Why the cycle in a cyclical psychosis? An analytic contribution to the understanding of recurrent manic-depressive psychosis

SUMMARY

In this paper, the psychopathology underlying recurrent manic-depressive psychosis is considered. In the introduction, it is noted that the opportunities for prolonged analytic case-studies of severe psychotic disorders have become more difficult since the closure of the specialist analytically oriented in-patient units in the NHS and the changes at Chestnut Lodge in the United States.

Material is presented from an analytic case-study of a patient with recurrent manic-depressive psychosis, followed in the National Health Service over a fifteen-year period. The material allows the reader to follow the recurrent nature of the psychopathology. Consideration is given as to why the analysis led to an intensification of the manic episodes, and the role played by defences against experiencing guilt in maintaining manic states of mind. Some recent improvement is related to the emergence of a third position, a shared reflectiveness between analyst and patient in helping the patient to live with and manage the manic episodes.

Whether or not a satisfactory therapeutic outcome is produced, it is argued that psychoanalytic studies of severe psychotic disorders not only deepen one's understanding, but also help in everyday general psychiatry with seemingly intractable states of mind.

Both past and more recent contributions from the psychoanalytic literature are reviewed for the light they shed on the clinical material and the condition in general.