Infantile Psychosis (International Dictionary of Psychoanalysis)
Infantile psychosis has recently been replacing the notion of infantile schizophrenia. Infantile psychosis can be defined as precociously pathological organization that develops out of the integration of the earliest relations. Later forms of exteriorization can also be manifested in childhood. The age at the first outbreak, the greater or lesser stability of the supports of equilibrium that are constituted, and the nature of the defense mechanisms have significant repercussions on the risk and incidence of later negative developments.
The principal psychic mechanisms at work lie somewhere between the neurosis-psychosis opposition, posed by Freud, and the Kleinian theory of fantasy and the precocious Oedipus: the predominance of projection and projective identification, the fusion between real and imaginary, with infiltration of primal shattering fears, direct instinctual expression and the search for satisfaction by the shortest way, principally in the register of oral drives.
Clinical polymorphism, the absence of pathognomonic signs, and the failure of any common etiology of pathogenesis all characterize the category of the infantile psychoses in child psychiatry. Psychosis is diagnosed on the basis of the seriousness of perturbations, their atypical quality and their duration, in the context of various presenting symptomsuch as behavior problems, compromising of intellectual efficiency and functioning, retardation and/or language anomalies, expressions of great anxiety, sleep, eating, and sphincter conduit disorders; and in rare cases delirium and hallucinations. In terms of occurrence, a clear distinction has been established between schizophrenia that is declared in adolescence, without as much variety in the forms it takes, and the child schizophrenics who present more individualized particularities.
In the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association, psychoses are not listed as a disorder nosology, but rather placed under the rubric of "general developmental disorders" among which figures infantile autism. The overall "a-theoretical" cast of the ensemble and its descriptive corollaries suggest an organogenic and negative conception of psychosis, implying interventions that consist principally in reeducation.
Until the beginning of the twentieth century, this dominant understanding of infantile psychoses was still borrowed in large measure from that of nineteenth-century psychiatry; advocating medical pedagogical treatment (Bourneville, Seguin, Vallee), as well as psychometric approaches (Binet, Simon). Backwardness, states of idiocy and insanity, and their anatomical-clinical correlations in etiological matters were some characteristics of the dominant conception.
A threefold transformation of thought then contributed to the emergence of infantile psychoses:
- the application to ever younger children of models coming from advances in adult psychiatry and psychoanalysis;
- the rejection of these adulto-morphic models, as clinicians took account of the specificities of children;
- the gradual passing of the hypothesis of homogeneity, and the recognition of the heterogeneity of clinical tableaux and their underlying conditions.
Wilhelm Weygandt, Emil Kraepelin himself, and especially Sancte de Sanctis in 1908 with "dementia praecossime," described the infantile forms of early insanity. Yet all of this was merely followed the Kraepelinian model of the child. With the introduction by Eugen Bleuler of the category of schizophrenics (1911), the emphasis shifted from dementia to the dissociation of psychic functions ("Spaltung"). Among disorders called secondaryresponses of the sick soul"as the hermetic isolation of "autism," a term coined by Bleuler by subtracting "eros" from the Freudian notion of autoeroticism.
This new dynamic approach progressively influenced studies of children. From the thirties, in the United States (Charles Bradley, Howard Potter) and Europe (Georges Heuyer, Jacob Lutz, Léon Michaux), the notion of infantile schizophrenia, an autonomous endogenic illness resulting in a dramatic alteration in the developmental curve, became a familiar one. For Lutz, it was strictly opposed to organic and encephalopathic madness, or to gradually developing retardation. An overall conception of the malady was enlarged to include different clinical types and an approach to intra-familial relations. The work of Melanie Klein and her treatment of psychotic, even autistic children (cases of Dick, 1930; Erna, 1932) was especially influential, and took place well before the descriptions of precocious infantile autism by Leo Kanner (1943) and of symbiotic psychosis by Margaret Mahler (1952).
The emergence of the concept of infantile psychosis first in the United States, then in Europe, from the end of the 1940s is linked to several factors:
- the dissemination of psychoanalytic works relative to children and concerning early development: Melanie Klein, already mentioned, Anna Freud, René Spitz, Donald Winnicott;
- a progressive disengagement from any etiological presupposition;
- a challenge to the notion of dementia as an endogenous condition with ineluctable processes which had been itself a factor in negative prognoses.
Post-Kleinian authors in Great Britain attempted to make further progress in investigating the origins of thought and its disorders: Herbert Rosenfeld located the role of projective identification in the psychotic process; Wilfred Bion stressed the impact of destructive drives against activities of liaison, perception, and attention, while describing a normal projective identification; Hanna Segal developed the notion of "symbolic equation" in schizophrenia, where the symbol is confused with the thing it symbolizes.
In France, after the early work of theorization of Serge Lebovici, René Diatkine, Conrad Stein, and Denise Kalmanson came up with a comprehensive psychological profile of infantile psychoses. The contributions of Roger Misès and Jean-Louis Lang should also be emphasized as having illuminated the rapport between psychoses and flaws in organic constitution. While the neurosis-psychosis opposition still maintains considerable heuristic value, the complexity and flexibility of the child's systems have resulted in proposing the concepts of pre-psychosis, developmental disharmony, and para-psychosis.
The British school, through Donald Meltzer, proceeded to a synthesis of the Kleinian concepts in the very unfolding of the psychoanalytic process in the child (1948) and the observation of stages of psychic growth and of "dimensionality." Esther Bick's insight into a primal mode of narcissistic identification, "adhesive identification" (1968), extended the hypothesis formulated by Winnicott of premature traumatic separation and psychotic depression. Subsequently, Frances Tustin developed an original conceptualization of autistic defense mechanisms, distinguishing "shell states" (autisms) from "confusable states" (schizophrenias), where there has been access to tridimensionality. Finally, the study of the competencies of the infant, coupled with direct observation as well as the notions of interactional epigenisis and phantasmic interactions (Lebovici, 1983), posed the problem of the consistency of psychoanalysis with new models of premature dysfunctionalities (Didier Houzel, Bertrand Cramer). The idea that the baby creates the mother as much as she creates the baby has contributed to reflection on the access to maternality (Racamier, 1979) and on the role maternal depression plays in the psychotic process.
Leo Kanner described early infantile autism (1943), and he deduced it from the Bleulerian concept of the autism of schizophrenia. It was then applied to the "extreme autistic solitude" manifested from the start of life beginning in certain children. However, the question of whether this is a special category, in spite of Kanner's integration of it in the general framework of infantile psychoses, remains unresolved. The especially rigid homeostasis of their constitution locates these children in the register of the unchangeable, capable of no effect of projection, action or possession. A line can be drawn here between autism and infantile psychoses. Because the autistic system is relatively unstable, future development, once a major breakdown has been avoided, will include passage by "symbiotic" madness. Some authors, however, see in this a confirmation of the developmental continuity of various forms of child psychosis.
Described by Margaret Mahler in the child of two to four years of age, "symbiotic psychosis" is based on a primal indistinction between the psyche of the baby and that of the mother, and on a regression to this state of "symbiosis." Psychosis involves the tentative restitution of the mania of omnipotent fusion with the mother's image. Marked by ambivalence, its symptomology includes a loss of functional skills and major manifestations of disturbance at the prospect of a separation from corporeal contact. Its onset is connected with maturation of the functions of the ego and the unconscious mobility of parental cathexes. A manifestly pathological "symbiotic" upsetting of equilibrium, a result of separation or sudden loss, can result in a secondary autistic condition.
Other early developmental disharmonies, psychotic in structure and composite clinical articulation, have been described. One consideration is that psychoses that are externalized later, from the age of four-to-five to puberty, can be seen as evolving adjustments to these early forms, and in continuity with them. On the other hand, without underestimating the significance of unrecognized fault lines, they surface in children who seem safe from them. Clinical configurations correspond to variable classifications of the signs of a need for help, polymorphic in nature, as has been mentioned above. Pseudo-neurotic (phobias, obsessions) and pseudo-maladjustment forms should be remarked, as well as complex motor or instrumental disorders, and some school failures, where psychosis is a factor.
The ensemble of these theories, not excluding neurobiological, environmental, and historical factors, tends to be situated outside of linear reductive causality. For René Diatkine, the understanding of psycho-pathology necessitates a reflection on the etiology of "normalcy." From the time of The Interpretation of Dreams (1900a), the Freudian hypothesis of the hallucinatory return of the experience of satisfaction linked normal development and psychotic functioning. Melanie Klein, in her description of the precocious Oedipus and schizoid-paranoid and depressive positions, situated "early psychotic stages" as potentialities in any human being. Infantile psychoses were the result of fixation at this early pre-psychotic phase, in which splitting, introjection, and projection dominate. They signify the failure of the depressive phase central to the second six months of life, when the child is faced with persecutory anxieties of annihilation. Projective identification, with its dimension of aggressive intrusion into the body of the mother to control her from the inside, was the key to narcissistic object relations of the schizoid-paranoid position. However, Melanie Klein has been criticized for using metaphors borrowed from psychopathology to describe the general organization of the psyches well as for the absence of a clear conceptual opposition between neurosis and psychosis.
Serge Lebovici and René Diatkine are of the opinion that the ensemble of psychic functioning and the economic equilibrium between different systems are what permits the differentiation of every form of psychic organization with regard to the "treatment" of projective identification. Consequently, according to Diatkine, "the optimal form of development of the pre-Oedipean organization" could be represented "as an interaction between two psychotic positions (schizoid-paranoid and depressive positions)" (1955) which is similar to some of Bion's formulations. Psychosis would correspond to the relative primacy of the primal processes in the lowering of tensions and the reestablishment of economic equilibrium, a condition of psychic continuity. The tendency toward repetition of this primacy is what is pathognomonic. Cathexis and meaning would be established, consequently, accorded to a "primal" logic, without suppression of secondary processes. René Diatkine emphasized the crisis, decisive for psychic development, leading to the installation of the object in the second six months of life. The presence/absence opposition assumes qualitative significance, and the maternal object, lost by definition as soon as constituted, is cathected ambivalently. The working through of the ambivalence is crucial, the object of love and hate being doubly inscribed, internally and externally. Symbiotic psychosis corresponds to the impossibility of working-through, a consequence of serous perturbations in the earliest exchanges: painful representation becomes non-representation. The environment can contribute to the stabilization of this pathological equilibrium or it can favor the constructive recapture of mental representations. Projective identification, which becomes very significant when introjection organizes desire permanently in the depressive position, allows the loved object to be spared by addressing itself to a third party. This primal triangulation is the jumping off point of the oedipean constitution, as in Kleinian formulations. For Wilfred R. Bion, projected hatred and envy become so intense, in the pathological projective identification, that the identificatory object, unable to contain and work through them, is experienced as a "superego," crushing and destructive of the capacities of psychic development. The inversion of the alpha function necessary for the assimilation of emotional experiences results in catastrophic hallucinations and anxieties.
Donald W. Winnicott regarded failures of the early processes of illusion-disillusion, shared between the mother and the child, as the source of the psychosis centered on phases of the formation of "the continuous feeling of existence." The lack of access to a "primal maternal preoccupation" (1965) would deprive the subject of an essential early period of illusion. For Wilfred Bion, this particular maternal phase can be considered from the point of view of a mutual projective relation of identification between the mother and the baby, reintroducing the role of the object and the environment into Kleinian theories. The containing and working-through capacities of the mother are what soothe the persecutory anxiety of the child ("capacity for maternal reverie").
Lacanian theorization relative to infantile psychoses were developed on the basis of the concepts of the foreclosure (the "Verwerfung" of Freud) of the Name-of-the-Father and of the mirror stage as "formative of the function of the I." The foreclosed signifiers, outside of symbolization, return to the heart of the Real in hallucination. The mirror phase, between six and eighteen months, marks the first version of an ego in the experience of a primal identification, anticipating a corporal unity. For Maud Mannoni, psychoses are inscribed in the maternal unconscious, with the psychotic child being unrecognized as a desiring subject, excluded from access to oedipean triangulation, and frozen as partial object subjected to maternal omnipotence. Finally, Piera Aulagnier's notion of the "imaginary body of the child" should be mentioned. This introduces an imaginary working through by the mother, prior to birth and anticipating the libidinal cathexis of the baby. The pictographic representation of the complementary object zone, attached to the primal process, bears witness to the disjunctive ruptures of corporal space in psychosis.
In summary, it can be affirmed that, in clinical practice, psychotic polarity is represented by projective expansion, immediate hallucinatory satisfaction and disorganization, whereas neurotic polarity is represented by the efficacy of symbolic transmission, the multiplication of liaisons, and the capacity to differentiate and work through.
A desirable early psychoanalytic treatment, extended in time, in the context of flexible institutional guidelines, should go along with a recognition of the different levels, perceptible but unpredictable, of psychic functioning of patients, as well as of related family circumstances.
See also: Adhesive identification; Anaclisis/anaclitic; Autism; Autistic capsule/nucleus; Autistic defenses; Black hole; Breakdown; Child analysis; Deprivation; Developmental disorders; Dismantling; Empty Fortress, The; Individual; Infantile schizophrenia; Lack of differentiation; Mirror stage; Primitive agony; ; Psychotic potential; Self-mutilation in children; Sucking/thumbsucking; Symbiosis/symbiotic relation; Tube-ego.
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