Tinnitus, paranoid psychosis, homicide and the identificate in an amiable man

A mild-mannered man developed paranoid psychosis following the onset of tinnitus. He subsequently killed a workmate whom he believed had poisoned him causing tinnitus. Post-homicide, the patient’s calm state was rapidly restored. We eventually came to understand that prior to the tinnitus the patient’s inner world was dominated by a phantasy of an idealised ever-available, ever-understanding internal maternal object unconsciously represented by the patient’s love of classical music which unfailingly assuaged his anxiety. Tinnitus, denying him this soothing input, was unconsciously experienced as a hated paternal object destroying the loving union of mother and infant. The homicide victim came to represent this paternal object, the source of projected oedipal murderousness. Retrospectively, the patient’s easy-going ‘chameleon-like’ pre-breakdown personality was understood as a pathological organisation based on acquisitive projective identification with a phantasised mother with ideal receptive capacity – an ‘identificate’ (Sohn 1985) – with (paternal) violence and destructiveness split off and inaccessible. Failure of separation, denial of loss and lack of acceptance of the Oedipus situation precluded the development of the ‘third position’ required for insight and symbolisation. Five years weekly psychotherapy in a secure unit provided some understanding of his inner world and the tragic course of events together with a significant degree of psychic development.