toward an integrated theory of schizophrenia*

Transcription

1 426 SCHIZOPHRENIA BULLETIN toward an integrated theory of schizophrenia* William N. Goldstein Introduction Freud's theory of schizophrenia was most explicitly put forth in 1911 in Psycho-Analytic Notes on an Autobiographical Account of a Case of Paranoia (the Schreber case) and in 1914 in On Narcissism: An Introduction. At that time Freud differentiated between schizophrenia and paranoia and explained his theory according to his concepts of libido theory. He noted that libidinal development proceeded from autoeroticism to narcissism and finally to object love. In schizophrenia he postulated a fixation point at the autoerotic stage (first 1 to 2 months); in paranoia, at the narcissistic phase (immediately following the autoerotic phase). Years later in the lives of individuals with early fixations, the outbreak of schizophrenic or paranoid symptoms would be brought about by a current stress. The current stress in paranoia was always thought to involve unconscious homosexual impulses, whereas in schizophrenia it might or might not involve homosexual impulses. The exact nature of the current stress in schizophrenia was left unclear. According to this theory, still advocated by some today, the outbreak of symptoms in later life would take place in a three-stage process and would be regulated by alterations in the economy of the libido. This process of altering the libido was seen in Freud's time ( ) to be analogous in both the neuroses and the psychoses. Stage one was thought to consist of the withdrawal of the libido from the objects in the external world (or from the mental repre- *Reprint requests should be addressed to the author at 1724 Evelyn Dr., Rockville, MD sentations of such). Stage two (which could be thought of as part of stage one) would consist of the withdrawn libido being placed on the ego. The ego would thus be hypercathected with libido, resulting in megalomania. This megalomania would correspond to a psychical mastering of the libido; a failure of this psychical function would result in the libido being placed onto the body itself, with a corresponding hypochrondria. Stage three would consist of an attempt at restoration, an attempt by the libido to recathect objects (or object representations). This would be the "restitutive stage" and would be influenced by the fact that the patient had regressed to the autoerotic or narcissistic stage of development. This would be the "noisy phase," the phase where the psychotic symptoms would be overtly manifest. In paranoia (with the corresponding narcissistic stage regression), reconstruction would be attempted by the mechanism of projection (with the corresponding delusions of persecution and grandiosity); in schizophrenia (with the corresponding earlier autoerotic stage regression), hallucinatory mechanisms would characterize the attempt at recovery. As stated, this three-stage process of alteration of the libido was seen to be analogous in the neuroses and psychoses. Stage one would be the same in both. Stage two in the neuroses would be characterized by the withdrawn libido being placed onto objects in phantasy rather than onto the ego. The libido being placed on objects in phantasy would correspond to a psychical mastery of the libido; a failure in this psychical function would result in the outbreak of anxiety. Thus an introversion onto phantasies in the neuroses would correspond to megalomania in the psychoses, and hypochondria in the psychoses would correspond to anxiety in the

2 VOL. 4, NO. 3, neuroses. Stage three in the neuroses would consist also of an attempt at restoration. Because the fixation point in the neuroses would be later than the narcissistic phase, the regression here would utilize more "mature" defenses such as conversion, reaction-formation, displacement, etc., and the symptoms would not result in a break with reality like those of schizophrenia and paranoia. Freud thought that because of the nature of the libidinal withdrawal in schizophrenia and paranoia, the patient could not form a transference and thus could not be treated by psychoanalysis. Despite the fact that Freud elaborated on aspects of schizophrenia in a number of later papers, he never revised his earlier theory of By the end of his life he had alluded to conflict in structural terms (regarding the psychoses), had stressed the importance of the ego in schizophrenic phenomena, and was utilizing a drive theory that included both libido and aggression. However, as stated, he failed to integrate his later ideas into a new theory of schizophrenia; and at death, his theory of schizophrenia remained largely unaltered (Pao 1973). The coming of the structural theory, the detailed elucidation of ego and superego formation and functioning, a drive theory based on the aggressive as well as the libidinal drive, and a comprehensive study of early object relations have necessitated a reformulation of Freud's theory of schizophrenia (Arlow and Brenner 1964; Pao 1973). In this paper we will examine selected aspects of more recent developments in the theory of aggressive drives, early object relations, and ego and superego formation. We will also briefly consider precipitating events, defenses, conflict, deficiency, regression, and transference in the development of schizophrenia. Then an attempt will be made to integrate these new concepts with Freud's original theory of schizophrenia. It should be noted that this paper will not attempt to review the literature on the subject. The goal will be to present a theory of schizophrenia that makes sense in view of post-freudian developments, utilizing only selected writings on the subject. It is hoped that this attempt will present a simple but fairly thorough way of viewing and understanding schizophrenia. The Kleinians and Aggression The importance of aggression was early recognized by Melanie Klein. The Kleinians believe that sufficient ego exists at birth to experience anxiety, to use defense mechanisms, and to form primitive object relations in phantasy and reality. The immature ego at birth is exposed to anxiety stirred up by the conflict between the life instincts and the death instincts (also present at birth). It is the relationship of the immature ego to these instincts at birth that characterizes the first 6 months of lifetermed the paranoid-schizoid position. During the paranoid-schizoid position, the whole idea is for the immature ego to get rid of the death instincts (the bad objects) and to retain the life instincts (the good objects). Thus the infant tries to retain (introject) the ideal (good) objects and to keep out (project) the bad objects. The leading anxiety of the paranoid-schizoid position is that the persecutory object (bad object, death instinct) will get inside the ego and overwhelm and annihilate the ideal (good) object and self. The mechanisms of defense of introjection, projection, splitting, primitive idealization, denial, and projective and introjective identification are utilized to get rid of this anxiety. When these defenses fail to master the anxiety, disintegration, fragmentation, and splitting into bits or fragments (bizarre objects) may take place in the ego and damage it. This is seen to happen when there is too much death instinct (congenital) or when the infant cannot keep the death instinct away from the ego because of a predominance of bad experience over good in the first 6 months (environmental). When this does happen, in essence, we have the basis for the development of schizophrenia (Klein 1946; Segal 1964). This account of Kleinian theory, although quite abbreviated, gives us some background to allow us to make some comparisons between Klein's and Freud's theory of schizophrenia. The fixation point for schizophrenia, according to the Kleinians, is seen to be during the first 6 months of life, similar to Freud. However, the psychodynamics and psychogenetics are explained in terms of the economy of the aggressive drive (death instinct) rather than of the

3 428 SCHIZOPHRENIA BULLETIN libido. The basic defect is seen to be an overabundance of aggressive drive. The current stress would always involve the flowing over of this aggressive drive rather than an upsurge of unconscious homosexual impulses. The normal defenses of splitting, primitive idealization, denial, and projective and introjective identification during the paranoid-schizoid phase, and the more pathological defenses of disintegration, fragmentation, and splitting of the ego into bizarre objects, are emphasized. In contrast to Freud, schizophrenics are certainly seen as capable of forming transference. It is the emphasis on aggression in schizophrenia, the description of the primitive defenses, and the idea that schizophrenics can indeed form transference that stand out as major contributions by the Kleinians to the conception of schizophrenia beyond Freud. The relationship of aggression to schizophrenia has been greatly elaborated on by Bak (1954) and Hartmann (1953) and will be discussed later in this paper. Early Object Relations Early object relations have recently been clarified and elucidated in detail by Margaret Mahler (1970). During the first year of life Mahler postulates the child going through an autistic phase (of approximately 1 month) during which he is oblivious to anything except himself, followed by a symbiotic phase (up to around 5 to 10 months) in which he views his mother (or primary love object) as an extension of himself. This is followed by a separation-individuation phase (lasting up to age 2 or 3) in which the child very gradually differentiates and separates himself from his mother and begins to establish his identity as a person in his own right. The autistic and symbiotic phases are actually very analogous to Freud's autoerotic and narcissistic phases, Freud's autoerotic stage actually lasting a little longer than Mahler's autistic. However, where Freud could not be specific about these phases, Mahler describes all aspects of the early years in detail. Emphasis is continually on the child, as his personality unfolds in relationship to the mother. It is Mahler's work of early childhood that has been for many the basis for understanding the psychogenetics of schizophrenia. Mahler herself thought that the early interaction between mother and child during the autistic and symbiotic stages was the key to determining whether an individual would become schizophrenic. She postulated schizophrenia occurring either when the mother provided inadequate mothering by her own right or when the mother was unable to provide adequately because of a greatly predisposed, oversensitive, and vulnerable infant (genetically). Searles (1968) utilizes Mahler's concepts and postulates that schizophrenia is the outcome when the mother-infant! symbiosis fails to resolve into individuation, or even worse, when the symbiosis fails to be firmly established. Federn's (1952) concept of defective ego boundaries is relevant here. Federn's concept of schizophrenia centers around the fact that schizophrenia is caused by defective ego boundaries. Because the boundaries are defective (decathected, to use his term), the schizophrenic has difficulty telling himself from others and his own ideas from external reality. Federn relates all schizophrenic symptoms to a breakdown of the ego boundaries. It is clear that his concept of defective ego boundaries is related to Mahler's symbiotic phase of development where the infant views the mother as an extension of himself (where he cannot distinguish his ego boundaries from those of his mother). Many writers besides Mahler have described the intricacies of the mother-child or familychild interaction during early childhood in attempts to elicit defects in this interaction that are specific for the development of schizophrenia. Implicit among this group of writers is the concept that something went wrong in the early family-child interaction that helped cause the child to become schizophrenic. Depending on which writer we listen to, the specific defect is thought to be caused by inadequacies of the mother, inadequacies (possibly of hereditary origin) of the child, or a combination of these. A number of different theories have evolved as to exactly what did go wrong in the family in these early years. Thus we have the popular

4 VOL. 4, NO. 3, concept of the schizophrenogenic mother, the double bind theory (Bateson et al. 1956), the concept of skewed and schismatic families (Lidz et al. 1957), the concept of "pseudomutuality" (Wynne et al. 1958), and others, all based on the intricacies of early infant-family interaction. Lewis Hill (1955) and Theodore Lidz (1973), among others, have excellent short books on this. The descriptions of the family interactions of many of the above writers go well beyond the first year of life, but it is thought that the initiation of these types of interactions certainly goes back to the autistic and symbiotic phases as described by Mahler. To overemphasize a point, whatever the specific defect in child-family interaction, it seems clear that the vicissitudes of the family-child interaction during the autistic and symbiotic phases are crucial to understanding the psychogenetics of schizophrenia. The Ego in Schizophrenia Freud's theory of schizophrenia predated his structural theory. "With the coming of his structural theory and the description and elucidation of the ego and the superego, new light has been thrown on the theory of schizophrenia. The concept of the schizophrenic having a defective ego (and superego) and the psychogenetics of these defects have become very important. Today there is controversy between a deficiency theory and a conflict theory of schizophrenia, the former ascribing schizophrenia mainly to a defective ego, the latter ascribing it mainly to structural conflict. One often hears that schizophrenia is an "ego disease" and many talk of the ego defects in schizophrenia as the predominant phenomena. Whereas these defects seem of obvious importance, it seems that this is sometimes overemphasized. Nevertheless it is quite important, and with the elucidating of ego functions one can now take an "ego inventory" and focus on the precise ego deficiencies in schizophrenic patients. Bellak (1958, 1970), Beres (1956), and Hartmann (1953) have all made outstanding contributions here. Bellak (1958) originally described seven ego functions: 1. Relation to reality, subdivided into three parts: (a) adaptation to reality, (b) reality testing, and (c) sense of reality 2. Regulation and control of drives 3. Object relations 4. Thought processes 5. Defensive functions 6. Autonomous functions 7. Synthetic function Bellak (1970) later added several other ego functions (i.e., judgment, adaptive regression in the service of the ego, and stimulus barrier) but the earlier list seems more useful. As stated, with the aid of these ego functions, one can take an "ego inventory" and evaluate a patient in terms of these differential ego functions. Bellak (1958, 1970) found that although there was marked variation statistically, the schizophrenic patient had low scores on all ego functions. He was able to compute numerical values for the various ego functions to make various predictions and prescribe various therapies for his patients. While one would not want to get "carried away" with this approach, assessment of the various ego functions would seem crucial in schizophrenic patients (and in any other patients, for that matter). In evaluating the various ego functions there are those who place special importance on the ego function of thought processes in schizophrenics. This all started with Bleuler's four A's (Bleuler 1911): autism, affect, association, and ambivalence, and since that time, disorders in thinking have been postulated by many as the specific defect in schizophrenia. Arieti (1955, 1970) certainly presents this point of view and Oppenheimer (1971) presents an exhaustive description of numerous thought disorders and their relationship to schizophrenia. This view of schizophrenia as a specific defect in thinking is fairly widespread and many have written on this topic. Whereas there is often a corresponding emphasis on a genetic (biochemical, hereditary, etc.) defect as the cause of the thought disorder, there are also those who attribute this defect to a regressive process of a psychological nature. In this paper, thought processes

5 430 SCHIZOPHRENIA BULLETIN will be viewed as important but as only one of many important ego functions when considering schizophrenia. Relation of Drives, Ego/Superego, and Object Relations Hartmann (1953) has contributed greatly to the psychogenesis of ego (and superego) formation and to discussing the ego defects in schizophrenia. He has helped clarify the relationships between ego (and superego) formation, instinctual drives, and object relations. In particular, he explains the relationship of aggression to ego functioning and to schizophrenia. Along with Kris and Lowenstein (Hartmann, Kris, and Lowenstein 1949) he states that in normal development, libidinal and aggressive energies are neutralized and then utilized for ego (and superego) formation. He particularly stresses the importance of neutralized aggression, although neutralized libido certainly contributes also. He emphasizes that the proper neutraliz 'on of aggression is a precondition for the formation of a mature ego. Although neutralization is necessary for all ego functions, special stress is laid on the defensive function. The relationship between an individual's ability to neutralize and good early object relations is noted. Hartmann (1953) postulates that in schizophrenia there is a defect in primary autonomous factors in the ego contributing to the vulnerability of defense and of neutralization. In other words, because of this defect, schizophrenics have difficulty neutralizing aggression and libido. Because neutralized energy is not available for the formation of the ego and superego, both these structures turn out to be greatly deficient. As a further consequence of this inability to neutralize, there is much unneutralized (free) libido and aggression in the schizophrenic. Both unneutralized libido and aggression can lead to great problems but the unneutralized aggression seems of more significance, often leading to explosive and unmanageable outbursts of rage and assaultiveness. Hartmann (1953) mentions that the relative inability of the schizophrenic to neutralize aggression (and libido) might well have a hereditary basis but he also correlates this inability with poor early object relations. His main contribution to the theory of schizophrenia is his correlation of the schizophrenic's inability to neutralize aggression with his defective ego (and superego) formation and with his early object relations. Robert Bak (1954) has elaborated on Hartmann's theory. Referring to Hartmann, he assumes that the ego's inability to neutralize the aggressive drives constitutes the core of the ego disorder. He further states that it is the upsurge of aggressive drive (either due to excess aggression or the inability of the ego to neutralize) that is the precipitating psychodynamic event in bringing about a psychotic reaction. Psychosis (schizophrenia) is thus seen as the outcome of the conflict between the ego and aggression. Defenses against aggression include withdrawal, projection, and varying grades of regression of the ego to the point of its undifferentiated phase. The Superego in Schizophrenia Compared to the ego, the superego has been relatively overlooked in the literature on schizophrenia. Regarding the superego, Hartmann (1953) refers to this structure as being defective in schizophrenia. It is described as having a low level of organization, of integration and differentiation, and a lack of stability or consistency. Hartmann (1953) relates this in some ways to the superego's relationship with the poorly formed ego. Pious (1949) is more specific in relating the schizophrenic's difficulties with the aggressive drive to defective superego formation. He postulates a defective superego in schizophrenia and a flooding of the psychic apparatus with death instinct because of this deficit. Hoedemaker (1955) relates the etiology of schizophrenia to the presence of overwhelmingly pathologic identifications from the early years and relates this to superego-like structures. It makes sense to view the superego in the

6 VOL. 4, NO. 3, schizophrenic as defective analogous to the way that we view the ego to be defective. The formation of the defective superego would be related to a failure to neutralize aggression, to poor ego formation, and to poor early object relations. Although a more detailed discussion of superego formation in the schizophrenic will not be attempted here, it should be mentioned that this would include a discussion of superego functions and a discussion of the psychogenetic formation of the superego beginning in the first year of life (superego precursors) and going at least through the oedipal period. Symptom Formation: The Role of Conflict Arlow and Brenner (1964, 1969) have utilized many of the post-freudian concepts in schizophrenia, as mentioned above, to propose their "conflict" theory of schizophrenia. They view symptom formation in schizophrenia as analogous to symptom formation in neuroses and explain the differences (delusions, hallucinations, breaks with reality, etc.) mainly on the basis of defensive disturbances in various ego functions under psychic conflict. They summarize the psychopathological characteristics of the psychoses that differentiate them from the neuroses in three ways: (1) that in psychoses the degree of instinctual regression or instinctual infantilism is greater; (2) that in psychoses there is a greater prominence of manifestations of the instinctual drive of aggression; and (3) most importantly, that in psychoses there are more widespread abnormalities of various ego and superego functions. They emphasize that these ego and superego abnormalities come about defensively under the initiation of psychic stress. With these assumptions in mind they' are able to explain all the various symptoms of schizophrenia. Thus the presence of symptom formation would be analogous in neuroses and psychoses. A psychic conflict would precipitate a regression that in the psychotic would be greater (to an earlier phase) than in the neurotic. The outcome of the defensive struggle between id and ego/superego would bring about the various symptoms. The degree of regression, the preponderance of aggression, and the (defensive) alteration of ego and superego functions would account for the severity of the symptoms in psychoses and neuroses. Arlow and Brenner (1964, 1969) cite much clinical data to support their findings. They emphasize the analogous processes of sympton formation in the neuroses and psychoses. Freud himself, when he put forth his theory of schizophrenia, also proposed analogous processes in neuroses, although these processes were much different from those discussed above by Arlow and Brenner. Much of Arlow and Brenner's theory seems sound. However, there does seem to be a relative deemphasis on disturbances in ego and superego functioning due to faulty endowment or maldevelopment (possibly based also on poor object relations) and a relative overemphasis on the defensive nature of these'disturbances. Arlow and Brenner (1964, 1969) see their theory as very much fitting the clinical data, but others (Freeman 1970) see Freud's original descriptions as more in line with clinical findings. The problem here may be due to the type of schizophrenic patients one chooses to observe or work with. The concept of schizophrenia encompasses such a vast variety of individuals that we really have to know what type of schizophrenic patients various writers are referring to when they make their conclusions. There are many schizophrenics that fit very neatly in Arlow and Brenner's conceptualizations; but there are also many chronically regressed, withdrawn, and autistic patients that might tempt one to reconsider Freud's original ideas on the subject. Nevertheless, I think even these very severe and chronic schizophrenics can be fitted into the broad outline of Arlow and Brenner's conception. Nathaniel London (1973) has published a relevant article in which he separates out of Freud's original theory two contradictory theories of schizophrenia. One (which he terms the unitary theory) asserts an essential continuity between schizophrenia and neurotic behavior, considers intrapsychic conflict and defense as primary determiners of schizophrenic behavior, and is somewhat analogous to the conception of Arlow and Brenner (1964, 1969).

7 432 SCHIZOPHRENIA BULLETIN The second (which he terms the specific theory) considers schizophrenia to be a unique psychological deficiency state resulting from decathexia of mental representation of objects. In general, London favors the latter theory. This paper will not be further discussed here, but it certainly is evidence that the controversy between the confljct and deficiency theories of schizophrenia continues today. An Attempt at an Integrated Theory We have briefly examined selected aspects of recent developments in the theory of schizophrenia. This paper will now conclude with an attempt to integrate these new concepts with Freud's original theory and to arrive at a simple but fairly thorough way of viewing and understanding schizophrenia. Freud originally distinguished between schizophrenia and paranoia. Schizophrenia was thought to have an earlier fixation point than paranoia, to the autoerotic instead of the narcissistic phase of development (Freud 1958). Today this distinction between schizophrenia and paranoia is sometimes made, but cases of "true" paranoia are rare to nonexistent. The idea of a more organized form of schizophrenia (paranoia) having a later fixation point than a more disorganized form (schizophrenia itself) is a good one. Thus the broad idea of fixation points in the first year of life for schizophrenia with the more organized forms of the illness having later fixation points remains valid. But we can best refer to Margaret Mahler's work on early object relations to help us with the psychogenetics of schizophrenia (Mahler 1970). We can thus say that the psychogenetic difficulty is usually during the symbiotic stage and less frequently in the autistic phase. The interaction between mother and child at this point is such that the child fails to resolve the symbiosis and to separate into an individual in his own right; or worse yet, that the symbiosis fails to be firmly established (Searles 1968). The concept of defective ego boundaries (Federn 1952) is intimately related to this. The mother-child interaction is of key importance. Poor object relations (between mother and child) can be seen to be due to a deficient child on a hereditary basis, or to a poor environment offered by the mother, or to both. Statistically speaking, the environmental influence would seem to be most important. Ultimately, the type of schizophrenia and the degree of severity would correspond to the quality of early object relations and the timing of early deficiencies in this mother-child relationship. Mahler (1970) has emphasized the early mother-child relationship; however, it is sometimes necessary to expand this concept of failure of the child-mother symbiosis to failure of the familychild symbiosis or to failure of the total family environment. Either way, the key factor here is a failure in the interaction between family and child. We can now invoke Hartmann and the ego psychologists to explain how poor object relations in the first year of life (and in later years also) are interrelated to the formation of a defective ego (Hartmann 1953). Ego formation, neutralization of the instinctual drives, and object relations are all intimately related. Poor object relations (plus possible hereditary factors) do not allow proper neutralization of the drives; and proper neutralization of the drives (particularly the aggressive drive) is a precondition for the formation of an effective ego. Thus we have the development of a defective ego in schizophrenia. This ego can be evaluated by its functions, as described by Bellak (1958, 1970) and Beres (1956). The precise deficiencies in object relations and drive neutralization will determine the exact ego deficits. Obviously the picture will vary from extreme deficits in all ego functions to lesser deficits in a selected few. Superego formation can be considered to be intimately related to early object relations (beginning in the first year and going at least through the oedipal period), to drive neutralization, and to e'go formation. With'poor early object relations and improper neutralization of the drives, superego deficiencies will occur in schizophrenia in a somewhat analogous manner to ego deficiencies. The exact deficits in the superego will depend on the precise deficiencies in object relations, drive neutralization, and ego formation. Difficulties in neutralizing aggres-

8 VOL. 4, NO. 3, sion will also help explain the severe aggressive and assaultive states often seen in schizophrenia. Thus in the first year of life the preconditions for schizophrenia are laid down. Under the influence of poor object relations (in the first year and continuing into later years) we have defects in the ability to neutralize aggression, plus defects in ego and superego formation. Although these defects can often be seen in the personalities and habits of the individual in his early years, the actual outbreak of schizophrenic symptoms often does not occur until adolescence or later. The precipitating event that evokes these symptoms was thought by Freud (1911) to be an upsurge of unconscious homosexual impulses in paranoia. (He was less specific in schizophrenia.) Klein (1946) and Bak (1954) have postulated the precipitating event to symptom formation to be an upsurge in aggressive impulses. Today we can postulate an upsurge of either the libidinal (heterosexual or homosexual) or the aggressive drive as the precipitating psychodynamic event. This upsurge in drive can be either absolute or relative (related to a weakening of the ego and/or superego) and can often be related to loss of object and loss of love. Any event that can alter the drive-ego/superego balance to a significant degree can be thought of as capable of precipitating symptoms. But almost by definition, it would seem that the formation of actual symptoms (based on increased drive) would imply psychic conflict. This brings us to the mechanism of symptom formation. It seems reasonable to invoke Arlow and Brenner's (1964, 1969) scheme of thinking here in place of Freud's original ideas (based on libido theory alone). With the coming of his structural theory, Freud revised his ideas on symptom formation for the neuroses, and it seems reasonable to do so for the psychoses also. Thus we have a precipitating event causing an upsurge of drive (absolute or relative) and stimulating psychic conflict. Libidinal and/ or aggressive drives are in conflict with ego and/or superego, however defective the latter might be. Symptoms would result as compromise formations from the battle between the drives and the defective ego and superego; they would depend on the nature of the ego and superego defects, the defenses utilized, and the ensuing regression. The regression would naturally be to the original period of difficulty, usually the symbiotic period. Defenses utilized in symptom formation would also be related to the ego defects and to the regression. Of course, with the regression all ego and superego defects would be accentuated. A typical defensive outcome (compromise) might be the production of delusions and hallucinations, and if and when these failed to restore order, more disorganized defenses as described by Klein earlier (Segal 1964) might emerge. Just as neuroses can be thought of as consisting of character (ego-syntonic) neuroses and symptom (ego-dystonic) neuroses, psychoses (or schizophrenia) can be conceptualized as consisting of ego-syntonic and ego-dystonic components. The ego-syntonic components would include various psychotic characterological traits (psychotic character). These traits would be based on character that was formed under the influence of ego and superego defects present since the early years. The ego-dystonic psychotic symptoms, in contrast, would only occur in response to current psychic conflict and to an ensuing regression to the symbiotic (or autistic) phase of development. There would be some overlap descriptively in what would be considered psychotic (schizophrenic) character as opposed to psychotic symptoms. For example, some types of thinking problems could be classified as either. Differentiation of '.psychotic character from psychotic symptoms would be made primarily according to the method of formation and would be analogous to the differences in neurotic character and neurotic symptom formation. Psychotic character would result directly from ego (and superego) deficiencies whereas psychotic symptoms would depend on psychic conflict, regression, and the superimposed ego (and superego) deficiencies. Finally, although this paper has avoided discussion of the relation of the theoretical issues to either clinical illustrations or more practical problems such as therapy, a few words will be

9 434 SCHIZOPHRENIA BULLETIN said about the therapeutic issue of transference. Freud, in utilizing his libido theory, felt that since the libido of schizophrenics was withdrawn to the ego or self it could not be utilized for the formation of transference. By utilizing a more modern theory than Freud's libido theory (as described above) we can conceptualize transference with schizophrenic patients as analogous to that with neurotic patients. But because of the nature (instability) of early object relations, the ego and superego deficits, and the primitive defenses employed, the transference can at times be much more difficult both to conceptualize and to utilize. A more detailed discussion of this or other therapeutic issues will not be attempted in this paper. Summary Freud based his theory of schizophrenia on a prestructural libido model. The coming of the structural theory, the detailed elucidation of ego and superego formation and functioning, a drive theory based on the aggressive as well as the libidinal drive, and a comprehensive study of early object relations have necessitated a reformulation of this theory. This paper has examined selected aspects of recent developments in the above areas and has made an attempt to integrate these new theoretical concepts with Freud's original theory. An effort has been made to arrive at a simple but fairly thorough way of viewing and understanding schizophrenia. Psychodynamics, psychogenetics, precipitating events, the drives, ego, superego, defenses, conflict vs. deficiency, symptoms vs. character, regression, and transference have all been discussed in regard to the above. References Arieti, S. Interpretation of Schizophrenia. New York: Robert Brunner, Arieti, S. The concept of schizophrenia. In: Cancro, R., ed. The Schizophrenic Reactions. New York: Brunner/Mazel, pp Arlow, J.A., and Brenner, C. Psychoanalytic Concepts and the Structural Theory. New York: International Universities Press, Arlow, J.A., and Brenner, C. The psychopathology of the psychoses: A proposed revision. International Journal of Psychoanalysis, 50:5-14, Bak, R. The schizophrenic defence against aggression. International Journal of Psychoanalysis, 35: , Bateson, G.; Jackson, D.; Haley, J.; and Weakland, J. Toward a theory of schizophrenia. Behavioral Science, 1: , Bellak, L. Schizophrenia: A Review of the Syndrome. New York: Logos Press, Bellak, L. The validity and usefulness of the concept of the schizophrenic syndrome. In: Cancro, R., ed. The Schizophrenic Reactions. New York: Brunner/ Mazel, pp Beres, D. Ego deviation and the concept of schizophrenia. The Psychoanalytic Study of the Child. Vol. 11. New York: International Universities Press, pp Bleuler, E. Dementia Praecox or the Group of Schizophrenias. (1911) Translated by J. Zinkin. New York: International Universities Press, Federn, P. Ego Psychology and the Psychoses. New York: Basic Books, Freeman, T. The psychopathology of the psychoses: A reply to Arlow and Brenner. International Journal of Psychoanalysis, 51: , Freud, S. Psycho-analytic notes on an autobiographical account of a case of paranoia. (1911) In: Strachey, J., and Freud, A. The Standard Edition of the Complete Works of Sigmund Freud. Vol. 12. London: Hogarth Press, pp Freud, S. On narcissism: An introduction. (1914) In: Strachey, J., and Freud, A., eds. The Standard Edition of the Complete Works of Sigmund Freud: Vol. 14. London: Hogarth Press, pp Hartmann, H. Contribution to the metapsychology of schizophrenia. In: Eissler, R.S.; Freud, A.; Hartmann, H.; and Kris, E., eds. The Psychoanalytic Study of the Child, Vol. VIII. New York-International Universities Press, pp Hartmann, H.; Kris, E.; and Lowenstein, R. Notes on the theory of aggression. In: Freud, A.; Hartmann, H.; and Kris, E., eds. The Psychoanalytic Study of the Child. Vol. III/IV. New York: International Universities Press, pp Hill, L. Psychotherapeutic Intervention in Schizophrenia. Chicago: University of Chicago Press, Hoedemaker, E. The therapeutic process in the treatment of schizophrenia. Journal of the American Psychoanalytic Association, 3:89-109, 1955.

10 VOL. 4, NO. 3, Klein, M. Notes on some schizoid mechanisms. International Journal of Psychoanalysis, 27:99-110, Lidz, T. The Origin and Treatment of Schizophrenic Disorders. New York: Basic Books, Lidz, T.; Cornelison, A.; Fleck, S.; and Terry, D. The intrafamilial environment of the schizophrenic patient: II. Marital schism and marital skew. American Journal of Psychiatry, 114: , London, N. An essay on psychoanalytic theory: Two theories of schizophrenia. International Journal of Psychoanalysis, 54: , Mahler, M. On Human Symbiosis and the Vicissitudes of Individuation. Vol. I. New York: International Universities Press, Oppenheimer, H. Clinical Psychiatry: Issues and Challenges. New York: Harper & Row, Pao, P. Freud's theory of schizophrenia. International Journal of Psychoanalysis, 54: , Pious, W. The pathogenic process in schizophrenia. Bulletin of the Menninger Clinic, 13: , back issues available Searles, H. Phases of patient-therapist interaction in the psychotherapy of chronic schizophrenia. In: Searles, H., ed. Collected Papers on Schizophrenia and Related Subjects. New York: International Universities Press, pp Segal, H. Introduction to the Work of Melanie Kleinijtiew York: Basic Books, Wynne, L.; Ryckoff, I.; Day, J.; and Hirsch, S. Pseudo-mutuality in the family relations of schizophrenics. Psychiatry, 21: , The Author William N. Goldstein, M.D., is Assistant Professor of Psychiatry, Georgetown University, and is associated with the Washington Veterans Administration, Washington, D.C. He is also in the private practice of psychiatry in Chevy Chase, Md. Two previously out of print back issues of the Schizophrenia Bulletin have recently been reprinted: Schizophrenia Bulletin, No. 1, December 1969 Schizophrenia Bulletin, No. 8, Spring 1974 If either or both of these issues are missing from your collection, let us know and we will send you a copy free of charge. Requests for back issues should be sent to the following address: Schizophrenia Bulletin, NIMH, 5600 Fishers Lane, Rm. 10C-26, Rockville, MD USA.

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