1
Psychologist , Doct oral St udent , e- m ail: lim iranda78@hot m ail.com ; 2 Nurse, Professor, e- m ail: isane@uol.com .br. Cam pinas St at e Universit y, Medical Sciences School, Brazil
Disponible en castellano/ Disponível em língua portuguesa SciELO Brasil w w w .scielo.br/ rlae
THE TRI GGERI NG OF PSYCHOSI S AND I TS CLI NI CAL TREATMENT I N SUBSTI TUTI VE MENTAL
HEALTH EQUI PMENT: A THEORETI CAL CONTRI BUTI ON I N THE FREUDI AN PERSPECTI VE
Lilian Mir anda1
Débor a I sane Rat ner Kir schbaum2
Miranda L, Kir schbaum DI R. The t r igger ing of psychosis and it s clinical t r eat m ent in subst it ut ive m ent al healt h equipm ent : a t heor et ical cont r ibut ion in t he Fr eudian per spect ive. Rev Lat in am Enfer m agem 2007 set em br o-out ubr o; 15( 5) : 942- 8.
The pr esent st udy goal w as t o build a fr am ew or k based on t he Fr eudian psy choanaly sis in or der t o under st and t he psychosis m ode of pr oduct ion. The m et hodology consist ed of cont ent analysis of t er m s r elat ed t o t he concept st udied. Based on t he assum pt ion t hat t he psychot ic sym pt om s are a result of a fixat ion on t he pr im ar y n ar cissism , w e con clu de t h at t h e f u sion of lif e an d deat h pu lses, as w ell as t h e egoic con st it u t ion t hrough ident ificat ion processes in t he oral phase, can keep t he individual t ied t o prim it ive figures of ident ificat ion and prevent him ( er) from m aking new libidinal invest m ent s, which lead t he individual t o feel a const ant t hreat and deat h in life. The at t em pt s m ade by t he psychot ic person t o escape from t his st at e of deat h and t o relat e w it h ex t er nal r ealit y ar e ex pr essed in for m s k now n as sy m pt om s, such as delusions and aggr essiv eness.
DESCRI PTORS: m ent al healt h; psy choanaly sis; m ent al disor der s
EL ACCI ONAR DE LA PSI COSI S Y SU CLÍ NI CA EN LOS EQUI POS SUBSTI TUTOS DE LA
SALUD MENTAL: UNA CONTRI BUCI ÓN TEÓRI CA EN LA PERSPECTI VA FREUDI ANA
Est e t rabaj o t iene com o obj et ivo const ruir un m arco esclarecedor del m odo de producción de la psicosis, según el referencial t eórico del psicoanálisis freudiano. La m et odología consist e en analizar el cont enido de los t ex t os que t r at an de los t ér m inos v inculados al concept o en foco. Tom ando por base el supuest o de que los sínt om as psicót icos result an de una fij ación en el narcisism o prim ario, concluim os que la fusión de las pulsiones de vida y de m uer t e, j unt o con la const it ución del yo por m edio de pr ocesos de ident ificación en la fase or al, pueden m ant ener al individuo suj et o a prim it ivas figuras de ident ificación e im pedido de hacer nuevos invest im ient os libidinales, lo que le im pr im e una const ant e sensación de am enaza y de m uer t e en v ida. Los int ent os que el psicót ico pr esent a par a escapar de est e est ado de m uer t e y r elacionar se con la r ealidad ext er na son expr esos baj o las form as que conocem os com o sínt om as, por ej em plo los delirios y los cuadros de agresividad.
DESCRI PTORES: salud m ent al; psicoanálisis; t r ast or nos m ent ales
O DESENCADEAMENTO DA PSI COSE E SUA CLÍ NI CA NOS EQUI PAMENTOS SUBSTI TUTI VOS
DE SAÚDE MENTAL: UMA CONTRI BUI ÇÃO TEÓRI CA NA PERSPECTI VA FREUDI ANA
O obj et ivo dest e t rabalho é const ruir um quadro esclarecedor do m odo de produção da psicose, t endo a psicanálise fr eudiana com o r efer encial t eór ico. A m et odologia ut ilizada foi a análise de cont eúdo dos t ex t os que cont inham os t erm os ligados ao conceit o a ser est udado. Baseando- se no pressupost o de que os sint om as psicót icos advêm de fixação no nar cisism o pr im ár io, conclui- se que a fusão das pulsões de vida e de m or t e e a const it uição egóica, por m eio de pr ocessos de ident ificação na fase or al, podem m ant er um indivíduo ligado a f igu r as pr im it iv as de iden t if icação e im pedido de f azer n ov os in v est im en t os libidin ais, o qu e lh e im pr im e const ant e sensação de am eaça e de m or t e em v ida. As t ent at iv as que o psicót ico apr esent a de fugir desse est ado de m or t e e de se r elacion ar com a r ealidade ex t er n a são ex pr essas sob as f or m as qu e se con h ece com o sint om as, a ex em plo dos delír ios e dos quadr os de agr essiv idade.
I NTRODUCTI ON
W
it h t he adv ent of t he Psy chiat r ic Refor m , w h ich st ar t ed in Br azil at t h e en d of t h e 7 0 s, t h eint er pr et at ion and ex planat ion of psy chot ic suffer ing
and of it s t r eat m ent possibilit ies hav e gone t hr ough
s e v e r e c h a n g e s . N o w a d a y s , i n v o l u n t a r y
h osp it alizat ion an d t h e u se of in v asiv e t h er ap eu t ic
t echniques w it hout clear cr it er ia t o j ust ify it , ar e not
r ecom m en d ed an d r est r ict ed b y f ed er al law s( 1 ). I n
addit ion, t he int ervent ionist m et hods, whose paradigm
was based on t he asylum m odel( 2), were crit icized and
overcom e t hrough t he effort s of m ent al healt h workers
i n v o l v ed w i t h t h e i d eo l o g i ca l , so ci a l a n d p o l i t i ca l
proposals of t he ant i- asylum fight and of groups linked
t o t h e Un iv er sit y an d scien t ific societ ies, con cer n ed
wit h t he invest igat ion and im plem ent at ion of et hically
based t echnologies( 3 ).
Som e st u dies, h ow ev er, in dicat e t h at t h ose
w ho int er v ene daily in psy chot ic pat ient s, especially
n u r si n g p r o f essi o n al s, w h o ar e r esp o n si b l e i n t h e
or ganizat ional cult ur e of healt h ser v ices for const ant
co n t a ct w i t h p a t i e n t i ssu e s r e l a t e d t o se x u a l i t y,
m ed icat ion u se an d ad m in ist r at ion of p at ien t liv es’
r o u t i n e , r e p o r t co m m o n a n d i n t e n se u n p l e a sa n t
feelings of im pot ence and confusion w hen facing t he
p o s s i b i l i t i e s o f i n a d e q u a t e m a n a g e m e n t , o f t e n
p r e v e n t i n g t h e m f r o m r e s p e c t i n g t h e p a t i e n t s ’
alt er it y( 4).
Ot her st udies show t hat par t of t he cur r ent
su f f er in g of p r of ession als lin k ed t o t h e Psy ch iat r ic
Ref or m is du e t o a lack of t h eor et ical su ppor t t h at
focuses on t he basic pr inciples of psy chot ic pat ient s’
m ent al funct ioning and offer st r uct ur al elem ent s for
underst anding t he hum an being from t he point of view
of psychosis or of an em ot ional world( 5). The pat ient s
p r e s e n t p r o c e s s e s t h a t e x p r e s s t h i s p s y c h i c
f u n ct ion in g w h en t h ey r ep or t t h eir ex p er ien ces of
p e r s e c u t i o n , b o d y a l t e r a t i o n s a n d f e e l i n g s o f
d e p e r so n a l i za t i o n , a s w i l l b e i l l u st r a t e d t h r o u g h
exam ples at t he end of t his art icle.
Based on t his assum pt ion about t he need for
f u r t h er t h eor et ical in st r u m en t s t o w or k in cu r r en t
m ent al healt h equipm ent , and aim ing t o cont ribut e t o
t hese w orkers’ educat ion and pract ice, in t his art icle,
t h e a i m i s t o t h eo r i ze o n t h e p r o cess o f p sy ch i c
form at ion t hat can t rigger psychot ic experiences. The
explanat ion will be based on t he st udy of psychosexual
d ev el o p m en t , f o r m a t i o n o f t h e eg o a n d p u l si o n a l
dualit y, concept s for m ulat ed by Sigm und Fr eud( 6).
METHODOLOGY
This is a Concept ual St udy, whose t heoret ical
r ef er en ce is Fr eu d ian p sy ch oan aly sis. Th e m et h od
u sed w as sk im m in g of all t ex t s t h at con t ain ed t h e
t e r m s n a r ci ssi sm , p u l si o n a l l i f e , p u l si o n a l d e a t h ,
psy chosis, dem ent ia, par anoia, nar cissist ic neur osis,
m elan ch oly, delir iu m an d h allu cin at ion , in dicat ed b y
t h e n am e in d ex of t h e Com p let e Wor k of Sig m u n d
Fr e u d . Ne x t , i ssu e s a r e se l e ct e d l i n k e d t o w h a t
t rigger s psychosis and cont ent analysis is per for m ed,
b ased on t h r ee t h em at ic cat eg or ies: p sy ch osex u al
developm ent , t he concept of pulsional deat h and t he
r e l a t i o n b e t w e e n t h e s e t w o t h e m e s a n d e g o
for m at ion( 7 ).
RESULTS AND DI SCUSSI ON
The for m at ion of t he ego
Fr om t h e p er sp ect iv e of p sy ch oan aly sis( 8 ),
healt h is m arked by t he possibilit y of genuine cont act
wit h t he ot her, t hat is, by m om ent s in which t he hum an
b ein g is cap ab le of ack n ow led g in g an d ov er com in g
alt er it y an d , in v iew of t h e d if f er en ce, cap ab le of
f er t ilizin g, allow in g f or biological pr ocr eat ion , w h ich
p er p et u at es t h e sp eci es, an d t h e sy m b ol i c, w h i ch
pr oduces t he cult ur al and m at er ial goods fr om one’s
so ci a l e n v i r o n m e n t . Th e co m p l e t i o n o f a h e a l t h y
developm ent for m an occur s w hen ( s) he r eaches t he
genit al phase, w hen ( s) he is able t o r epr ess his( er )
n ar cissist ic in t er est s in f av or of a gen it al ch oice of
par t n er s, a ch oice t h at im plies t oler an ce of w h at is
relat ed t o a not - I( 8).
How ev er, t h is ab ilit y t o ch oose is acq u ir ed
t h r ou gh a com plex dev elopm en t cou r se, in it iat ed in
t h e f i r st m o m e n t s o f l i f e , w h e n t h e b a b y i s st i l l
i m m e r s e d i n n a r c i s s i s m a n d i s u n a w a r e o f t h e
ex ist en ce of an y on e else, t h ou gh ( s) h e depen ds on
ext ernal care t o survive. The int eract ion process wit h
t h e w o r l d a n d w i t h t h e i n t e r n a l p u l si o n a l l i f e i s
r esp on sib le f or t h e f or m at ion of t h e p sy ch e in t h e
baby( 9- 10). Nev er t heless, t her e ar e som e v icissit udes
o n t h i s p a t h t h a t ca n i n cu r i n m e n t a l su f f e r i n g ,
including psy chosis( 11- 12).
Sev er al aut hor s( 8- 9) affir m t hat , for psy chot ic
p at ien t s, r ealit y g en er ally is in v asiv e an d scar in g ,
m u ch m o r e t h an f o r t h o se w h o su f f er f r o m o t h er
causes t er r ible sensat ions of par anoia and r eact ions
t hat can appear in a cont inuum from affect ive blunt ing
u p t o h et er oaggr essiv en ess.
I n a Fr eu d ian p er sp ect iv e, t h e r elat ion sh ip
hum an beings est ablish wit h t he ext ernal world is built
b y t h e e g o : “ a co h e r e n t o r g a n i za t i o n o f m e n t a l
processes”( 10), whose t ask is t o cont rol t he approaches
o f d i sch a r g e o f e x ci t a t i o n t o t h e e x t e r n a l w o r l d ,
super v ise all m ent al pr ocesses and t est r ealit y.
A baby, at t he beginning of his( er) life, relat es
w it h t h e ex t er n al w or ld b ecau se s( h e) n eed s it t o
survive, but does not recognize t he world as det ached
from ( him ) herself. The cont act wit h t he m ot her offers
pleasur able sensat ions or iginat ed fr om t he sat iat ion
of hunger, but t hen associat ed t o t he st im ulat ion of
t he m out h m ucosa and several ot her sensorial st im uli,
su ch a s sm el l s a n d so u n d s. Th i s en t i r e sen so r i a l
ex p er ien ce is in cor p or at ed b y t h e b ab y an d leav es
m arks, or t races, which get organized in order t o form
in t his baby an individual way of int eract ing wit h t he
w or ld( 8).
At t h e sam e t im e as t h ese sen sor ial t r aces
a r e b e i n g i n t e r n a l i z e d , t h e b a b y, b a s e d o n t h e
ex p er i en ce o f su ck i n g , i n i t i a t es a p r o cess t h a t i s
an alogu e t o t h e act of dev ou r in g an d in cor por at in g
t h e m ot h er ’s im age, as s( h e) f eels h er. S( h e) does
n ot con cr et ely d ev ou r s or at t ack h er, b u t d esp ises
som e aspect s t hat belong t o her and assim ilat es, in
him ( her ) self, ot her s, w it hout concer n ( because t her e
i s n o c o g n i t i v e c o n d i t i o n t o d o i t ) w i t h h e r
su b j ect i v en ess. Th e t r aces o f t h i s w h o l e co m p l ex
in cor p or at ion is f or m in g t h e b ab y ’s eg o an d g iv es
him ( er) t he feeling, even if st ill vague, of possessing
a s u b j e c t i v e w o r l d . H o w e v e r, t h i s r e f e r s t o a
r elat ion sh ip t h at f or t h e baby is f elt as su ch , sin ce
( s) he is unaware of anyone else t han him - / herself t o
r elat e w it h. I n t he per iod w hen t he for m at ion of t he
e g o i s i n i t i a t e d , e v e r y t h i n g ( s) h e l o v e s, t h a t i s,
everyt hing t hat gives him / her pleasure, is felt as being
him - / herself, w hich t herefore configures a narcissist ic
st at e( 11- 12).
Regar ding t he concept of pleasur e, it should
be clarified t hat , in t he t heoret ical perspect ive adopt ed
her e( 13), t he only obj ect iv e of all liv ing beings is t he
com plet e absence of st im uli, so t her e is no need for
m o v e m e n t s t o w a r d s t h e w o r l d , w h e r e p o s s i b l e
answ er s for one’s dem ands ar e found. How ever, t his
st at e can nev er be obt ained because biological bir t h
i m p l i es t h e ex i st en ce o f i n t er n a l st i m u l i , su ch a s
hunger, and ex t er nal ones like light . I n v iew of t his
fir st im possibilit y, im posed by life, t he hum an being
get s sat isfied w it h a st at e of const ant st im uli or no
dist ur bance. Associat ed t o ot her fact or s, such st at e,
as show n below , per m it s t he for m at ion of t he ego.
The for m at ion of t he ego and t he pulsional t heor y
The descript ion of t his ego form at ion process
is based on t he idea t hat all of us possess a pulsional
deat h, a power t hat works t owards t he non- m ovem ent .
I t is not necessarily an effort for physical deat h, but a
direct ion t owards a st at e of non cont act wit h aspect s
of life t hat im ply fur t her st im uli. The pulsional deat h
st im ulat es t he living being t o m aint ain his( er) affect ive
ex pect at ions as t hey w er e or iginally r ecor ded in t he
p sy ch e, w it h ou t t h e n eed f or ar d u ou s at t em p t s t o
co n n e ct t h e m t o r e p r e se n t a t i v e t h a t m a k e t h e m
socially shar eable( 1 3 ).
Join t ly w it h pu lsion al deat h , t h er e is in t h e
o r g a n i s m a p o w e r t h a t p u s h e s t o w a r d s t h e
d e v e l o p m e n t o f i n t e r a ct i o n p o ssi b i l i t i e s w i t h t h e
ext ernal world and cont act wit h one’s own needs: it is
t he pulsional life( 13). This pow er w ould help us in t he
t ask of associat in g p sy ch ic r ep r esen t at iv es t o t h e
affect ion w e ex per im ent , giv ing t hem r epr esent at ion
of t he word( 14). I t is only t hrough t hese represent at ions
t hat w e can com m unicat e w it h t he w or ld, m aking us
underst and and com prehend ot her people’s dem ands.
At t he sam e as t he ego, by it s ident ificat ion
an d su blim at ion w or k , h elps t h e pu lsion al deat h t o
ob t ain con t r ol ov er t h e lib id o, it also w or k s in t h e
accum ulat ion of a lot of libido, wit h desires t o live and
be loved( 10).
Wh at is p ar ad ox ical an d at t h e sam e t im e
br in gs t h e k ey t o an u n der st an din g of psy ch osis is
t h a t t h e p u l si o n a l d e a t h , so m e t i m e s, a l so w o r k s
t owards life. As explained before, any person’s m ent al
su r v iv al r eq u ir es t h e ex ist en ce of an eg o, ev en if
r u dim en t ar y ; an ego t h at begin t o f or m it self f r om
incor por at ions of obj ect s. How ev er, t he st udy of t he
t h eo r y o f p u l si o n s sh o w s u s t h a t t h i s p r o cess o f
incor por at ion can only be under st ood by t ak ing int o
account t he work of t he pulsional deat h, because t hat
is what pushes t he baby t o annihilat e t he obj ect and
dest r oy it s alt er it y, t hus per m it t ing it s incor porat ion,
aft er w hich t he ident ificat ion pr ocess occur s, w hose
m arks will form t he ego and, consequent ly, t he baby’s
own way of dealing wit h him ( er) self and wit h int ernal
an d ex t er n al st im u li( 1 2 ). Th u s, lif e in it iat es t h r ou g h
I n a n o r m a l d e v e l o p m e n t p r o c e s s , t h e
pulsional life, act ing concom it ant ly w it h t he pulsional
d e a t h , w o r k s i n s u c h a w a y t h a t t h e b a b y c a n
ex p er im en t ot h er f or m s of p leasu r ab le sen sat ion s.
On ce t h is b ab y h as a r u d im en t ar y eg o, ( s) h e can
different iat e what belongs t o him - / herself, even t hose
t hings t hat are closely linked, but are part of anot her
realit y, which in som e ways are det ached from his( er)
eg o. Wit h t h is p er cep t ion , ( s) h e f aces t h e n eed t o
invest in an ext ernal world, so ( s) he m anages t o find
t h e a n s w e r s t o h i s ( e r ) n e e d s a n d d e s i r e s . Th i s
invest m ent requires t he pulsional life t o work in order
t o perm it a connect ion bet ween affect ions and m ent al
r ep r esen t at iv es.
W h e n e v e r y t h i n g i n t h i s m o v e m e n t o f
c a t e c h i z a t i o n o f t h e e x t e r n a l r e a l i t y h a p p e n s
r e a s o n a b l y w e l l , t h e b a b y a b a n d o n s p r e v i o u s l y
incorporat ed obj ect s and m anages t o connect t o ot her
f igu r es, especially t h e pat er n al on e( 1 1 ). Th u s, ( s) h e
can experience t he Oedipus com plex and acquire t he
abilit y, t o a great er or lesser ext ent , according t o how
t his experience occurred, of perceiving t he ot her and
r e l a t e w i t h h i m ( e r ) . Ma k e s l o v i n g ch o i ce s, g e t s
in v olv ed w it h t h e alt er it y an d can pr odu ce m at er ial
an d sy m b o l i c g o o d s, b esi d es g en er at i n g ch i l d r en ,
perpet uat ing t he life of t he species( 13). However, when
t h e r e a r e i n t e r c u r r e n c e s i n t h i s p r o c e s s , s o m e
diseases are t riggered, including psychosis, addressed
b elow .
Th e dev elopm en t of psy ch osis
I n t h e ca se o f t h o se p eo p l e w h o p r esen t
psy chot ic suffer ing, it is obser v ed t hat t her e w as no
nor m al dev elopm ent unt il t he Oedipus Com plex . The
psychosis is creat ed from a fixat ion in t he narcissist ic
phase and a consequent difficult y t o abandon t he first
ob j ect s of id en t if icat ion( 9 ). How ev er, t h is d if f icu lt y
i m p l i e s a f i x a t i o n i n f i g u r e s i n c o r p o r a t e d a n d
int roj ect ed from deat h processes, t hat is, people who
cannot abandon t heir fir st obj ect s and inv est in t he
ex t er nal r ealit y in a less dest r uct iv e w ay ar e alw ay s
focused on figur es w hose alt er it y w as annihilat ed by
t h e i d en t i f i ca t i o n p r o cess. Th u s, t h ey m a n a g e t o
ca t ech i ze o n l y t h em sel v es a n d b eg i n t o l i v e i n a
const ant st at e of nar cissism( 12).
I t is im port ant t o st ress t hat , for t he individual
under developm ent , t he fixat ion in narcissism im plies
sev er e d if f icu lt ies t o ack n ow led g e t h e ex ist en ce of
t h e o t h e r - t h e p a t e r n a l f i g u r e - w h o p o sse sse s
ascendancy ov er him and can im pose lim it s. His/ her
libido goes t hr ough t he ot her phases of developm ent
m a r k e d b y f i x a t i o n , w h i c h p r o d u c e s e v e n m o r e
fix at ions and v icissit udes.
I n t his cont ext , when t he Oedipus com plex is
experienced, t he abilit y t o deal wit h frust rat ion is very
r e d u ce d a n d , co n se q u e n t l y, i n t e n se p r o ce sse s o f
r e g r e s s i o n t o p r e v i o u s p h a s e s o f p s y c h o s e x u a l
developm ent occur, especially t o t he oral phase. Facing
p r ob lem s t o d eal w it h t h e im p ed im en t s an d lim it s
im plicit in cont act wit h t he ot her, t he individual t ends
t o st ay fix ed on t hose figur es ( s) he int r oj ect ed, not
abandoning t hem in favor of an acknow ledgem ent of
h is ow n f ailu r es an d n ot b ein g ab le t o m ak e n ew
invest m ent s in t he ext er nal w or ld( 9,11,14).
An individual wit h a narcissist ic fixat ion always
get s involved w it h obj ect s t hat are deeply associat ed
t o t h e f ir st f igu r es in cor por at ed. I n v iew of h is/ h er
in v olv em en t s, h e n ev er aban don s h is/ h er obj ect of
love, because his( er) ego is t he obj ect ; however, when
a frust rat ion in relat ion t o t he obj ect occurs, whet her
in t h e r eal or im agin ar y w or ld, t h e ego is also t h e
cause of frust rat ion, since it is com plet ely m ixed wit h
t he obj ect . I nst ead of abandoning and at t ack ing t he
obj ect , t h e in div idu al aban don s an d at t ack s h is/ h er
ow n ego, becau se t h e obj ect as an ex t er n al en t it y
does not ex ist .
The obj ect r elat ion in t he par anoia
What paranoiacs is concerned, it is concluded
t h at t h eir p er secu t in g ob j ect s ar e ob j ect s of lov e,
b ecau se t h ey ar e ch osen , n ar cissist ically, t h r ou g h
int r oj ect ion and ident ificat ion pr ocesses. I n or der t o
defen d t h em selv es fr om t h e su ffer in g t h ese obj ect s
cause, t hey m ak e use of t he pr oj ect ion m echanism ,
put t ing t he t hr eat on som eone w ho possesses, ev en
i f a t t h e u n c o n s c i o u s l e v e l , s o m e s i m i l a r i t y o r
connect ion w it h t heir per secut ing obj ect( 9).
Becau se h e does n ot bear t o lose t h e f ir st
obj ect of ident ificat ion, psychot ic pat ient s t end t o keep
t h em sel v es i n an i n er t st at e, n o t acq u i r i n g o t h er
o b j e ct s f r o m t h e g e n i t a l p h a se . Th e r e f o r e , t h e y
exper im ent a const ant deat h t hr eat , w hose sour ce is
t heir fir st and ir r eplaceable obj ect of lov e. They ar e
t r ap p ed b ecau se, f r om t h e p er sp ect iv e of cr eat ion
t h r ou gh iden t if icat ion , t h ey ar e t h e delir iou s obj ect
it self( 9- 10).
When t he person suffers frust rat ions im posed
fixat ions were m arked. A regression t o t he narcissist ic
phase im plies a ret urn t o t he libido at t hat m om ent in
life when t he individual had all his dem ands m et and
cou n t ed w it h t h e cer t ain t y of self- su f f icien cy. I t is
exact ly in t his narcissist ic phase t hat t he t races of t he
f i r st sen so r i a l ex p er i en ces a r e f o u n d , t r a ces t h a t
ret urn t o regression, but ret urn t o t he form t hey were
m ar k ed , i n sm el l s, sou n d s, t act i l e sen sat i on s an d
f r a g m e n t e d a n d d i st o r t e d i m a g e s, t h u s cr e a t i n g
hallucinat ions, t he classic psy chot ic sy m pt om( 12).
Tr y ing t o get out of t he self- absor pt ion and,
in a way, t o int eract wit h t he world, t hat is, t rying t o
c u r e t h e m s e l v e s , p s y c h o t i c p a t i e n t s c r e a t e
e x p l a n a t i o n s f o r t h e i r h a l l u ci n a t i n g e x p e r i e n ce s,
developing delirious t hat j ust ify t he const ant sensat ion
of deat h in life.
Tw o cases of p sy ch osis ab ou t w h ich Fr eu d
m a d e i n t e r e st i n g a n a l y se s ca n b e t t e r cl a r i f y t h e
pr ocesses descr ibed her e. The fir st is about a j udge
w ho w r ot e a book of m em or ies( 1 5 ) in w hich he t ells
about his psy chot ic ex per ience. He descr ibes sev er al
sy m p t om s t h at cou ld b e g r ou p ed in h y p och on d r ia,
r elat ed t o int ense feelings of body t r ansfor m at ion, in
which t he j udge believed t o be dead and decom posing,
o r f e l t h i s b o d y w a s b e co m i n g a w o m a n ’s b o d y,
b esi d es t h e p er cep t i o n o f a co n n ect i o n w i t h Go d .
Joint ly w it h t hese sensat ions, he built a delir iun t hat
he w as being per secut ed and unfair ly har m ed by his
d o c t o r Fl e c h s i g , w h o m a f t e r a p e r i o d o f d e e p
a d m i r a t i o n S c h e r e b e r b e g a n t o a c c u s e o f t h e
m u r d er in g of sou ls. I n ad d it ion , ov er t im e, h e g ot
v eh em en t ly in v olv ed w it h m y st ical- r eligiou s delir ia,
b eliev in g h e h ad t h e m ission t o r ed eem t h e w or ld
and rest it ut e it t o a st at e of beat it ude.
B a s e d o n h i s b o o k o f m e m o r i e s , Fr e u d
analyzes Schereber( 9), proposing t hat t he persecut ion,
r el i g i osi t y, em ascu l at i on an d sel f - r ef er en ce d el i r i a
w er e under st ood as m ent al m anifest at ions, lik e any
ot her im pulses of t he hum an m ind. Aft er careful and
d e t a i l e d d e scr i p t i o n a n d a n a l y si s o f t h e r e l a t i o n
Sch e r e b e r m e n t i o n s h e h a d w i t h h i s d o ct o r a n d
post er ior per secut ing figur e, Fr eud pr oposes t hat t he
o r i g i n o f t h e d el i r i a a n d p a r a n o i a w er e l i n k ed t o
sexualit y. He explains t hat , when Schereber felt him self
aut hor ized t o assum e a posit ion of higher pow er, or
w hen, at an adv anced age, he r ealized he could no
longer have a son t o cont inue his lineage, he revived
narcissist ic conflict s of prim it ive origin. He t hen affirm s
t hat t he root of all paranoia lies in t he first phase of
libido dev elopm ent , accor ding t o pr ev ious asser t ions.
The acquisit ion Schereber m ade of a posit ion
o f h i g h e r a u t h o r i t y w o u l d c o r r e s p o n d t o t h e
in t en sif icat ion of lib id o w h ich , b ein g t oo p ow er f u l,
sought an escape t hr ough t he w eak est point , in t his
case narcissism . Since, in t his period of psychosexual
d ev elop m en t , t h er e is n o ch oice of ob j ect y et , t h e
m ovem ent of t he libido is hom osexual ( t he person is
his own t arget of love invest m ent ) and, consequent ly,
in t he case of par anoiac disease, conflict s link ed t o
hom osex ualit y em er ge. This giv es r ise, for ex am ple,
t o t he delirium of em asculat ion and love for t he doct or
which, in a process of inversion - since t he ego would
n ot b ear su ch lov e - b ecom es t h e p er secu t or. Th is
n ar cissist ic r egr ession pr ov ok es t h e en lar gem en t of
t h e ego, sin ce all t h e libido is deposit ed in it an d,
t hus, t he m egalom ania, ex per ienced by t he r elat ion
wit h God and t he t ask of saving t he world.
A y e a r a f t e r d e d i c a t i n g h i m s e l f t o t h e
Schereber case, Freud published anot her st udy about
t h e r e l a t i o n o f p a r a n o i a w i t h n a r c i s s i s m a n d
h om osex u alit y : A case of par an oia t h at con t r adict s
t h e psy ch oan aly t ic t h eor y of t h e disease( 1 6 ). I n t h is
ar t icle, h e r epor t s on t w o in t er v iew s h e h ad w it h a
lady referred t o his office by a lawyer. She had sought
legal help because she felt persecut ed by a m an wit h
whom she had had an affair, but her lawyer, suspicious
o f a d i s e a s e , r e f e r r e d h e r f o r a p s y c h o a n a l y t i c
consult at ion. As she saw her self follow ed by a m an,
Fr e u d i n i t i a l l y s u s p e c t e d b e a c a s e t h a t w o u l d
cont radict t he hom osexualit y in t he origin of paranoia.
Ho w e v e r, a f t e r a m o r e d e t a i l e d i n v e st i g a t i o n , h e
r ealized t hat t he lady had a hom osex ual r elat ion ( at
an unconscious level of fant asy) w it h her m ot her, for
w h o m sh e r e n o u n ce d f r o m h e r e n t i r e so ci a l l i f e ,
j u st if ied b y t h e n eed t o t ak e car e of h er, an d sh e
reinforced t his relat ion in t he professional cont act wit h
her boss. By allowing herself t o get sexually involved
w i t h a c o l l e a g u e f r o m w o r k ( t h i s w a s t h e f i r s t
i n v o l v e m e n t i n h e r l i f e ) , s h e e x p e r i e n c e d a n
in t en sif icat ion of libido, w h ich escaped t h r ou gh t h e
w eak er point of t he psy chosex ual dev elopm ent ; t he
n ar cissism an d con sequ en t h om osex u alit y. Th e lady
m a n a g e d t o g e t i n v o l v e d w i t h a m a n t h r o u g h a
r egr essiv e pr ocess in w hich, nar cissist ically, she did
not t ake t he m ot her as t he obj ect of love, but ident ified
h er self w it h h er, b ecom in g h er ( at an u n con sciou s
fant asy level) and loving her own fat her, unconsciously
r e p r e s e n t e d b y t h e c o l l e a g u e . Th e i n c e s t u o u s
m an if est at ion cr eat ed g u ilt an d p er secu t ion . As it
o r t h e b o s s p e r s e c u t i n g h e r, s h e p r o j e c t e d t h e
per secut or figur e in t he m an. I t is not ed once m or e
t h at h om osex u alit y is u n der st ood as a t en den cy t o
r el at ed o n l y w i t h w h at i s si m i l ar b ecau se, b y n o t
accept ing som et hing t hat w ould hur t t he nar cissism ,
t h e gir l iden t ifies h er self w it h t h e m ot h er, som eon e
she consider s, at m ent al lev el, t o be her self.
Th ese cases con t r ib u t e t o m ak e clear t h at
p sy ch o t i c p a t i en t s’ a t t i t u d es, o b ser v ed b y h ea l t h
p r of ession als, ar e or ig in at ed in com p lex em ot ion al
processes t hat are not very evident in t he observat ion
o f b eh a v i o r s. Fr eu d i a n p sy ch o a n a l y si s h el p u s t o
underst and t he unconscious m echanism s t hat need t o
be considered in pat ient m anagem ent , and especially
in pr act ices t h at in v olv e body car e, becau se sex u al
i ssu es u se t en d t o b e d eep l y m o b i l i zed w h en t h e
professional has som e cont act wit h t he body of t hose
( s) he delivers care to. Nursing professionals are possibly
the m ost requested of all team m em bers to be in contact
w i t h t h e se p r a ct i ce s a n d i ssu e s, e v e n t h o u g h ,
oft ent im es, t hey do not receive t he t heoret ical support
t o underst and t hem in t he dim ension explored here.
FI NAL CONSI DERATI ONS
Af t er car ef u l con sid er at ion of t h e Fr eu d ian
t h eo r y, so m e r ef l ect i o n s ca n b e p r o p o sed o n t h e
possibilit ies of psychot ic pat ient s’ t reat m ent s. The first
one refers t o deliria: as seen, t hey are an at t em pt t o
a t t r i b u t e r e p r e s e n t a t i o n o f w o r d t o r e g r e s s i v e
e x p e r i e n ce s m a r k e d b y h a l l u ci n a t i o n , t h a t i s, a n
a t t e m p t t o r e l a t e w i t h t h e w o r l d . Th e d e l i r i o u s
discour ses indicat e t he pr esence of t he pulsional life
i n t h e sea r ch f o r a p o t en t i a l co n n ect i o n b et w een
se n so r i a l e x p e r i e n ce s a n d so ci a l l y sh a r e d co d e s.
Hence, it should be em phasized t hat delir ia m ust be
v alued and car efully and r espect fully hear d.
Regarding t he polem ic issue t hat involves t he
v iabilit y of t h in k in g in t r an sf er en ce r elat ion sh ips in
psy chosis, t he r eading of Fr eud’s t ex t s pr oposes t he
following reflect ion: I t is im possible not t o adm it t hat
people wit h narcissist fixat ion face difficult ies t o relat e
w it h t he ot her. How ever, it is also cer t ain t hat t hese
people have had a kind of relat ionship at t he st art of
t heir lives which, in an am bivalent way, t hey devoured
and incorporat ed t he obj ect , so t hat t hey could ident ify
t hem selves wit h it aft erwards. I n view of t hese ideas,
it can be proposed t hat a psychot ic, from t he Freudian
point of view, can develop a t ransference relat ionship
wit h t he t herapist . However, it is a relat ionship in which
t h e t h e r a p i st w i l l b e d e v o u r e d a n d i n co r p o r a t e d ,
b eca u se h e w i l l u se t h e r el a t i o n sh i p m ech a n i sm s
charact erist ic of narcissism , a phase in which t he libido
is fix ed.
The w ork w it h t his ident ificat ion process and
t h e p at h t ow ar d s a con st r u ct ion of a p ossib ilit y of
con t act w it h fr u st r at ion s an d t h en w it h figu r es t h at
possess a m ore preserved alt erit y, will be t he t ask of
a par t ner ship est ablished bet w een pr ofessionals and
pat ient s. I t m ust be adm it t ed, t hough, t hat t his is not
a sim ple t ask , because t he pr ofessional w ill init ially
need t o deal wit h a relat ionship in which his/ her own
subj ect iv it y is com plet ely annihilat ed by t he pat ient .
However, if t his relat ionship can be creat ed along t he
t r eat m ent , t he nar cissist indiv idual w ill less and less
n e e d t o r e g r e s s t o h i s / h e r f i r s t e x p e r i e n c e s o f
sat isf act ion an d w ill, lit t le by lit t le, be able t o deal
wit h t he lim it at ions and differences of t he professional
w h o a c c o m p a n i e s h i m / h e r, d i m i n i s h i n g h i s / h e r
ident ificat ions and m aking less dest ruct ive invest m ent s
in t he ex t er nal r ealit y.
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