Psychosis and psychotic functioning in adolescence

ABSTRACT

This paper presents an overview of the main issues that underlie the outbreak of a psychosis in adolescence. The author addresses significant questions that arise in connection with the use of the terms psychosis, psychotic functioning, and adolescent breakdown, examining different theoretical and clinical approaches to psychosis in adolescence. One of the main areas to be explored is the use of the specific diagnosis of psychosis in adolescence when we witness fluctuating mental states, variability, and changeable behaviour.

A central point in the development of a psychotic process is the relationship to external reality. This break with reality was characterized by M. and M.E. Laufer as specifically lived out in relation to the reality of the adolescent's changing body. This paper will look at these authors' understanding of psychotic episodes, psychotic functioning, and psychosis, as well as other theoretical perspectives. The paper will address the economic aspects linked to drive increase, the complex interplay of early anxieties, unconscious phantasies and internal object relations, along with the role of identity, the superego and trauma. The paper also discusses different modalities of treatment and stresses the benefit of psychoanalytic treatment for disturbed adolescents.

Acknowledgements

I am grateful to my colleagues from the EPF Forum for the Psychoanalysis of Adolescents for their thoughts and comments on my paper.

Notes

1 It could be said that the concept of ‘identity’ is an area that attracts different perspectives in psychoanalysis (see for example Abend (1974), Jacobson (1964), Eissler 1958, Blos P., 1962)

2 In order to address this Moses Laufer underlined a number of characteristics that are part of normal adolescence and which would be altered in states of developmental breakdown: 1) The adolescent knows that he has ways of feeling valued and admired without having to remain totally dependent on his parents 2) However much he may feel guilty or ashamed of some of his private thoughts and feelings coming from his body, he can still enjoy the pleasure from these thoughts and feelings and he can seek relationships which in part enable him to remain in touch with these feelings from his body 3) Even though there are times when he may have thoughts which worry and shame him (because of their connection to a sense of abnormality) he feels that these thoughts will not ultimately overwhelm him and that he does not have to be tied to them and can have other sources of pleasure 4) However much despair or hopelessness he can still feel self-respect

3 According to the DSM 5, the new description of psychosis is placed under the title Schizophrenia spectrum and other psychotic disorders . There is now an elimination of classical sub-types (paranoid, disorganized, catatonia, etc) with the key symptoms being 1) delusions, 2) hallucinations, 3) disorganized speech, 4) disorganized or catatonic behaviour, and 5) negative symptoms. In the DSM-5, two of these five symptoms are required AND at least one symptom must be one of the first three (delusions, hallucinations, disorganized speech)

4 “In contemporary psychoanalysis, psychosis is also used variously to describe a mental state in which there is a loss of reality testing; the presence of paranoid, erotic, or other kinds of intense transference states; the presence of highly aggressive primitive conscious fantasies; problems in self-other differentiation’ (Auchincloss, 2012).

5 This was not so much the case with Lacan who disagreed with what he saw was a tendency in psychoanalysis (particularly in ego-psychology) towards placing too much importance on developmental stages and on ego-adaptation to the transformations of puberty. A number of Lacanian analysts have developed ideas on psychosis in adolescence such as addressing the foreclosure of the paternal function (Dor 1997; Lacan 1981; Rassial 2000).

6 ‘We find the opinion that, in the majority of cases, the manifestations of the adolescent process are not predictable since they depend almost wholly on quantitative relations, i.e. on the strength and suddenness of drive increase, the correspondent increase in anxiety causing all the rest of the upheaval’ (Freud A., 1958, 265)

7 ‘psychoses actuelles’ in French (Porret 1991, 22)

8 “While the end of adolescence thus is the stage of an overt identity crisis, identity formation neither begins nor ends with adolescence: it is a lifelong development largely unconscious to the individual and to his society. Its roots go back all the way to the first self-recognition: in the baby's earliest exchange of smiles there is something of a self-realization coupled with a mutual recognition” (Erikson 1956, 69).

9 … the man's alpha-function whether in sleeping or waking transforms the sense-impressions related to an emotional experience, into alpha-elements, which cohere as they proliferate to form the contact barrier. This contact barrier, thus continuously in process of formation, marks the point of contact and separation between conscious and unconscious elements and originates the distinction between them. (Bion, 1962, 17)

10 It started as a walk-in service for adolescents in the borough of Brent in London and soon became a research Centre on adolescent breakdown. It provided consultations (at that time it was called ‘interviewing’ to accommodate its style to the specific necessities and characteristics of this age group), psychotherapy and five times-week psychoanalysis to some adolescents (Bronstein & Flanders, 1998, Laufer & Laufer 1989) The Brent Consultation Centre was later called Brent Adolescent Centre and is nowadays called The Brent Centre for Young People. Its current director is Maxim de Sauma