Psychoanalytical/psychological definitions of psychosis.

Intro
Psychosis is defined as a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality. Although this definition is generally accepted by both psychoanalysts and psychologists/psychiatrists alike, the way in which psychosis is diagnosed and treated differs dramatically. Psychoanalysis is very focussed on the development of psychosis and in moulding a persons life to accommodate for the symptoms of each individual patient. Psychiatry looks at psychosis more systematically diagnosing a disorder and then treating this disorder in the same way for every patient. Psychosis is a term that covers a large number of mental disorders and a few psychoanalytical structures and can be used to describe someone who is considered outside of discourse.

The term psychosis designates mental illness in a broad sense. Within psychosis there are many different manifestations that are dealt with differently by psychoanalysis and psychiatry. The term psychosis was coined in 1841 by Karl Friedrich Canstatt, psychiatry was coined in 1808 by Johann Reil and psychoanalysis was coined by Sigmund Freud in 1896 (Lecture on psychosis, Australian Centre for Psychoanalysis, 10th of May 2014.) Freud produced the basis and model for the psychoanalytic understanding of the psychoses and the first theory of psychosis. The first theory of psychosis, which was presented in Freud's case study of Daniel Paul Schreber based on his memoirs, is that psychotics cannot engage in discourse in order to create a social bond. Daniel Paul Schreber was Senatspraesident in Dresden and he was suffering from paranoia. His memoirs helped Freud establish the first theory of psychosis. Jacques Lacan developed this theory of psychosis after writing his PhD about a psychotic person.

In Psychoanalysis it is believed that psychosis develops from an unsuccessful traversal of the Oedipus complex. Successful traversal of the Oedipus complex involves a weakening of the mothers power allowing the child to develop a basic trust or acceptance in the symbolic law. The symbolic law is the law of interrelationships which is assumed through language. In order for the child to develop this trust, they must realise that there is more to life outside of the relationship with the mother. If this trust is not developed then the child is liable to form a psychotic structure. In psychoanalysis a person who is psychotic is considered outside of discourse – language in action. That is someone who doesn't understand the way people communicate or human discourse. A psychotic person will have a literal understanding of words, for them meaning is fixed. They can be unable to understand sarcasm, metaphors or irony. An example of the literal meaning that words take is a line from Buechner's 'Lenz'; “nur war es ihm manchmal unangenehm, dass er nicht auf dem Kopf gehn konnte.” (s79,line 9-11) This literally means that it was annoying to him that he could not walk on his head.

When treating a patient in psychoanalysis the first step will always be to establish whether this person is psychotic or neurotic as this will dictate largely how they are treated. A key difference in the treatement of psychotics as opposed to neurotics is that confronting a psychotic could trigger an episode. Psychotics are unable to admit that anything is their fault, blame is attributed exclusively outside the self. A clear indicator of psychosis is the absence of doubt. The patient will convince themselves of things that they then believe completely true regardless of how ridiculous they are. If they believe that the CIA is following them then there is no doubt for them that this is true. Nothing will convince them otherwise. Another indicator is the way in which they speak. As mentioned previously they take things very literally and their speech is often disorganised and random.

Other than direct confrontation there are a few things that can trigger a psychotic episode. A trigger is something that leads to a loss of the structure that holds them in place and created a hole in meaning that they cannot deal with. Psychosis is often triggered when the person is fully enmeshed in a dual relation with another person and a third – authoritative – figure threatens the equilibrium. For example the relation between a person and a job is threatened by the boss – authority figure – firing them. This is taking away that structure that holds them in place. A trigger is an unassimilable invasion of their fragile world. When a psychotic break is triggered it can manifest in several different ways. Delusions are a common symptom of psychosis. Psychoanalysis believes that delusions can be a good thing as they are created by the psychotic to explain the hole in meaning that was created by the trigger. A more radical option would be for the person to strike out violently. Another manifestation is catatonia, where a person won't speak or move for an extended period of time. This is seen as a refusal of language related to the fact that they never developed a trust in the symbolic law.

Psychoanalytical treatment of psychosis is centred around gaining the patients trust in order to learn their story and triggers with the aim of preventing any future psychotic breaks. This is quite the opposite of the psychiatric approach which is to treat the separate symptoms with medications. Sigmund Freud did not believe that it was possible to treat psychotics as they are outside of discourse, meaning he could not work with the transferance. He refused to take on patients that he had diagnosed as psychotic and would only treat neurotics. Lacan however believed they could be helped and in current times it is possible for psychotics to be treated by psychoanalysis.

Psychiatry believes that there is a group of illnesses which disrupt the functioning of the brain so much, they cause a condition called psychosis. When someone experiences psychosis they are unable to distinguish what is real — there is a loss of contact with reality. Most people are able to recover from an episode of psychosis. (http://www.sane.org/information/factsheets-podcasts/185-psychosis) The treatment of psychosis is the main focus of psychiatry as opposed to onset or development. When diagnosing psychosis a psychiatrist will establish symptoms and compare them with the DSM. If the patient is showing enough symptoms from a specific disorder they are diagnosed with this and treated accordingly. Contrary to in psychoanalysis, where it is believed that the psychotic structure develops at a very early age, psychiatry believes that psychosis is something that is developed later in life and only begins at the first episode and can be cured with medication. The causes of psychosis are unknown but research suggests that it can be hereditary, a result of psychoactive drug use (or triggered by drug use), a result of medical conditions and brought on or triggered by stress. The main psychiatric treatments available to people diagnosed with psychosis are medications or counselling.

The diagnosis of psychosis in both psychoanalysis and in psychiatry is based on different categories. In psychoanalysis there are three basic structures: neurosis, perversion and psychosis. Within these categories there are then sub categories, for example in psychosis there is: paranoia, schizophrenia, autism and melancholia (now called manic depression or bipolar.) There are very few categories in psychoanalysis as opposed to psychiatry. Psychiatry uses the DSM (Diagnostic and Statistical Manual of Mental Disorders) written by the American Psychiatric Association. The DSM categorises the different manifestations of psychosis into around 20 disorders within the section for diagnostic criteria. Where the DSM categorises these manifestations as disorders that must be treated externally (with drugs), psychoanalysis sees them as the order that one must work with. When treating psychosis in psychoanalysis the analyst works one by one with the speech of the patient. The most important diagnosis is between neurosis and psychosis as it is important that each one is dealt with differently. Within these diagnoses there are limited categories and the specific symptoms of the patient are taken into account and treated accordingly. In psychiatry psychotic disorders are diagnosed more systematically. The DSM contains a list of symptoms and all the psychiatrist must do is establish how many of these symptoms the patient is displaying. If they are displaying more than the required amount of symptoms related to a certain disorder they can be diagnosed. They are then treated with whichever medication is used for that disorder. Some respected theorists have suggested that it can be the drug companies that come up with the categories. For example bipolar suddenly became a common diagnosis when the patents began to run out on the biggest-selling mainstream antidepressants in the mid 90s. (Darian Leader, Strictly Bipolar, Penguin Books London 2013)

Although psychoanalysis and psychiatry may use the same umbrella term of psychosis, the way in which this is diagnosed and treated remains different.