an independent clinical condition, reducing the extent of this morbid entity; and 3 grouped together into a single clinical entity diseases which had previously been considered separated: hebephrenia, catatonia, and much of what had been called paranoia.
This new entity, dementia praecox, would later be called schizophrenia. Nobre de Melo, , p. What Hecker added was the identification of anomalies in syntactic construction and a tendency to deviate from the normal way of speaking and writing — formal changes in language that, according to Hecker, express a profound breakdown of the Ego and are early indications of the intellectual weakening that will occur later. Kraepelin made these similarities prevail over the phenomenological differences.
The same criterion allowed him to separate these diseases from maniac-depressive psychosis, notwithstanding the occurrence of manic and depressive states in both, since an essential notion of maniac-depressive psychosis is the full recovery of the personality at the end of each episode, which does not occur in hebephrenia or catatonia.
Regarding to paranoia, as it was considered until that time, it encompassed all the psychoses in which there was chronic delirium, whether accompanied by other changes or not, and regardless of evolution. Cacho, Kraepelin further refined the notion, distinguishing two types of chronic delusions: dissociated delusions, which are accompanied by sensory errors hallucinations and sooner or later end in psychic decline, and interpretative and systematically evolving delusions which are not accompanied by hallucinations, do not compromise other psychological functions, and never end in dementia.
He only used the term paranoia to describe the latter case. The effects of this damage on mental life predominates in the emotional and volitional areas. For this reason, the German school was noted for producing broad categories of classification, while the French school was known for its description of conditions characterized by their differences and specific qualities.
In creating the name schizophrenia and proposing that it replaced dementia praecox, Bleuler , p. Bleuler , p. In the most serious cases, all manifestations of affect are abandoned; in less severe cases, affect is inappropriate.
Another symptom is added to these, which Bleuler , p. In his Manual of psychiatry , Henri Ey gives this disease a systematic description which is worth summarizing here Ey, Bernard, Brisset, s. According to Ey, the absence of a rigorous definition does not prevent most clinicians from understanding it in practice with regard to the diagnosis of schizophrenia:.
Generally, schizophrenic psychosis is understood to mean a set of disorders dominated by discordance, ideoverbal incoherence, ambivalence, autism, delusional ideas, poorly systematized hallucinations, and profound affective disturbances in the sense of detachment and strangeness of feelings — disorders that tend to evolve into a deficit and a dissociation of personality Ey, Bernard, Brisset, s.
These two poles are complementary and connected by the following common features which are inherent to the disease: ambivalence, the bizarre, impenetrability, and isolation. The first line, the one of the dissociation, consists of the breakdown of life related to the psyche, the internal discordance of psychological phenomena.
The second line, that of positive or productive symptoms, culminates in delirium, at least in paranoid schizophrenia, but includes the entire series of hallucinations and experiences that begin with the feeling of strangeness or xenopathy of thought and of mental functioning — delusional intuitions and perceptions, mental automatism, depersonalization, and the experience of influence.
In paranoid schizophrenia, these phenomena are important and culminate in some delusional construction, but not to the extent of comprising systematic delirium, as they do in paranoia. Its evolution moves toward impoverishment. In the same year that Bleuler published his article, Freud , p. As a matter of fact, schizophrenia came to replace a wide variety of clinical conditions that can only be gathered into a single entity by their deficient nature. It became the dominant notion of psychiatry, while at the same time it established the prevalent idea of mental illness as a deficit.
The cognitive slant of the DSM will reinforce this approach. Freud and Lacan: psychosis is a condition of the subject, heterogeneous to neurosis. It is beyond scope of this work to go deeper into the psychoanalytic reading of psychosis initiated by Freud and formalized by Lacan. We will recall its fundamental bases that are sufficient for the argument we are pursuing here. Not being a psychiatrist, Freud did not have a significant case-by-case analysis of psychotics, and could not take psychoanalytic theorizing of this disease very far.
In the words of Lacan , p. Essentially, it asserted that the delusions and hallucinations of a psychotic are formations that arise from the same issues in face of which a so-called normal subject constitutes himself or herself cf. Freud, , p. Freud formulated that the formation of the subject corresponds to the introduction of these subjective elements into the psyche, although they are housed in the unconscious, as unconscious knowledge i. This knowledge operates on the subject in absentia; it propels him as desire to respond to the requirements of life and desire, and produces as symptom points of impasse, of the impossibility of permitting a certain dimension, of the difficulty of doing something, or even in the form of symptoms identified by the clinical tradition related to anxiety, depression, dissociation, obsession etc.
Hence the difficulty of establishing a sharp border between the normal subject and neurosis as a pathology in psychoanalysis. Therefore, the mechanism is the introduction via identification of unconscious knowledge about desire and the sexual, knowledge that forms the subject himself, but which remains inaccessible to him in terms of consciousness.
In the matter of the psychosis, armed with this key of understanding, Freud was able to formulate that paranoid delusion inflected these same elements, but did not know how to explain why they did not appear in the psychological interiority of a subject who could be grappling with his desire, but, instead, appeared disconnected from reality, in the form of a delusion in which the subject was always placed as an object of persecution, of delusional love, of sexual intent, of a voice in a hallucination that always injures, threatens or commands etc.
This is what is underscored by the princeps case of Freudian psychosis theory, which we have already mentioned, the Schreber case Freud, As a contemporary of Kraepelin and Bleuler, Freud , p. And he criticized the term schizophrenia created by Bleuler, for being based on a psychological characteristic that is not exclusive to this disorder, the splitting p.
It was probably his interest in deciphering order and meaning where psychiatry tended to see disorder that led Freud to grant a higher status as paranoia in the field of psychosis in other words, to organized delusion to the detriment of schizophrenia which implied disorganization, dissociation, deterioration.
Unlike Freud, Lacan was a psychiatrist and entered psychoanalysis through the psychosis clinic. Psychosis is not dementia. Psychoses are That is to say, psychosis and neurosis are functional logics to which the subject is submitted. Lacan showed the heterogeneity of these logics, and at the same time the main lines of psychosis as a structure.
The subject is forced to exist in the language which precedes him and which is imposed on him as law. The Freudian terms of intersection between paternal inheritance and assumption of sex by the subject are considered by Lacan as dimensions established by language itself, by the symbolic, for every subject.
Within the limits of this study, we will say that while neurosis which is also our normality is the structure formed by interiorization, by the subject, of the injunctions established by the symbolic system father, generational chain, sexual difference , psychosis corresponds to the situation where the subject cannot create a psychological interiority from these dimensions, a symbolized experience of himself.
Consequently, it is not that these dimensions do not exist for the psychotic, since they were also established in their injunctive character for him, and they are what constitute and move the social bond itself. However, they have a particular form of existence, existing outside the general symbolization that structures the subject, outside any symbolization that would allow the subject to have them as the elements of his subjectivity.
This is what lies at the heart of the distinction between neurosis and psychosis and supports the affirmation of psychosis as a structure, as opposed to the idea of psychosis as a deficit.
In this way, as a kind of confluence of work in psychiatry and psychoanalysis throughout the twentieth century, a distinction was established between neurosis and psychosis, with each designating a class of pathology, a background condition, that corresponds to a specific way of being in life and in relation to the other; in Lacanian terms, a structure.
The advent of the third edition of the DSM in represented a milestone for psychiatry, a drastic change in course. XXIV; emphasis in the original. The nosographic entity of maniac-depressive psychosis gave way to the notion of mood disorders.
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Fundamentos de La Clinica