Ask an Analyst: Dr. Anna Shane is Queried

December 19, 2010

Today I received an interesting question, that may perhaps encourage a discussion about psychosis? Here it is:

I’ve read that in analysis the neurotic/hysteric faces lack or castration, but that with a psychotic you don’t work in the symbolic but in the imaginary register, and strengthen it because that’s what they have to hold on. How does one recognize, just by listening to someone talk, if he/she has a psychotic structure? The reason I ask is because I’m afraid of talking with someone and triggering a psychotic break.

Dr. Shane Replies:
Actually it’s easiest to diagnosis psychosis, and differentiate it from mere madness. It’s in speech, since the psychotic can speak but can’t utilize the properties of speech, which for us are metaphor and metonymy – everything the psychotic says is real, he really means it. In Shereber, the rays of the sun are real rays, no metaphor. You can find something similar in those with brain damage, some lose that ability, for example I once saw a guy with a head injury and I was giving him directions and said, go through the swinging door, which was at that time propped open, and he thought I was joking because it wasn’t actually swinging. In contrast, psychotics can’t get jokes, which doesn’t mean they haven’t learned to join in with laughing. It is possible to trigger an psychotic episode, by allowing a psychotic to blunder into some logical impossibility (which can happen if free association is encouraged) and then they freak out, or by pointing out a logical impossibility. I did that once, but then I figured it out in enough time and then just repeated her certainties, and she reconstituted, very scary, but I was just starting out then and I didn’t know how easy it was to bring out, I was clumsy. We don’t treat psychosis with psychoanalysis, for that reason, and also because it’s not something that can be reversed. When you speak about staying in the imaginary, that’s what it means, no access to the symbolic because it hasn’t been installed, so everything is too real, and way too scary. So, they come up with some delusion that explains their experience, that is also unfortunately and sometimes tragically real, and can lead to violence. It’s a miserable state to be in, just terror. You can find something perhaps on non-manifest psychosis, which can be diagnosed the same way, but where the psychotic has found a way to function. Those guys who always know the train schedules, and immerse themselves in those facts – that can be a way to cope. There is also something that used to be called psychotic reaction, which is where someone seems fine unless they get on the subject of some conspiracy theory, like the Kennedy assassination, and then you find their ‘certainty.’ Psychotics need certainty. But they can all be diagnosed through language, if your person has access to metaphor and can get a joke, then he doesn’t have that structure.

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