The development of psychodynamic models

The development of psychodynamic models of understanding psychosis over the last century, by Maurizio Peciccia.

Federn, Abraham and Jung were amongst the first psychoanalysts to work with psychotic individuals. Federn, (1929) maintained that the mind was invaded by the unconscious and by dreams because the ego had become disinvested of libidinal love weakening its borders leading to fragmentation and invasion externally by reality and internally by dreams.

Abraham (1908) and Freud (1917) had previously described psychotic internal representations of others as depriving of love and distant but distinct from the ego. Federn, highlighted the opposite situation: due to the weakness of its boundaries, the Ego and objects merge.

Jacobson (1954) linked her theories to those of Federn when she described the fusion in psychotic patients between the representation of the self with the representation of the others.

Contemporaneously, Klein (1946), described projective identification as creating a phenomenon similar to the fusion between self and others and their representations. In projective identification unacceptable aspects of self are located outside of self and into others and their internal representation. Hanna Segal, pointed out that “the difficulty of forming or using symbols is one of the basic elements in schizophrenic thinking”. Between two different objects, either no interest, no symbolic link develops or, on the contrary, interest is excessive: the two objects coincide and become the one object; in place of the symbol there is then “symbolic equivalence” (Segal, 1950). (Note – 'Internal object' is a term used commonly in Kleinian theory to denote an inner mental and emotional image of an external figure, also known as an external object, together with the experience of that figure. The inner world is seen to be populated with internal objects.’)Mahler (1952, 1958) differentiated two types of psychoses calling them symbiotic and autistic. Symbiotic psychoses are characterized by the fusion of the other and the self. In autistic psychoses, on the contrary, there is a lack of affective awareness of the presence of others: the other does not exist in the subject's perception; the children do not perceive their mothers as living beings.

Winnicott (1965) described a now widely recognized theory of psychotic disorders of the self. He stated that “holding” deficiencies in early childhood affect the cohesion and unity of the self of the future psychotic patient (Winnicott & Khan, 1965) creating a future vulnerability in the face of later stresses.

In the middle of the 1980's Stern (1985) elaborated a revolutionary model of child development according to which many states of the self contemporaneously evolve integrating, without losing any of their actual and potential autonomy even in adult life. According to the empirical observations of Stern, the child has, from the first days of life, the ability to differentiate himself or herself from the environment (e.g. Rochat, Hespos, 1997). At the same time, the infant is able to establish close symbiotic ties with other people and external objects -e.g. neonatal imitation- (e.g. Meltzoff, Moore, 1977).

While Mahler's model of child development is linear –i.e. it proceeds continuously from symbiosis to separation- Stern's model is circular because it assumes that the self of the child circularly and repeatedly oscillates between states of contact-fusion and states of separation-differentiation. Stern's developmental model of the self directly or indirectly influenced contemporary psychoanalysis. Today it is widely accepted that in emotionally healthy human beings, different self-states can coexist in a sufficiently balanced way - meaning that they push the person at the same time both toward union with others and toward separation from other- (Auerbach, Blatt, 1996; Benedetti, Peciccia, 1994; Bolognini, 2004; Mentzos, 1991; Ogden, 1992; Solan, 1991).

In this theoretical context, psychosis has been linked to a too intense conflict that divides and shatters the self, resulting in a ‘crack’ between the drives towards union with and separation-from the other. The severity of this conflict may leading to the person experiencing a dissolution of the self and a sense of psychic death (Auerbach, Blatt, 1996; Green, 1986; Mentzos, 1991; Peciccia and Benedetti, 1996). It has been proposed that the conflict of the psychotic patient between identification, closeness and even union on the one hand and differentiation processes on the other might be have its psychological origins to an antecedent poor integration of opposite states of the self, called “symbiotic and separated self” (Peciccia and Benedetti, 1996).

Others outside of no psychoanalysis describe, with other words, psychotic phenomena similar to that of the lack of integration between different self states.

According to the phenomenologist Fuchs (2015) psychotic patients lack an independent “third position” from which they could compare and integrate their own and another’s point of view. Intersubjectivity which is based on the ability to oscillate between our own point of view (the “ego-centric”, embodied perspective) and the other’s point of view (the allo-centric, decentred perspective) is therefore, in some psychotic persons, deeply disturbed. Fuchs stated (2015)“delusions typically manifest themselves as a peculiar inability or refusal of the patient to adequately take the other’s perspective into account. Nevertheless, regarding content, delusions notoriously show a pervasive reference to others by whom the patient feels observed, spied at, persecuted”.

From a neurophysiological point of view evidence has accumulated of psychotic dysfunctions involving both the mirror neuron system (Metha et al.2014), correlated to self-other identification (Olds, 2006) and the multisensory integration network correlated to self-other differentiation (Gallese and Ebish, 2013). Furthermore Ebisch et al., (2013) illustrated abnormal connections between the mirror neurons system and the multisensory integration network. These transdisciplinary correlations provide empirical evidence for ideas arising from psychodynamic oriented psychotherapies.

Further reading

(links to articles are provided if possible, sometimes in another form, for instance as chapter in a book instead of an article or a comparable article of the same author.)

Abraham K (1908). The psycho-sexual differences between hysteria and dementia praecox. Selected papers on psycho-analysis. London, 1927. Die psychosexuellen Differenzen der Hysterie und der Dementia praecox. Zbl. Nervenheilk. Psychiat. N.F. 19, 521. (40-1, 65, 70, 76-7) Chap. II see book go to chapter 2

Auerbach, J. S., & Blatt, S. J. (1996). Self-representation in severe psychopathology: The role of reflexive self-awareness. Psychoanalytic psychology, 13(3), 297-341 see full text article

Benedetti, G., & Peciccia, M. (1994). Psychodynamic reflections on the delusion of persecution. Nordic Journal of Psychiatry, 48(6), 391–396.see abstract

Bolognini, S. (2004). Psychoanalytic empathy. Free Association Books London. see book on amazon

Ebisch, S. J., Salone, A., Ferri, F., De Berardis, D., Romani, G. L., Ferro, F. M., & Gallese, V. (2013). Out of touch with reality? Social perception in first-episode schizophrenia. Social cognitive and affective neuroscience, 8(4), 394–403. See full text Pdf

Federn P (1929). The Ego as subject and object in narcissism. In: Ego psychology and the psychoses. London: Imago (1953). See abstract

Freud S (1917). Introductory Lectures on Psycho-analysis (Part III). Lecture 26: The libido theory and narcissism. SE 16, 414.see chapter in another book

Fuchs T (2015). The intersubjectivity of delusions. World Psychiatry 14:2-June 2015 see full text article

Gallese, V., & Ebisch, S. (2013). Embodied simulation and touch: The sense of touch in social cognition. Phenomenol. Mind, 4, 269–291.see full text article

Green A. (1986). On private madness. Madison CT. New York: Int. Univ. Press see book

Jacobson, E. (1954). Contribution to the metapsychology of psychotic identifications. Journal of the American Psychoanalytic Association.

Klein M (1946). Notes on some schizoid mechanisms. In Envy and Gratitude and Other Works, 1946-1963 New York: Delacorte, 1975 pp. 1-24 see book on google

Mahler, M. S. (1952). On child psychosis and schizophrenia: autistic and symbiotic infantile psychoses. The psychoanalytic study of the child. see comparable article

Mahler, M. S. (1958). Autism and symbiosis, two extreme disturbances of identity. The International journal of psycho-analysis, 39(2-4), 77. See first page of Pdf

Meltzoff, A. N., Moore, M. K. (1977), Imitation of facial and manual gestures by human neonates, Sciences, 198, pp. 75-78. See full text article

Mentzos, S. (1991). Psychodynamische Modelle in der Psychiatrie. Vandenhoeck & Ruprecht.

See book on amazon

Ogden TH (1992). The Dialectically Constituted/decentred Subject of Psychoanalysis. II. The Contributions of Klein and Winnicott. Int. J. Psycho-Anal., 73:613-626 see abstract

Olds, DD (2006), Identification: psychoanalytic and biological perspectives. J Am Psychoanal Assoc. 54/1 see abstract

Peciccia, M., & Benedetti, G. (1996). The splitting between separate and symbiotic states of the self in the psychodynamic of schizophrenia. In International Forum of Psychoanalysis (V. 5, page. 23–38). Taylor & Francis. see abstract

Peciccia, M., Mazzeschi, C., Donnari, S., & Buratta, L. (2015). A Sensory-Motor Approach for Patients with a Diagnosis of Psychosis.Some Data from an Empirical Investigation on Amniotic Therapy.Psychosis,7(2),141–151 see article in psychosis

Rochat, P., Hespos, S. J. (1997). Differential rooting response by neonates: Evidence for an early sense of self, Early development and parenting, 6, pp. 105-112. go to abstract

Segal H (1950). Some Aspects of the Analysis of a Schizophrenic. Int. J. Psycho-Anal. 31:268-278. P.270.see chapter in book Listening to Hanna Segal: Her Contribution to Psychoanalysis by Jean-Michel Quinodoz l

Stern DN (1985). The Interpersonal World of the Infant. New York: Basic Books. See book

Winnicott, D. W. (1956). Primary maternal preoccupation. Tavistock London.see chapter in book The Maternal Lineage: Identification, Desire, and Transgenerational Issues, Door Paola Mariotti

Winnicott, D. W., & Khan, M. M. R. (1965). The maturational processes and the facilitating environment: Studies in the theory of emotional development. Hogarth Press London. see full Pdf!

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