1Freud did not produce a systematic theory of the onset of psychosis, failing to transform his research into an original and precise concept akin to repression in neurosis.
[1] Although he devotes an article to the clinic of the onset of neurosis entitled Types of Onset of Neurosis, [2] he does not do the same for psychosis. However, the interest that the founder of psychoanalysis maintains in this subjective
catastrophe is undeniable, and he never gives up on trying to give an intelligible account of it. In fact, the body of Freud’s work contains at least seven clinical cases of the onset of psychosis, which I am going to discuss in this article. 2Contrary to the doctrine of degeneracy, and as early as 1894, Freud considers hysteria, obsessional neurosis and hallucinatory confusion as “three forms of defense.” [3] He understands them as the clinical varieties of the ego’s defending itself against an incompatible
representation, differing however in their efficacy. In this respect, hallucinatory confusion is 3 […] a much more energetic and successful kind of defence [than the two others]. Here, the ego rejects [Verwift] the incompatible idea together with its affect and behaves as if the idea had never occurred to the ego at all.
[4] 4This is the first occurrence of Freud’s use of the term Verwerfung, which he will later apply to hysteria;
[5] i.e. he does not suppose the mechanism to be specific to psychosis. In addition, he argues that the content of hallucinatory confusion “consists precisely in the accentuation of the idea which was threatened by the precipitating cause of the onset of the illness.”
[6] Freud bases his argument on an observation of a young woman, in love with a man whom she imagines to return her love. After several disappointments have led to the formation of symptoms of a hysterical nature, a decisive event occurs: the young man, who has been invited to a celebration at the woman’s family’s home, never arrives. The waiting provokes a state of high
psychical tension in the patient, reaching its peak at the end of the day: 5 She passed into a state of hallucinatory confusion: he had arrived, she heard his voice in the garden, she hurried down in her nightdress to receive him. From that time on she lived for two months in a happy dream, whose content was that he was there, always at her side, and that
everything was as it had been before. [7] 6According to Freud, the representation of the young man’s absence has undergone a Verwerfung. He therefore concludes that the psychotic process can be conceived of as follows: 7 The ego breaks away from the incompatible idea; but the latter is inseparably connected with a piece of reality, so that, in so far as the ego achieves this result, it, too, has detached itself wholly or in part from reality. [8] 8By understanding the hallucination as the ego’s satisfaction by foreclosing (Verwerfung) the inadmissible reality, Freud replaces the traditional conception of the onset of psychosis with a new understanding. 9In this draft, Freud includes paranoia in the group of the psychoneuroses and considers its onset as an activation of a specific kind of defense, in response to a situation that the subject is unable to bear. [9] He highlights the notion of a psychical predisposition to
paranoia and then focuses on trying to shed light on its mechanism. For this purpose, he discusses the case of a young woman (about thirty years old), who suffers from a persecutory delusion. Several years earlier, she had told her older sister about a scene which had occurred in their shared home: a young man, their lodger, had placed his penis in her hand. A delusion ensues: 10 She thought their women neighbours were pitying her for having been jilted and because she was still waiting for the man to come back: they were always making hints of that kind to her, kept on saying all kinds of things to her about the man, and so on.
[10] 11Observing that the patient now denies the occurrence of the traumatic scene, Freud is interested in the specificity of the paranoiac defense: 12 So what she was sparing herself was the reproach of being a ‘bad woman’. Afterwards she came to hear the same reproach from outside. Thus the subject-matter remained unaffected; what was altered was something in the placing of the whole thing. […] The judgement about her had been transposed outwards: people were saying what otherwise she would have said to herself. [11] 13Focusing on the mechanism which generates the delusion, Freud suggests that 14 […] the
purpose of paranoia is thus to fend off an idea that is incompatible with the ego, by projecting its substance into the external world. [12] 15He then asks questions about the mechanism of projection and its operational modes and
answers that what we see is a pathological aberration, used for the purpose of defense, of the normal mechanism of projection. When a subject is aware not only of the contents of his ideas and affects but also their origins, he is little surprised that another person might guess at them. As Freud says, this is the normal way in which the mechanism of projection functions. However, when the subject forgets the internal origin of his own ideas and affects because they are unbearable to him, he
attributes their content to another person: this is the paranoiac misuse of projection. Freud then asks if the mechanism functions identically in other cases of paranoia. He speculates that in general, 16
17The psychotic delusion is therefore identified as a defensive psychical reaction with a narcissistic dimension. It is interpreted according to the neurotic model, i.e. the delusion would thus represent the return of the repressed. 1.3. Draft K (1896)18In 1896, Freud argues that two conditions are necessary to the onset of a psychoneurosis: “that the cause […] is of a sexual kind and that it occurs during the period before sexual maturity. [14]” He then adds another, third dimension, related to a hereditary disposition, which he hardly explains at all. In his understanding, the psychopathological dimension of the psychoneuroses stems from a disturbance of normal psychical mechanisms: “of conflict (hysteria), of self-reproach (obsessional neurosis), of mortification (paranoia), of mourning (acute hallucinatory amentia).” [15] In paranoia, mortification is gradually disordered and becomes transformed, once a certain threshold has been passed, into suspicion. This is paranoia’s primary symptom. In this draft, Freud attempts to bring neurosis and psychosis closer together, based on the following argument: the experience of the original event in psychosis is supposed to be analogous to that of obsessional neurosis, i.e. it is pleasurable. While in paranoia, the original event was experienced as pleasurable, its memory generates “unpleasure [that] is referred to the patient's fellow men in accordance with the psychical formula of projection.” [16] 1.4. The New Neuro-psychoses of Defense (1896)19Two years after his first article arguing for the new category of the psychoneuroses, Freud claims that his initial views have been confirmed, especially his idea “to look on defence as the nuclear point in the psychical mechanism of the neuroses in question.” [17] Nonetheless, they deserve to be partially amended, so as to include the latest advances made in the Drafts H and K, including the addition of paranoia to the group of the psychoneuroses. Freud puts forward the hypothesis that each of the psychoneuroses is characterized by both the specific mechanism of repression it employs and the kind of content that is repressed, leaving a particular imprint on the symptom. [18] In this research, Freud relies on an observation of a thirty-two-year-old female patient, presenting a case of paranoia. He thus begins the first psychoanalytic treatment of a psychotic subject, [19] assuming that “unconscious thoughts and repressed memories […] could be brought into consciousness […] by overcoming a certain resistance.” [20] The cure confirms his previous beliefs. He collects the patient’s unconscious and repressed thoughts, namely her earliest memory of being naked in front of her brother and feeling no shame at all. The woman also mentions sexual touching. Freud considers that the patient is retroactively reproaching herself, in the present, for the scenes of shared nudity with her brother. He also writes the following about the young woman’s hallucinations, during which she has visions of female sexual organs: “I had found, therefore, that these hallucinations were nothing else than parts of the content of repressed childhood experiences, symptoms of the return of the repressed.” [21] He focuses on analyzing these symptoms in order to identify paranoia’s distinctive mechanism of repression: 20
21Projection enables the movement from a self-reproach to a reproach addressed to others, and later made by others. We can thus summarize the Freudian approach to symptom-formation, characterized by repression, in the three psychoneuroses as follows: in hysteria, the site of the attachment of the affect, separated from the repressed representation, is the body; in the case of obsessional neurosis it is located in other substitutive representations; in paranoia it is situated in the other. 2. President Schreber (1911)22Previously, Freud had difficulty establishing a truly differential clinic of psychosis and neurosis because the notion of Verwerfung (1894) had been little explored. His analysis of Memoirs of my Nervous Illness by Daniel-Paul Schreber allows him to make a real conceptual leap in his approach to psychosis, by bringing in the notion of the subject. He considers the onset of Schreber’s psychosis as a clinical incidence of “the grave conflict which had broken out within him.” [23] Pursing the path pioneered by Karl Abraham, [24] Freud now devotes himself to investigating this conflict and its current and predisposing causes. In doing so, he revisits certain characteristics of the “structure of paranoia,” [25] understood based on a stratification of the psyche and its dynamism. 2.1. The Incubation Period23After his first hospitalization (December 1884 - June 1885) at Professor Flechsig’s clinic in Leipzig, during the second half of 1893, Schreber’s psychic condition progressively worsens. He is again hospitalized, this time in the Sonnenstein asylum. Beginning his analysis by looking at the incubation period of Schreber’s second psychotic outbreak, Freud identifies two important facts which occur between Schreber’s appointment as the president of the Dresden Supreme Court in June 1893 and the moment he takes office in October 1893. During this time, Schreber repeatedly dreams about the return of his illness, including the appearance of the figure of Professor Flechsig, and he imagines “that after all it really must be very nice to be a woman submitting to the act of copulation.” [26] Freud suspects a link between Schreber’s unconscious attraction to Flechsig and this homosexual daydream. The fantasy of Schreber’s transformation into a woman constitutes the primary element, based on which the entire delusion will be constructed. A clinical detail confirms Freud’s hypothesis: during an extended absence of his wife, Schreber is subject to a new “mental break-down,” which as he says ensues after “a quite extraordinary number of emissions.” [27] According to Freud, the break-down appears to be triggered by the joint influence of the following two causes: unconscious homosexual fantasies necessary to the nocturnal emissions and the absence of Schreber’s wife, who previously exercized the function of a protector, preventing her husband from succumbing to his unconscious tendencies. Freud considers that the death of Schreber’s older brother Gustav in 1877, followed by that of his father in 1861, are in agreement with his hypothesis of a nostalgic attachment, fixated by transference onto Fleschig. Questioning the conditions of this nostalgia, Freud refers to the Schrebers’ difficulties in producing a child and the frustration which resulted from it. So that, Freud writes: 24
25In this way, Freud is able to shed light on the President’s regression to a feminine position central to the construction of the delusion. 2.2. The Paranoiac Modes by which the Homosexual Fantasy is Contradicted26Reconfiguring his original thesis regarding the psychoneuroses, Freud states that: “what lies at the core of the conflict in cases of paranoia among males is a homosexual wishful phantasy of loving a man.” [29]
He then changes his mind slightly, pointing out that the psychical conflict connected to the refusal of unconscious homosexuality is in no way limited to paranoia – not even to psychosis. Paranoia’s only exclusivity are the three modes of contradicting the statement “‘I (a man) love him (a man)’” [30] Each corresponds to a specific type of delusion: “Delusions of jealousy
contradict the subject, delusions of persecution contradict the verb, and erotomania contradicts the object.” While the proposition of the delusion of jealousy results directly in the contradiction of the subject of the sentence, the propositions of the delusion of persecution and of erotomania require a second step, that of projection. In both cases, since projection operates on the subject of the contradiction, the proposition finds itself rejected onto another subject. Freud concludes that
projection represents the most significant trait in the formation of the paranoiac symptom. He assumes that the link between the content of what is rejected and what returns from without is similar to repression, which, he believes, is based on a three-step model: [31] 27Previously, Freud had argued that the second step of repression in paranoia takes the path of projection, the subject projecting the homosexual feelings he is trying to suppress onto one or several persons. Conscious that such a mechanism cannot alone account for paranoia, he now takes a major step in his approach to the psychotic phenomenon by claiming that “what was abolished internally returns from without.” [32] While the normal process of secondary repression corresponds to the withdrawal of the libido invested in an object, Freud suggests that in paranoia we see a more efficient withdrawal, which he calls “paranoiac withdrawal.” He therefore attempts to identify a psychotic mechanism that is more radical than the neurotic repression. 3. A Case of Paranoia in a Young Woman Patient (1915)28In 1915, Freud reports another observation of the onset of psychosis. Embarrassed by one of his clients’ complaints
about the persecution she has suffered at the hands of a former lover, a lawyer initiates a meeting with Freud, to whom the young woman tells her story. After she had been courted for a certain period of time by a colleague at work, she finally agrees to meet him in his flat. During their lovemaking she is surprised by a noise – “a kind of knock or click.” [33] On her
departure she runs into two men who seem to whisper to each other as she passes them, one of them hiding a camera. The woman remembers the noise she heard in the room and imagines that the man must have taken intimate pictures of her. Concerned, she presses her lover with questions, but is not satisfied with his answers and eventually contacts a lawyer. 29 4. The Case of the Young Doctor (1916-1917)30In May 1907, Freud argues that the mechanism of paranoiac projection must be divided into two steps, namely into “the breakdown into repression of the libido and return of the libido.” [36] In other words, the subject withdraws his libidinal investment from an object-representation; he then transforms it into a perception, which he finally projects outside. The following month, Freud constructs three cases of repression, of which we only retain the second, where “repression is transformed into a rejection [Verwerfung]” of reality. A speculative conception, since as he writes to Jung soon after, paranoia “shows only the return of the libido.” [37] Between 1916 and 1917, Freud assumes that during this return of the libido, the initially tender feelings can be transformed into hate, which then constitutes an extreme, even vital danger for the object that is simultaneously loved and hated. [38] He reports an observation of a young physician who left the place of his medical practice following a series of death threats he had issued against his former best friend, now the object of his delusions of persecution. In the course of several brief conversations, Freud learns that the two men had previously given in to their mutual attraction. The patient then tells him that his illness began when he had succeeded, for the very first time, in sexually satisfying a woman. He then felt a sharp pain in his head, which he compares to the feeling “as though an incision were being made at an autopsy for exposing the brain.” However, his intimate friend specializes precisely in the field of pathological anatomy, a branch of medicine that involves dissecting human corpses. It slowly dawned on the young doctor that it was this friend alone who could have sent the woman to him in order to tempt him. He now attributes to him the entire set of persecutions of which he is the object. The clinical elements reported by Freud are arranged according to a chronology that proceeds from the original sensation to the identification of the lover as the persecutor. In Freud’s view, this temporal structure suggests that paranoiac delusions function as a defense against a homosexual libidinal impulse. 5. A Bout of Delusional Jealousy (1921)31In his 1921 article focusing on the psychoanalytic examination of the psychic mechanisms of jealousy, Freud distinguishes between three “layers or grades of jealousy [that] may be described as 32
33Hence, for the subject, a crisis of delusional jealousy constitutes clinical incidence of sexual satisfaction. Freud then adds that the subject “had made no friendships and developed no social interests; one had the impression that only the delusion had carried forward the development of his relations with men, as if it had taken over some of the arrears that had been neglected.”
[42] 6. Onset of psychosis and Freud’s Second Topography34In 1924, Freud devotes two articles to the idea of the differential clinic of neurosis and psychosis. The difference concerns their respective triggering, rather than “the attempt at reparation which follows it.” [43] Freud conceives of the onset of neurosis as the result of a conflict between the id and the ego. Psychosis on the other hand is triggered by “a disturbance in the relationship between the ego and the external world,” [44] which is equivalent to a loss of reality. Based on the relationships between the three terms (the ego, the id and reality), the second topography allows Freud to distinguish between the triggering of the neuroses and that of the psychoses. Although the agent, namely the ego, remains the same, the operation and the nature of what it treats differ. Freud explains that in the case of psychosis, the withdrawal of a fragment of reality from the ego is made in favor of the id. Going back to the case of Miss Elisabeth von R., [45] Freud describes two possible reactions, a neurotic and a psychotic one, to the situation the subject is facing: standing by the deathbed of her sister, a young woman suddenly has a thought about her brother-in-law, with whom she is in love, “Now he is free and can marry me.” The neurotic reaction, Freud suggests, was to repress the desire, which then found a way to satisfy and express itself in the hysterical symptoms; on the other hand, “the psychotic reaction would have been a disavowal of the fact of her sister's death.” [46] Negating this event represents for Freud a loss of a fragment of reality, which is then followed by a second step. Indeed, like in neurosis, here too Freud discerns two different stages: “The first would drag the ego away, this time from reality, while the second would try to make good the damage done and re-establish the subject's relations to reality at the expense of the id.” However, and this difference is crucial, neurosis is not based on a denial of reality. In 1937, Freud will argue that the onset of psychosis follows a current rejection of a fragment of reality, which nevertheless actualizes an original rejection made in childhood. This means that the representation which had been denied was psychically preserved, rather than abolished. Moreover, Freud adds, the delusion draws its powers of conviction from the “historical truth which it inserts in the place of the rejected reality.” [47] He therefore concludes that, like hysterics, psychotics too suffer from reminiscences. Faced with the discovery of the historical truthfulness of what was rejected, Freud has no other model for psychosis but neurosis: he is unable to conceptually surpass the mechanism of repression. He never succeeds in raising the status of some of his indications about the rejection or Verwerfung of a single representation to the level of a theoretical concept. Conclusion: Freud’s Quest35To conclude, let us stress that the Freudian approach to the problem of the onset of psychosis is based on a classical causal model requiring two factors: a psychotic disposition and an event to which the subject reacts by employing a mechanism of defense that is identical to the psychical mechanism determining the psychotic structure. Freudian psychosis is therefore specified by a structure, and its triggering - “the Ausbruch, the triggering of psychosis, as Freud was already emphasizing in the 1895 Draft H” - intervenes “in response to an event which can be identified as a trigger.” [48] However, the precise mechanism remains obscure and Freud never manages to identify its distinctive properties. He himself 36
37In the 1920s, Freud introduces the concept of Verleugnung, translated as denial or disavowal, after having used Verwerfung, normally translated as a rejection, as early as 1894. Though he was unable to conceive of an original mechanism of psychosis, by “laying the groundwork and identifying a vacant point in the psychoanalytic theory, which would later be accounted for by Lacan’s coining of the notion of foreclosure,” he provided us with the foundations. [50] The “Freudian quest for the specific mechanism” [51] of psychosis therefore deserves to be highlighted, all the more so because it was never abandoned: in his Outline of Psychoanalysis, the founder of psychoanalysis is still looking for “the necessary preconditions for a psychosis.” [52] His search incites us to recognize how much the later theorizations of psychoanalysis owe to Freud’s inaugural and singular discoveries. Translated by Kristina Valendinova (revised translation). Notes
Which defense mechanism is most characteristics of the patient with paranoid schizophrenia?The results indicate that schizophrenic patients in comparison to healthy persons use the specific defense mechanisms (rationalization and negation) more often and have higher level of egocentrism. On the other hand both groups can be characterised by a low level of ability to change "ego".
What is the most common defense mechanism of a paranoid client?Option C: Projection is a defense mechanism in which one blames others and attempts to justify actions; it's used primarily by people with paranoid schizophrenia and delusional disorder.
What is the most used defense mechanism?Denial is one of the most common defense mechanisms. It occurs when you refuse to accept reality or facts. People in denial may block external events or circumstances from the mind so that they don't have to deal with the emotional impact. In other words, they avoid painful feelings or events.
What psychological defense mechanism is usually prominently used by patients suffering from a paranoid personality disorder?Paranoid Personality disorder is characterized by cognitive distortions of delusional intensity, based largely on the classical defense of projection. Projecting one's own negative features onto others fosters suspicion.
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Which defense mechanism is most characteristic of the patient with paranoid schizophrenia?
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