Meetings of the New York Psychoanalytic Society

November 13, 1962. THE PSYCHOPATHOLOGY OF THE PSYCHOSES. Charles Brenner, M.D.

The clinical phenomena of the psychoses, like the neuroses, can be satisfactorily understood in terms of Freud's basic concepts: the dual instinct theory, structural hypothesis, and the 1926 theory of anxiety. Dr. Brenner's view is consistent with that of Freud, who also felt that the psychic processes in psychoses and neuroses display a fundamental unity. Freud held that the essential characteristics of the psychoses which differentiate them from the neuroses were the break with reality, the occurrence of delusions and hallucinations, and the self-centeredness of the psychotic patient (megalomania, hypochondriasis, etc.). He believed these features could be understood as a result of regression to an earlier fixation point in the psychoses and a difference in defenses employed. The neurotic patient uses repression in which derivatives of instinctual wishes and defenses are barred from consciousness, although the wishes retain strong libidinal cathexis. In psychotic repression there is a decathexis of the unconscious mental representation. The libido thus detached is invested in the patient's self, giving rise to symptoms of grandiosity and hypochondrasis. Thus the psychotic defense involves regression to the narcissistic preobject stage of development. Delusions and hallucinations represent the restitutive phase of the illness in which the patient tries to reinvest with libidinal cathexes the mental representations of the object world.

Dr. Brenner questions the need to retain these two formulations as an integral part of the psychoanalytic theory of the psychoses. The symptoms of the first phase (world destruction fantasies, megalomania, and hypochondriasis), which were explained by the withdrawal of object cathexis, can better be understood as a consequence of three factors: instinctual regression, defenses against aggression, and ego and superego regression which is motivated