1 Mild Psychosis, the Body and Ordinary Psychosis

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1 Notes Introduction 1. In this book I use the term psychosis consistent with Lacanian nosology. In Lacanian theory, psychosis refers to a clinical structure and form of subjectivity distinct from both neurosis and perversion. Moreover, the clinical structure of psychosis is inclusive of various subtypes of psychosis, such as paranoia, schizophrenia and melancholia. In contrast, other nosological approaches, such as the DSM, utilise different terminology to refer to the same clinical entity. 2. Miller is a central figure in the French psychoanalytic tradition, and the World Association of Psychoanalysis provides seminars and courses for training analysts with a particular focus on the clinical and theoretical significance of Lacan s later teachings. The phrase Lacan s later teachings does not refer to a specific time period or set of ideas; however, it may roughly be situated in the 1970s, and, as Voruz and Wolf (2007) state, it is characterised by the reorganisation of fundamental psychoanlaytic concepts and the creation of new ones to theorise impasses and paradoxes inherent to psychoanalytic praxis. My book affirms this line of reasoning by examining the continuity and discontinuity in his theory of psychosis through investigating body phenomena in ordinary psychosis. 3. Theorists argue that an ordinary psychosis is difficult to diagnose, in part because it is a milder expression of psychosis with an atypical symptomatology. Thus, an ordinary psychosis does not constitute a new syndrome of psychosis; rather, it examines how classical forms of psychosis, i.e. paranoia, schizophrenia and mania, may emerge in relatively stable forms, such as when delusions and hallucinations are absent (Svolos, 2009). 4. I use the term onset when referring to the notion of the first psychotic episode and when discussing the idea of untriggered psychosis. In contrast, I use the phrase triggering events when referring to post-onset psychotic episodes I discuss these issues in detail in Chapters 4 and See issue 19 of Psychoanalytic Notebooks of the European School of Psychoanalysis for a collection of papers dedicated to the theme of ordinary psychosis. 6. Here Freud states the elucidation of the various mechanisms which are designed, in the psychoses, to turn the subject away from reality and to reconstruct reality this is a task for specialised psychiatric study which has not yet been taken in hand (1924 [1957], p. 186). 7. Lacan s classical theory of psychosis refers to the essays and seminars in the 1950s where the foreclosure of the Name-of-the-Father was first introduced (1958 [2006], 1993). 147

2 148 Notes 1 Mild Psychosis, the Body and Ordinary Psychosis 1. The neurosis/psychosis distinction provides a template for approaching clinical phenomena and, historically, formed the basis of classical psychiatry nosology (Beer, 1996). It remains central to Lacanian nosology and is a point I return to throughout this chapter. 2. See Maleval (2000) for a comprehensive Lacanian-oriented critique of BPD. 3. The severity dimension is a spectrum used to assess a range of factors such as suitability for psychoanalytic treatment and the form of which any psychoanalytic treatment may take. My focus on the severity dimension will outline the developmental assumptions underlying the deficit notion of psychopathology. 4. I use the term classical psychiatry to refer to the field of psychiatry that emerged in the nineteenth century around the ideas of Kraepelin, Bleuler and others (Cutting and Shepherd, 1987). 5. A third clinical structure, perversion, is also utilised in Lacanian theory (Dor, 1997), but will not be discussed here owing to its marginal status in the clinical field (Fink, 1997) and ongoing doubt over its nosological status (Miller, 2009). 6. Freud, like Jung, claims that hallucinations are attempts at recovery in schizophrenia. Despite this, I focus on Freud s text on Schreber, as this thesis has clearer import to my latter discussion of symptom formation in psychosis. For a discussion of the reparative function of hallucinations in psychosis see Vanheule (2011a, 2011b). 7. See Vanheule (2011b) for a slightly different reading on the status of the neurosis/psychosis distinction in Lacan s later teachings. 8. Sauvagnat, F. (2009) Elementary Phenomena and Ordinary Psychosis (unpublished manuscript). 9. Sauvagnat, F. (2009) Elementary Phenomena and Ordinary Psychosis (unpublished manuscript). 10. See also Sauvagnat, F. (2009) Elementary Phenomena and Ordinary Psychosis (unpublished manuscript). 2 Case Studies on Ordinary Psychosis and the Body 1. I analyse the three functions of the Name-of-the-Father operative in neurosis castration, identification and naming (Stevens, 2007) in Chapter Lacan makes this point throughout his teachings; for example, in L Etourdit he states that the schizophrenic s body is not without other organs, and that their function for each, is a problem for it by which the so-called schizophrenic is specified as being taken beyond the help of any established discourse (1972, p. 18). 3. Lacan s theory of the A-father is an important feature of his classical theory psychosis and its onset. In Chapter 5, I discuss the limitations of these ideas in cases of ordinary psychosis with reference to both the hole in the symbolic wrought by the foreclosure of the Name-of-the-Father and Lacan s idea of the real father derived from Freud s Totem and Taboo.

3 Notes Phallic signification and, more broadly, the phallic function, refers to the subject s regulation and organisation of jouissance under castration. Phallic signification structures the neurotic subject s relations with others, the imaginary body, sex, jouissance, symptoms and language. In Chapter 5, I explore disturbances to phallic signification and the imaginary in cases of ordinary psychosis by examining its relevance to the onset of psychosis. 5. These symbols are derived from Lacan s schema in On a Question Prior to any Possible Treatment of Psychosis (1958 [2006]). F 0 refers to the absence of phallic signification in the imaginary and is usually referred to as a consequence of P 0 or symbolic foreclosure. 6. Lacan states that in psychosis, feminisation of the male subject may occur owing to the foreclosure of the signifier the Name-of-the-Father. More specifically, the subject s feminine identification is attributed by assuming a passive position with an imaginary father: this relation is characterised by aggression, rivalry and erotic tension (Fink, 1997). Moreover, feminine identification occurs as a result of the absence of a phallic signifier. Sexual difference is not inscribed in the phallic function; as such, sexual identity is not assumed via the normative neurotic pathway. 7. In this article, Lacadée implies that there has been no clear onset of psychosis. He maintains that the emergence of invasive anxiety and the subsequent modulation of this experience via the hairdryer functions to deter the onset of psychosis. 8. As the Trésor de la langue française indicates, the term frigore is not, strictly speaking, a neologism; rather, it is a Latin medical term designating, among other things, forms of facial paralysis that may be caused by the common cold virus ( A frigore: Définition, n.d.). However, despite this, the emergence of perplexity that accompanied its verbalisation supports the notion that this signifier appeared in the real, as opposed to the symbolic. In addition, for Virginie, the signifier s facial paralysis and cold are significant, as she discovered the dead body of her infant brother; her description of this event is centred on stillness on the deceased s face (Lacadée, 2006). 9. In this case, although there was no unequivocal evidence of the onset of psychosis, it is highly probable that it occurred in Adam s history prior to engaging in psychotherapy. 10. The case material featuring Adam is taken from my own clinical practice. 11. The history of a head injury raises the question concerning the existence of a traumatic brain injury; unfortunately, Adam refused to seek any additional medical treatment, despite repeated encouragement to do so. This issue of organic brain injury is, of course, an important consideration, as there may be an organic basis to his psychiatric signs and symptoms. However, despite the absence of medical assessments, as all of his signs and symptoms existed prior to the head trauma except for the involuntary watery eye the assumption of a non-organic psychosis remains plausible. 3 Modern Psychiatry and Lacan s Theory of Psychosis 1. From a diagnostic perspective, it is important to note that not all automatisms reflect an underlying psychosis: automatisms are a necessary condition for a

4 150 Notes psychosis, although not a sufficient condition. In de Clérambault s theory of psychosis, multiple types of automatisms, which emerge across different functional modalities (motor, sensory, mental), are required to make a diagnosis of psychosis (Hriso, 2002a). In contemporary psychiatry, the idea of automatism is used in a narrow sense, referring to automatic acts with an unconscious motivation (Sadock and Sadock, 2003). 2. See also Sauvagnat, F. (2009) Elementary Phenomena and Ordinary Psychosis (unpublished manuscript). 3. It is important to differentiate the concept of foreclosure from the foreclosure of the Name-of-the-Father; in Lacan s later teachings, the concept of foreclosure becomes more important and is not necessarily associated with psychosis. I explore the theoretical importance of the term foreclosure in Chapter 5 in the broader context of triggering events. 4. See Vanheule (2011b) for an in-depth discussion of the delusional metaphor in the Schreber case. 5. Lacan s theory of psychosis does not provide a clear aetiology of how a psychotic structure emerges. This is owing primarily to the supposition that the subject will take an active stance in relation to the Other; thus, it is not possible to say what events predict psychosis as doing so effectively discounts the stance the subject takes in response to such events. Furthermore, while severe traumatic experience, particularly attachment trauma in earlier childhood, is often linked to severe disturbances, including psychosis, it has no necessary link to it. This position differs from other approaches (Hammersley et al., 2008) in which an unequivocal link is made between severe trauma/abuse and psychosis emerging later in life. 6. In these papers, Miller refers to incomplete triggering events, as opposed to the onset of psychosis, when referring to triggering events on the imaginary plane. I return to this issue in Chapter See also Sauvagnat, F. (2009) Elementary Phenomena and Ordinary Psychosis (unpublished manuscript). 4 Competing Lacanian Views of Psychosis and the Body 1. Freud identified five distinct formations of the unconscious: symptoms, dreams, jokes, bungled actions and the lapsus. 2. Freud s use of the term actual neurosis traverses the neurosis/psychosis distinction as it is inclusive of three distinct clinical syndromes: anxiety neurosis, neurasthenia and hypochondriasis ( [1957]). For a description of how Freud uses the term actual neurosis throughout his psychoanalytic writings see Laplanche and Pontalis (1973), The Language of Psycho-analysis. 3. The Diagnostic and Statistical Manual of Mental Disorders 4th Edition, Text Revision (2002) generalized anxiety disorder has its nosological antecedents in Freud s theory of the actual neuroses (Tyrer and Baldwin, 2006). 4. Freud s theory of the actual neuroses has been particularly influential in the area of psychosomatic theories of illness; see McDougall and Cohen (2000), Aisemberg and Aisenstein (2004), Taylor (2003) Verhaeghe (2004) and Verhaeghe et al. (2007) for a discussion of these issues.

5 Notes It is important to note that in Freud s early work in particular, the term psychoneurotic included psychotic phenomena. 6. Verhaeghe (2004) uses the term the actualpathological position of the subject when referring to the clinical phenomena outlined by Freud s idea of the actual neuroses; moreover, like Freud, his approach to actualpathological states moves across the diagnostic spectrum: neurosis, psychosis and perversion. Although my discussion focuses on actualpathological states in psychosis, the mechanism underlying actualpathology the failure of the Other to adequately mirror and hence modulate the subject s endogenous drive tension is applicable to neurosis, psychosis and perversion. 7. See Vanheule (2011b) for a good discussion of Lacan s idea of the object a in psychosis. 8. Verhaeghe (2004) uses the term the psychopathological position of the subject when referring to what Freud (1894a [1957]) called the neuro-psychoses of defense ; this includes hysterical neurosis, obsessional neurosis, anxiety hysteria and paranoia. What these entities have in common is that primary process mechanisms are active determinants in symptom formation. 9. References to infant/mother mirroring theories in the work of Winnicott (mother s holding function), Kohut (maternal mirroring function) and Bion (maternal containment) are an important part in Fonagy s work; in essence, Fonagy et al. (2002) state that their infant mother research provides an empirical basis in support of other psychoanalytic developmental theories derived from clinical experience. 10. An array of different mentalisation theories abound in Anglo-American psychoanalysis (Bouchard and Lecours, 2004; Godbout, 2005; Lecours, 2007; Mitrani, 1995); for a recent historical survey of how this term is used see Bouchard and Lecours (2008) Contemporary Approaches to Mentalisation in the Light of Freud s Project. 11. Disturbances to phallic signification in the imaginary are discussed in Chapter 5. 5 Revisiting the Body in the Onset of Psychosis 1. Akhtar s (1984) paper on identity diffusion provides a contemporary reading of as-if personality types, although his account is more expansive in addressing six core features of identity disturbance: incompatible identity traits, temporal discontinuity in the self, lack of authenticity, feelings of emptiness, gender dysphoria and ethnic/moral relativism. 2. Although this is not Stevens case, he provides a detailed description of the patient s history and symptomatology centred on the fibromyalgia. 3. I address the functions of the Name-of-the-Father in psychosis in Chapter See Sauvagnat, F. (2009) Elementary Phenomena and Ordinary Psychosis (unpublished manuscript). 5. To propose, as some clinicians sometimes do, that the psychotic subject is incapable of using or understanding metaphor is patently untrue; Lacan s theory of paranoid psychosis, which is built around the idea of a delusional metaphor, refutes this claim.

6 152 Notes 6. Although Wachsberger contends that there is no theory of unchaining prior to Lacan s introduction on the term, the focus on the accidental cause triggering psychosis is evident in the works of Kraepelin, Bleuler and others in the modern psychiatric tradition. 7. Of course, Lacan (1958 [2006], 1993) leverages this point of difference when developing his theory of foreclosure, as opposed to repression and disavowal. 8. Ruth Mack Brunswick was a psychiatrist and psychoanalyst who underwent training with Freud, and who remained a confidante and colleague until Freud s death. 9. Castanet and De Georges (2008) also contend that Lacan s focus on topology and knots provides an alternative model that addresses this impasse in localising triggering events to either P 0 or F 0 ; they claim that a focus on the symptomatic knotting and rupture on the real, symbolic and the imaginary (RSI) addresses this impasse. However, the utility of this position remains to be seen, as this point is not developed in detail. Moreover, although other theorists (Skriabine, 2004) also claim that an unknotting of the RSI correlates with the onset of psychosis, these claims remain undeveloped. In general, the clinical and theoretical significance of Lacan s research in topology and knot theory remains to be articulated in a comprehensive manner. 6 Ordinary Psychosis, Stabilisation and the Body 1. For example Harari (2002) uses this term in his monograph on Joyce. Here, foreclosure is an unavoidable dimension of psychic reality. The lack of signifier is constitutive of subjectivity and this form of foreclosure is normative to the speaking being. 2. S 1, the master signifier, and the Name-of-the-Father are central to Lacan s later teaching; ostensibly, the S 1 takes on the function of the Name-of-the- Father. 3. Lacan, J. ( ) RSI (trans. T. Chadwick), The Seminar of Jacques Lacan, , Book XXII (unpublished) and Lacan, J. ( ) Joyce and the Sinthome (transl. C. Gallagher) The Seminar of Jacques Lacan, , Book XXIII (unpublished). 4. Lacan, J. ( ) RSI (trans. T. Chadwick), The Seminar of Jacques Lacan, , Book XXII (unpublished). 5. One speculative consequence of this is that neurosis is closer to psychosis than previously thought. This also corresponds to the shift from categorical diagnosis (either neurosis or psychosis) to the logic of the set where neurosis and psychosis are elements belonging to the same set. Lacan s statement that we are all mad is actually a thesis that reorients clinical and theoretical inquiry to the structure of psychosis. See Miller (2007b, 2009) and the recent publication We re all Mad Here (Brousse and Jaanus, 2013). 6. Although some theorists refer to catatonia in terms of the unknotting of the real, symbolic and the imaginary (Sauvagnat, 2000), I focus on Miller s (2009) lexicon concerning the hole in the Other and the supplementary function of the signifier, as this corresponds with his line of inquiry in the field of ordinary psychosis.

7 Notes Lacan, J. ( ) Joyce and the Sinthome (transl. C. Gallagher) The Seminar of Jacques Lacan, , Book XXIII (unpublished). 8. Lacan, J. ( ) Joyce and the Sinthome (transl. C. Gallagher) The Seminar of Jacques Lacan, , Book XXIII (unpublished). 9. See Harari (2002) for an exposition of Joyce that critiques the notion of stabilised psychosis and that he was psychotic. 10. Lacan, J. ( ) Joyce and the Sinthome (transl. C. Gallagher) The Seminar of Jacques Lacan, , Book XXIII, p. XI 15 (unpublished). 11. Lacan, J. ( ) Joyce and the Sinthome (transl. C. Gallagher) The Seminar of Jacques Lacan, , Book XXIII (unpublished). 12. Schatzman s (1973) analysis of the Schreber case focused extensively on trauma, body discipline and psychotic symptomatology through examination of the sadism shown by the father toward the son. Schatzman uses the term transform to theorise how the father s pathology and harsh disciplinary methods, especially those involving the body, are transmitted to the son and, in particular, how this manifests in psychotic phenomena. Although his analysis does not constitute a primary focal point in this discussion, the important point to make here is that Schatzman s discussion of the Schreber case highlights how the subject s corporeal history figures in psychotic symptomatology. 13. In addition, Adam s conversations with his mother centred on whether his grandmother s life needed to be ended when it was; although he did not accuse his mother of thoughtlessly making this end-of-life decision, he was preoccupied and anxious about this topic, which highlights the persecutory relation between them. 14. The case material featuring Adam is taken from my own clinical practice. 15. Medical evaluations do not show any organic basis for the painful body phenomena. Although Deffieux (2000) considers the diagnosis of hysterical neurosis and conversion disorder, both he and the treatment team arrive at the diagnosis of paranoia with hypochondriasis owing to the invasive nature of jouissance on the body and the existence of paranoid traits. He concludes that it is a case of hypochondriasis in the paranoid spectrum, an observation that correlates with Freud s description of actual neurosis in psychosis (Freud, [1957]) and Verhaeghe s (2004) theory of actual pathology in psychosis. However, unlike these approaches, which emphasise the delusion as a form of recovery in the stabilisation of psychosis, another form of symptomatisation emerges to localise jouissance. 16. Freud s case history of hysteria, featuring Elizabeth von. R., is of interest here: she experienced leg pain at the spot where her father rested his foot when she was nursing him through his recovery (Freud and Breuer, [1957]). In this vignette, the body phenomenon was considered a conversion symptom due to operation of repression and displacement: Freud argues that a psychical conflict derived from forbidden sexual wishes were the key factors underlying this formation of the unconscious. Moreover, Miller s notion of body events contrasts with Verhaeghe s (2004) theory of body phenomena in psychosis the later stresses the endogenous excitation of the body and the failure of signifiers coming from the Other to regulate the internal drive tension, rather than the jouissance-riddled effects that language has on the subject.

8 154 Notes 17. See Harari (2002, p. 228) for a discussion of the term parlêtre. 18. Lacan s use of the term swarm in conjunction with the master signifier implies that S 1 is a plurality of signifiers that can be articulated into knowledge as the S 1, the swarm or master signifier, is that which assures the unity, the unity of the subject s copulation with knowledge (1998, p. 143). 19. One might consider autism to be another example of where the symbolic is equivalent to the real. However, as infantile psychosis emerges prior to the acquisition of language then this clinical structure has additional complexity. See Lefort (1980) for a Lacanian approach to autism. Afterword 1. Vanheule s (2011b) recent book on Lacan s theories of psychosis provides a useful discussion of topology, the real, symbolic and imaginary (RSI), and psychotic structure. His claim that Lacan viewed knot theory as a formal language, similar to other branches of mathematics and logic, is a useful starting point for orientating oneself to the knotting of the RSI in terms of onset, triggering events and stabilisation in a psychotic structure.

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18 Index actual neurosis, 74, 78 9, 81 2, 150, 153, 162 actual pathology, 153 A-father, 37, 41, 45, 68 9, 95, 102 4, 106, 108 9, , 114 anxiety, 36 7, 44, 45 8, 73 4, 78 82, 86 9, 105, 109, 120, 133, as-if phenomena, 10 12, 90, 96, 151, 144 attachment theory, 73, 80, 82 3 automatisms, 2, 52, 56 9, 61, 70, 149 athematic, 53 4, 58 60, 64 affective, 56 7 mental, 56 8, 63 4, 107 motor, 56 7 sensory, 56 7 volitional, 56 7 Bleuler, 2, 14 15, 55 7, 148, 151, body events, 37, 116, 135 6, , 153 Borromean knot, 44 code phenomena, conversion symptoms, 34, 73 9, see also neo-conversions de Clérambault, 52 4, 56 61, 63 4, 70, 149 delusional metaphor, 34 5, 43 4, 60, 65, 80, 89, 91, 125, 131, drives, 22, 81 2, 86 7 DSM, 1 3, 6-9, 13 17, 54 5, 147 elementary phenomena, 29, 32 3, 42, 49 50, 52 4, 61, 63 8, 70 3, 77, 92, , 133 4, 137, 140, 142, 144 5, 148 enigma, 35, 37 8, 45, 50, 65, 68, 70, 109, 111, 113, , see also perplexity formations of the unconscious, 21 2, 72 4, 76 8, 82, 86, 92, 124 7, 150 Freud, 4, 5, 11 12, 14, 21 4, 28, 59, 61, 66 7, 69, 72 5, 75 6, 79, 80 1, 91 2, 96, 102, 104 6, 121, 124, , 147 8, 150 1, 153 hole, 33, 36, 62 5, 69, 73, 88, 94, 96, 100 3, 108, , , 142, 152 hypochondriasis, 15, 17, 26, 34, 39, 42, 62, 69, 79 80, 86 8, 105 6, 108, 133, 137, 144, 150, 153 imaginary identification, 5, 11 12, 31, 38 9, 42, 45, 48, 51 2, 72, 95 7, 99, 102 3, 121, 135, 141 2, 144 interpretation, 48, 88, 89, 131, 137 jouissance localisation, 24, 37, 39, 42 3, 50, 75, 133, 139 Others, 37, Joyce, 98, 116, 120 2, 125 8, 138, 152 Kripke, language disturbance, 19, 33, 63 5, 94, 103, 107 8, 133 Mack-Brunswick, 69, 104 6, 151 madness, 1, 3, 63 matheme, 103, 131, 140 message phenomena, 131, metaphor, 19, 22, 51, 65, 87, 101, 103, 124, 126, 129, 151 paternal, 115,

19 166 Index metonymy, 42 3, 65, 126, 129, 136 mirroring, 56, 73, 81 7, 89 90, 92, 151 Name-of-the-Father, functions, 115, , 121 2, 125, 130, 142, 148, 149, 151 as supplementary device, 118 narcissism, 10 11, 45, 69, 96, 106, 111 negative symptoms, 14, 16, 57, 96 neo-conversions, 28, 72, 77, 79, 91, 100 neologism, 43, 63 4, 127, 132, 149 neurosis, obsessional, 21, 69, 76, 104 5, 151 hysteria, 21, 74 6, 79, 151, 153 object a, 81, 86, 121, 124, 151 perplexity, 18 19, 44, 63 4, 68, 70 1, 87 8, 92, 126 7, 131 3, 149 perversion, 12, 147 8, 150 phallic function, 38, 69, 94 5, 100 1, 106 8, , 149 psychiatry, contemporary, 1 2, 6, 8 9, 11 17, 20 1, 29, 54 5, 57, 59, 90, 149 modern, 1 2, 53 5, 59 60, 63, 67, 69 71, 149, 152 psychoanalytic diagnostic manual [PDM], 9 10, 96 psychosis schizophrenia/paranoia dichotomy, 23, 31 2, 34, 88, 91, 93, 115, 148 negative symptoms, 14, 16, 57, 96 positive symptoms, 16, 26 reality testing, 9 10 repression, 7, 11, 21, 32, 61, 74 7, 79, 96, 104, 118, 120, 151, 153 rigid designator, Schreber, 23, 61 2, 65, 108, 132, 148, 150, 153 sexuality, 39 41, 69, 94, 101, 108 9, , 131 signifier in the real, 33, 43, 45, 53, 64, 66, 70, 72 3, 77, 116, 121, 122 3, , , 142 signifying chain, 33, 45, 60, 63 5, 87, 101 3, 107 8, 125 6, , sinthome, 5, 29, 43 5, 52, 73, 95, 98, 116, 120 2, , 132 5, 142, transference, 8, 32, 39, 41, 86, 88 9, 144 topology, 145, 151 2, 154 unary trait, 121 untriggered psychosis, 4, 11 12, 25, , 113, 133 4, 147 Verwerfung, 61 Wolf man, 61, 68 9, 104 7,