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19/10.2022 - my great grandmother’s hand-sewn quilt tops are going on display at the magical little museum in randbøldal

[psychanalyse-et-psychopatho-blog]

Psychotic elementary phenomena and ordinary psychosis.

François Sauvagnat (Paru en danois: Sauvagnat F: Psykotiske elementær- fænomener og ordinær psykose. Drift; Tidsskrift for psykoanalyse, 1-2, 2013, p 27-44.)

Introduction

The phrase" ordinary psychosis" is currently extremely popular in Lacanian psychoanalysis, in spite of the translation problems that have occured: in South American Spanish, "ordinario" is frankly derogatory, to such an extent that some colleagues have preferred "psychosis actuales", on the basis of the Freudian idea of "actual neuroses" (neuroses in which no symptom formation is obvious). In the following lines, we will discuss three points. 1) The difference between "ordinary/extraordinary" psychoses 2)The relationship between "ordinary psychoses" and elementary phenomena 3) The advantages and limitations of the notion. From extraordinary psychoses... The phrase “ordinary psychosis” was coined around 1997-2000 (Conversation d'Arcachon and Conciliabule d’Antibes) to designate forms of psychosis that did not have the “extraordinary” quality of cases like Pierre Rivière, DP Schreber, Georg Cantor, Otto Gross, V Kandinsky, Attila Jozsef, Ernst Wagner, John Nash or Aimée, which have to some extent become "classical" cases. If we try to specify what has made them such, we find that they: 1) Displayed unequivocally and publicly psychotic pathology 2) Were able to bear witness of their mental functioning, most of the time by writing their memoirs and sometimes with such precisions that they were able to criticize the accuracy of psychiatric knowledge of their time. Most of them have been the starting-point or have been paradigmatic of psychopathological and/or psychoanalytic elaborations: Pierre Rivière has represented an extreme case of monomania, by his capacity to dispaly alternatively common sense, full-blown delusions, and lies; DP Schreber , in his memoir, writes a full blown critique of Kraepelin’s theory and demonstrates his capacities to stabilize his psychotic experiences by transforming them into a religion; Georg Cantor has not only magistrally contributed to set theory, but made it plain that his pathology played a major role in that; Otto Gross has been a major contributor to the concept of schizophrenia; V Kandinsky, thanks to his auto-observations, has been at the origin of the Kandinsky-Clérambault syndrome;Attila Jozsef has personally contributed to psychoanalytic theory, Ernst Wagner has described at length his delusions of relation, written theatre plays, and been cited as a living example of paranoia, John Nash has claimed that his delusions appeared to have the same accuracy as the probabilistic formulas he has created and Aimée has contributed ample documentation, not only of the various moments of her delusional experiences, but also of her poetic talents. 3) They caused to a large extent some stirring or even scandal by exposing their pathology, mainly because their mental abilities did not allow to think of them in terms of mental deficit as they showed exceptional creativity. 4) All of them have been considered as exemplarily demonstrative cases and used as such by prominent clinicians, who were able to underscore the unique qualities of these individuals. In other words, the reception of their subjective experiences was not less important in making them look “extraordinary”, than their own message. Pierre Riviere‘s case was discussed by alienists of the 1830ies long before Michel Foucault exhumed it; DP Schreber has been a major occasion of psychopathological debates, not only by his own psychiatrists, but also by S Freud and a whole array of major psychoanalysts including J Lacan; Georg Cantor’s case has allowed Imre Hermann to elaborate his mathematical phenomenological and psychoanalytic theory of manic-depressive states, and J Lacan to complete his theory of object a as a “frame”; Attila Jozsef’s case has been used as an argument in the discussions on psychotic transference, schizophrenia and psychotic borderline states; Ernst Wagner’s testimony has been used by Gaupp and Kretschmer to implement their idea that paranoia could be curable, and he was presented in several psychiatric congresses as the living proof of the existence of paranoia as a discrete entity; Aimée’s case has been amply used by J Lacan to justify his psychoanalytic and kretschmerian theory of personality. Although psychiatrists and psychoanalysts have not been very prolific on John Nash's case, a few remarkable publications have nevertheless underlined the specificities of his delusional style (Sergio Laia; Alain Cochet's doctoral dissertation). ...to low-profile "ordinary psychoses" Whereas these cases can be said to be exemplary in all these respects and in some way, heroic, there is little doubt that the great majority of persons with psychotic symptoms present a much lower profile. They are bound to appear much more “normal” to the man in the street, even if that term traditionally inspires some diffidence in Lacanian psychoanalysts; they would not elicit much more than a highly ambiguous diagnosis of “borderline personality” from psychiatrists and mental health personnel;to the outside observer, they would not show a clear-cut “triggering” or breakdown from a previous "apparently normal" state. In other words, they are not bound to inspire special interest, sympathy or passion to clinicians; and they are also bound to be misunderstood as neurotic or even perverse cases. In spite of all that, whenever they have the opportunity - or the willingness - to express what’s really on their mind, they would mention psychotic elementary phenomena. These cases have been termed, since the publication of the volume entitled “La psychose ordinaire”, ordinary psychotics. They are currently considered much more difficult to diagnose than “triggered psychosis”, and of course they also have opened a wide field of interrogations about what we really know concerning the mechanisms of stabilization or defences a psychotic subject is able to display. Among these interrogations: 1) Is this really a new paradigm, ie are these cases different from “classical psychoses”? 2) To what extent does the classical lacanian theory remain appropriate to understand such cases? 3) Should the theory of elementary phenomena be modified? Insomuch as the Lacanian theory of psychoses rests mainly on the notion of elementary phenomena, we will start with the 3rd question , and then try to answer the two others. What are psychotic elementary phenomena? The phrase “psychotic elementary phenomena” is still not familiar to clinicians belonging to the Anglo-saxon cultural domain, in spite of several publications that attempted to clarify what was at stakes. It is essential to the Lacanian diagnosis of psychosis, but has been widely misunderstood even in some French-speaking circles. As I have devoted a number of papers to this theme, I will try to summarize the main features of this notion. Its origin can be traced back to German and French psychiatry at the end of the XIXth century – mainly in the circles that tried to make the best of the new neurological knowledge gained in the study of aphasic syndromes after 1870. The general idea was of course that if neurological lesions could be proven in the various forms of aphasia, the same was likely to be found in psychotic symptoms since language pathology was conspicuous in them. In fact, although the phrase “elementary symptoms” is to be found in Kraepelin or Wernicke, "basic phenomena" in Clerambault, “elementary phenomenon” proper is much more characteristic of Lacan himself, and as we shall see, he gave it a special quality which was hardly to be found before him. To make a long story short, the failure to find neurological lesions univocally responsible for psychotic symptoms had lead most French clinicians to fall back on the notion of “psychological mechanisms” constituent of delusional states. The notion supposed that in a given clinical case, what the French called a "tableau clinique", by tactfully questioning the patient, you could trace out the different layers of the delirium, constituted by the action of these mechanisms; sometimes, these mechanisms appeared to function in a pure manner, other times they were mixted, some of them appearing more "primary" and others more "secundary". For instance, a psychotic individual attempting to murder a political leader could have experienced verbal hallucinations, and secondarily tried to explain them as the result of the evil deeds from the politician’s party, to finally arrive at the conclusion that he had to destroy this man in order to restore the laws of the universe. This was for instance the kind of explanation favoured by the followers of Magnan. However, Régis, who studied at length this sort of case (which he termed “regicides��) found that in a majority of cases, the primal phenomenon was delusional interpretation, ie a delusional insight, a sort of revelation in which the person found that he had a mission to save humankind, and from which he gradually deduced the necessity to uproot the current sovereign. Another example: in their classical description of the "illusion des Sosies" (what is currently called "Capgras syndrome"),Capgras and Reboul-Lachaux expose the case of a female patient who showed a combination of hallucinatory, interpretive and imaginary mechanisms; while some of the imaginary phenomena (she feels that she should save detained babies) represented on one side an attempt to explain auditory hallucinations, some others (the belief that her relatives were being modified) were influenced by interpretive mechanisms. In fact, the examination of the various kinds of elementary components of madness and their combinations became characteristic of French – and to some extent of German psychiatry (especially Carl Wernicke’s Breslau school) at the turn of the XXth century. By then, a number of mechanisms had been differenciated: - various forms of verbal hallucinations, ranging from very sensorialized to “silent hallucinations” that were practically indistinguishable from delusional interpretations, - delusional interpretations, ranging from mere intuitions to highly rationalized explanations - imaginary mechanisms, believed by some clinicians followers of Dupré to be at the root of psychotic mythomania and megalomania - discordance, a mechanism described by Philippe Chaslin as being fundamental in schizophrenia - delusional negation, a mechanism proposed by Cottard as being at the root of psychotic forms of depression (“mélancolie délirante”). Whereas these mechanisms enjoyed overall consensual recognition, other mechanisms remained more controversial, like “pathological passion”, a mechanism Clérambault presented as constituent of “pure erotomania” and other “psychoses passionnelles” ; and there was some uncertainty over the mechanisms underlying manic-depressive disorders. Besides, if these mechanisms appeared as mainly intellectual, they were understood as being paralleled by corresponding bodily experiences. For instance a persecutive idea determined by a delusional interpretation could, at times, be replaced by delusional hypochondria; mental or verbal discordance could also be expressed by bizarre motor antics and/or by disorders in body structuration; delusional negation was described by Cottard as a discreet state of mind, a sort of constant pessimism which could convert itself into the idea that the environment did not really exist anymore, and that the patient's own body was rotten, destroyed and immortal. Nevertheless, it was understood that in paranoia, the subjective experience of body structure remained relatively intact, whereas the distortions were maximal in schizophrenia. It was clear to everybody was that these mechanisms were intimate, “primary”, and that they usually were not easy to express. Most of the time, patients displayed secondary symptoms, some of them direct defences against the mechanisms, some of them negotiated with the environment, as Arnaud and Clérambault had demonstrated in some cases of délire à deux, called délires imposés where a frankly delusional patient practically negotiated the recognition and justification of some aspects of his delusional experiences with a significant other, this latter person being a neurotic ready to admit a banal and readily understandable persecutory claim, but nothing more. Now what were the main changes brought about by Lacan? To make a long story short once again, at least three things. Lacan seems to have, from the start, considered that the basic phenomena (as Clerambault for instance called them) should be called “phénomènes élémentaires” and considered as constituents of what he called “personnalité”. He did not deny that some biological causality might be involved to some extent, but considered that the Freudian “psychogénèse”, the “causalité psychique” had a crucial importance in the shaping of elementary phenomena, because elementary phenomena appeared as extreme forms of meaning. He subsequently described it as an imaginary phenomenon of defence (mirror stage), but later (in his “return to Freud”) portrayed it as directly related to the intimate structure of subjectivity. Another essential aspect is the relationship between transference and elementary phenomena. I have shown that in his seminal description of the “primary symptom” of paranoia, August Neisser claimed that these patients constantly insisted that their interlocutor "would know" why they were besieged by feelings of relation – Neisser was Serieux & Capgras’ main inspiration to describe the délire d’interprétation, a crucial reference in Lacan’s theory of paranoia. In other words, elementary phenomena implied a "subject supposed to know." A third point concerns the analogy between elementary phenomena and the structure of neurotic fundamental fantasy. There is at least one common point, the designation of the subject, obvious in the case of paranoia. Paranoiacs are beset by the feeling that they are being designated, looked at, spied on. Now what Freud has shown about neurotic fantasy in “A child is being beaten", is that in his most repressed fantasy, the neurotic represents himself as an object. This implied that there is a clear continuum from paranoia to neurosis. Schizophrenia might seem to be excluded from this, but in fact, most of them can be shown to be oscillating between moments when they are “bodyless”, “nameless”, and disorganized, etc, and moments when they manage to build up some paranoiac traits, for instance some delusional vocation. This is crucial for what follows. In fact, one can find in Lacan two streams that present a certain antagonism: 1) On one side, there is the idea that elementary phenomena are embedded in or even constituent of personality, ie, as I have written, that elementary phenomena are analogous to the neurotic fundamental fantasy; that is, neurosis should be considered as an -- extreme -- variety of psychosis. This notion is frankly expressed in the 1970ies with the RSI model, but it was also there previously, as we shall see. 2) On the other side, the idea, initially influenced by Edouard Pichon, that the difference between neurosis and psychosis rests on the fact that a certain loss has been accepted in neurosis, which has been denied in psychosis; this supposes a sort of a qualitative difference between neurosis and psychosis. One of the main reasons why the notion of "ordinary psychosis" was promoted is because some clinicians have tended to believe that the second aspect, ie, maximizing the differences between neuroses and psychoses, was the most important part of Lacan's teaching on the subject. I will contend that the notion of “ordinary psychosis” is important because it corrects several imprudent assumption: that Lacan’s concept of psychosis implied that psychosis had practically nothing in common with neurosis; or that elementary phenomena appeared exclusively a short time before the triggering of manifest psychotic disorders, and should be considered as belonging to an outdated part of Lacan's teaching. In fact, it is this viewpoint that should be seen as outdated, as it mainly rests on the notion that Lacan's concept of psychosis was processual, that is, followed a regular course. Here, I must quote a previous text, in which I tried to delineate what was at stakes with elementary phenomena : "Lacan has given to the expression ‘elementary phenomenon’ at least four sorts of meanings: 1. The possibility to isolate discrete pathognomonic symptoms. 2. The possibility to sort out in non-triggered psychotic cases minimal symptoms which can sum up most of the following delusional developments, in a way quite similar to the ‘fundamental fantasy’ in the neurotic cases. 3. The possibility to find hints of the modes of stabilisation’s that can be foreseen in a given patient. 4. Most of the elementary phenomena imply some sort of a ‘subject supposed to know’, which characterise the structure of the Other." Now it is quite clear that elementary phenomena are excellent candidates to account for discreet “ordinary psychoses”. Advantages and limits of the notion of "ordinary psychosis In non-Lacanian environments, cases that would currently be termed "ordinary pschosis" are usually diagnosed “borderline”. But of course, the problem is that “borderline” designates at least five different clinical issues (Sauvagnat 2004): - non-discernible psychoses - sexual orientation issues - “attachment problems” - acting out problems - character defense problems (what North Americans call “personality disorders”) To put it roughly, ordinary psychoses could roughly correspond to the first, ie the “psychotic borderline”; but the problem is that when one says “borderline”, one tends to think of the fifth, the Kernbergian “borderline personality syndrome”, which is an attempt to group these five distinct issues under the heading of personality disorders. In spite of that, one can consider that ordinary psychoses do correspond to pseudoneurotic schizophrenia cases, ambulatory schizophrenia, monomanias (XIXth century), abortive paranoias, psychotic as if personalities, and also of course the (true) bipolar before they are diagnosed as such. But it also invites us to think of the many other cases that have not been coined yet… because they are so ordinary. One thing is certain: "ordinary psychoses" cannot be considered as a specific or new entity; the phrase designates above all a clinical issue: the difference between what we know about psychoses and the quasi infinite variety of mental mechanisms a psychotic person can exert. Although one of the most frequently cited clinical examples given at the Conversation d'Arcachon concerned a schizophrenic subject whose functioning remained a mystery to his analyst (the patient felt "misty", in his own terms and finally displayed a full-blown negative therapeutic reaction), it is clear that one of the most inspiring cases was probably the one presented by JP Deffieux. This patient, who would in other times have been depicted as having an "as if" personality, was able to exert the most disparate callings, ranging from monk to prostitute, without ever seeming to be anchored to a minimally stable fundamental fantasy. But it is clear what is required here is to take seriously the last model Lacan has left us, the model of knotting, which implies that we should take as a starting point the type of difficult relationship schizophrenics have with their body - to them, "having", "possessing" a body is not an obvious phenomenon - but also the construction of the symptom. Many cases presented as exhibiting "ordinary psychosis" do not complain about a precise symptom, and obviously find it difficult to suppose a knowledge of the analyst concerning their difficulties; this makes them all the more ordinary, as ordinary citizens do not (or at least pretend not to) take their symptoms seriously. In this respect, they can be opposed to artists, of whom Aristotle claimed that their genius is always accompanied by "melancholia". If there is something the catch-phrase "ordinary psychosis" should invite us to do, it is certainly to study how these patients can, in effect, become more artistic. ------------------------------- References:

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