Tuesday, June 20, 2017

Sigmund Freud on Schizophrenia

Ruwan M Jayatunge M.D.

Schizophrenia is a mental disorder characterized by distortions in thinking, perception, emotions, language, sense of self and behaviour (WHO) and it is one of the most complex and disabling diseases (Weinberger & Harrison, 2011). Processing of social and emotional information has been shown to be disturbed in Schizophrenia (McCormick et al., 2012).  Schizophrenia has a multifactorial etiology (Siever & Davis, 2004) and it is affecting up to 1% of the population Searles , Makarewicz & Dumas ,2017).

Schizophrenia was originally called the senility of youth by the Psychiatrist E. Kraepelin in 1911. Kraepelin (1856-1926) originally called schizophrenia Dementia Praecox. He believed that the typical symptoms were due to a form of mental deterioration which began in adolescence.  Patients' cognitive dysfunction led Kraepelin to the assumption that schizophrenia is a form of juvenile dementia caused by a degenerative process of the human brain (Falkai et al., 2015).   

In 1911 Eugene Beuler first used the term schizophrenia elucidating the major symptomatology such as blunted emotions, disordered thoughts, and loss of awareness. Bleuler believed that schizophrenia patients experienced essential (fundamental) and accessory features. The essential features alone identified the patient Dementia praecox to schizophrenia (Adityanjee et al., 1999).  Bleuler deepened psychopathology, which depicted schizophrenic symptoms and their relation, and the importance of psychoanalysis for psychiatry (Tölle, 2008). Furthermore Bleuler criticized the term ‘dementia praecox’ because schizophrenia did not always first appear in adolescence and did not invariably end in deterioration (Adityanjee et al., 1999).     

Sigmund Freud (1856-1936) maintained an interest in the evolutionary origins of the human mind and its neurotic and psychotic disorders (Young, 2006).  Freud argued that the ego’s alienation from reality could cause psychosis. In 1924 Freud wrote that in psychosis the ego is dragged away from reality. Furthermore Freud predicted that paranoid delusions are motivated by unconscious homosexual impulses (Lester, 1975).

Freud was interested in Schizophrenia (which he called Dementia Praecox).  Freud’s interest in psychosis can be noticed since the very beginning of his theoretical work, as, motivated by his investigations regarding neurosis’ etiology, he compared characteristics of neurosis to classic psychotic pictures, such as melancholy and paranoia  (de Oliveira Moreira & Drawin 2015). Moreover Freud used to examine the blood of psychotic patients for the presence of infectious agents such as spirochete. Freud’s early consideration of schizophrenia as a non-psychotic continuation of mental disorders, he later concluded that some of its aspects could be comprehended from a psychological point of view.

Freud accepted Kraepelin’s nosology, therefore, but he didn’t share Kraepelin’s views on causes (Dalzell, 2009). Freud thought that Schizophrenia was a form of attachment disorder and stated that schizophrenia develops when a child did not successfully develop an “attachment” with the parent of the opposite sex. Freud considered that infant is born into a state of mutual adaptation with the mother (Cohen, 2007). As described by Freud disordered family patterns (schizophrenogenic mothers) are the cause of Schizophrenia. From the late 1940s to the early 1970s, the concept of the "Schizophrenogenic mother" was popular in the psychiatric literature. Research later confirmed that the mother who could cause schizophrenia in her offspring did not exist (Neill, 1990).   

Eugene Bleuler and Harry Stack Sullivan were influenced by Sigmund Freud. In  1911, Eugene  Bleuler  highlighted particular  characteristics  in  the  family of  schizophrenic patients,  such  as  extreme inflexibility, incapability  of  communication,  and  mutual hostility  (Avramaki & E Tsekeris  2011).  

Harry Stack Sullivan promulgated the importance of the child’s earliest interaction with the parents and its major distorting influence as etiologic in the pathology of schizophrenia (Neill, 1990). In the later years Harry Stack Sullivan echoed that mental illnesses are related to interpersonal relationships. Sullivan’s version of the developmental theory conceived by Freud was that schizophrenia is the outcome of interpersonal problems. Sullivan (1892-1949), well-known for his interpersonal theory of mental illness, is believed to have accomplished a high recovery rate in his treatment of schizophrenia during the 1920s (Wake, 2008).

Bateson and colleagues (1956) believed that if a child receives contradictory messages from their parents they are unable to construct an internally coherent perception of reality and it could lead to develop schizophrenic symptoms.

Evidence suggests that attachment styles may influence subclinical psychosis phenotypes (schizotypy) and affective disorders and may play a part in the association between psychosis and childhood adversity (Russo et al, 2017). Social attachment is a biological and affective need (Trémeau et al., 2016). In the later years Pinto, Ashworth and Jones (2008) hypothesized that the risk of developing schizophrenia can increase particular types of deprived childhood environments. Although schizophrenia is primarily genetic the social environment cannot be ignored. Studies show that the social environment can increase the 1% schizophrenia average by a factor of ten (Pinto et al., 2008). In addition Rajkumar (2014) indicates that disturbed childhood attachment leads to core psychological and neurochemical abnormalities which are implicated in the genesis of schizophrenia and also affect its outcome.

Although Freud was unacquainted with neurochemical abnormalities he based his theory of schizophrenia on a pre-structural libido model (Goldstein, 1978). As Freud described the libido is part of the id and is the driving force of all behavior. Libido is a motivational energy of the life instincts. 

According to the psycho-dynamic approach Schizophrenia is the result of the disintegration of the ego (Clarke, 2012). The Ego operates according to the reality principle. Fundamentally, the Ego has a set of psychic functions able to distinguish between fantasy and reality. It organizes thoughts and makes sense of the world. The Ego represents reason and common sense (Siegfried, 2014). Freud regarded Ego as a coherent organization of mental processes. Ego death represents a complete loss of subjective self-identity.

Freud stated that hysteria, obsessional neurosis and hallucinatory confusion are “three forms of defense (Freud, 1894). For Freud psychotic delusion was a defensive psychical reaction with a narcissistic dimension. As described by Freud delusional thinking arises as a result of the reaction-formation and projection of threatening unconscious homosexual wishes (Chalus, 1977). Furthermore he considered paranoia is a form of psychoneuroses (Freud, 1892).  Freud concluded that psychosis is triggered by “a disturbance in the relationship between the ego and the external world (Freud, 1924a).  Feldmann (1989) indicated that in schizophrenic delusion, there is some 'effort after meaning' manifest, compensating for psychotic disintegration.

Freud's 1911 hypothesis explains the basic disorder in schizophrenia consists in the patient's inability to maintain the object relations. The Object Relations theories emphasize the first years of life, ‘the pre oedipal period’ in which nature of early human relationships determine the healthy physical and psychological development of the person, which are supposed to be developed through experiences with significant persons and situations. The individuals with schizophrenia lack basic trust; have poor ego boundaries, and a vulnerability to psychosis, which may follow reality testing disturbances (Khanum & Ahmad, 2012).

In 1911 Freud argued that there is a unidirectional relationship between a delusional belief and consensually validatable reality: the delusion structures reality in accordance with the delusion's demand (Hole, Rush& Beck, 1979).

Klein (1948) concluded that object relation is a theoretical-derived concept comprising aspects of interpersonal functioning. Object-relations theory explains human behavior in terms of a person's inner experiences of others, which are called objects. Internalization of relationships, projective identification, and containment are concepts within object-relations theory that help to explain the confusing and frustrating behavior of acutely psychotic patients (Connick Jamison & Kane, 1996).
According to Khanum and Ahmad (2012) Object relation deficits are well studied in patients of schizophrenia. The disturbed object relation may take the form of either physical or emotional withdrawal (Weiner, 1966).   

Between 1905 and 1911 a perspective slowly appeared in Freud's works -- a perspective which he considered "historical" and which he eventually named "history of the libido's development" ("Entwicklungsgeschichte der Libido") in 1911( Cotti ,2004). The psychoanalytic sense of "libido," which Freud describes as an energy that can be directed to human beings or, as in the case of the anchorite in the example, sublimated and directed toward non-human objects such as God or nature. For Freud, libido was the major force in personality development, and he posited sexual conflicts as the heart of neuroses, sexual fixations as the essence of perversions (Person, 2005).  

Freud believed that schizophrenia occurs when the ego becomes overwhelmed by demands of id or besieged by unbearable guilt from the superego. In schizophrenia disintegration of the ego occurs. The ego cannot cope so it uses defense mechanisms to protect itself which is regression. The schizophrenic’s fantasies become confused with reality which gives rise to hallucinations and delusions. Freud is suggesting that the schizophrenic is dreaming and the hallucinations are not really happening, but they cannot tell the difference between dreams and reality. 

For Freud Schizophrenia was an infantile state. He stated that symptoms such as delusions of grandeur reflect this primitive state. He further thought that auditory hallucinations reflect the persons attempt to re- establish ego control. Freud assumed that that patients with Schizophrenia regress to a state of primary narcissism. The conception of narcissism according to Freud involves a number of different issues and hypotheses (Palmowski, 1989).

Primary narcissism is the initial focus on the self with which all infants start and happens from around six month up to around six years. It is a defense mechanism that is used to protect the child from psychic damage during the formation of the individual self. According to Freud   new-born babies are characterized by primary narcissism, that he defines as the “libidinal complement to the egoism of the instinct of self-preservation.” In other words, primary narcissism, which would predominate until the development of the Ego, corresponds to an innate instinctual behavior which is mainly driven by the desire and energy of the newborn to survive, and by a capability of satisfying these instincts on itself (“auto-ero-tism”) ( Perogamvros,  2012)    

In 1911 Freud analyzed the Daniel Paul Schreber 's  memoirs. Schreber - a German judge was diagnosed with Dementia Praecox. Freud used his "libido" theory to analyze Schreber’s illness. Freud considered this to be a consequence of two libidinal cathectic fixations (Silber, 2014).

Based on his analysis Freud concluded that the disorder could not be treated psychoanalytically because of the disorder's inherent deficits in the capacity for object relatedness, including the therapeutically necessary development of transference to the treating person (McGlashan, 2009). However Around 1907 to 1908, some of Freud’s inner circle, Federn, Jung, and Abraham, began to express that psychoanalysis could be applied effectively to schizophrenia (Osborn, 2009). 

According to Freud’s libido decathexis-restitution model of schizophrenia in 1914 he argued that these patients cannot develop transferences towards the analyst, and therefore, analysis cannot be effective. However in 1924 Freud attempted to widen the scope of psychoanalysis to include more severe psychiatric illness, including schizophrenia (Ridenour, 2016). Freud’s approach coincide with Kohut (1984) who argued that psychoanalytic treatment begins with the understanding phase –empathy and moves towards the explaining phase –interpretation  (Ridenour, 2016; Kohut,  1984).  

Freud's "Project for a Scientific Psychology" (1895) reflected his attempt to explain psychic phenomena in neurobiological terms. His basic hypothesis was that neurons were vehicles for the conduction of "currents" or "excitations," and that they were connected to one another. Using this model, Freud attempted to describe a number of mental phenomena, including: consciousnesses, perception, affect self, cognition, dreaming, memory, and symptom formation. However, he was unable to complete his exploration of these mental processes because he lacked the information and technology that became available over the following century (Glucksman, 2016). If Freud had lived several more productive years he would have given a more rational explanation of Schizophrenia.

 Dr. Tom Dalzell - St Vincent's University Hospital, Dublin, Ireland


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  1. Dear Doctor,
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    click on පොතකියවිමට link even though it was written in Sinhala this Most Ven Rerukane chandawimala has manage to write this book more than 50 years ago using sutta pitaka extractions, you will be amazed how Buddha was able to analyse the human mind

    1. Once I tried to translate Abhidamma in to English ; I tried to compare Freudian mind analysis and Abhidamma

    2. Doctor this is from Suththa Pitaka extraction, this shows deceptive nature of the human mind you very rarely get to listen to this type of Dhamma sermons. Most Buddhist do not know about this


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