top of page
Writer's pictureanaluciamarsenise

Beyond Diagnosis


Artowork: Anxiety (1894) by Edvard Munch

 

Diagnosis, as expressed in the DSM (Diagnostic Statistical Manual), and more widely used in the practice of psychiatry, can best be understood not as a definition of a person's state of mental health, nor as a description of their characteristics and identity. Diagnosis is merely a tool that helps some members of the healthcare professions to recognize a patient's predominant symptoms in a name. For example, by saying that someone is bipolar, you can recognise that there are mood swings, just as, if someone suffers from obsessive-compulsive disorder, that there is a behavioural pattern of obsessive thoughts and compulsive, ritualistic behaviours. However, no description of symptoms provides information about the person's personality or the nature of their distress. To understand mental health, it is essential to look at the person in their entire historical and social context, as well as their developmental history and relationships/experiences throughout life.  Symptoms of obsession and compulsion in a person who has not had a loving family and who has suffered neglect will be very different from the reality of a person with the same symptoms but who has grown up and experienced a family as a secure base.


The symptom is a manifestation of anguish and it is essential to understand the nature of this anguish.  In the first case, a person who hasn't had the basis of a continuity of secure and welcoming relationships may have great difficulty seeing themselves as an individual person. After all, if no one has seen them, if they haven't existed for anyone else on a continuous basis, how can they exist for themselves? In this person, the compulsions may come from an anguish of fragmentation, of annihilation, in other words, the person has such behaviours to give a sense of control and avoid coming into contact with the overwhelming anguish resulting from neglect. In the second case, once the person has had the experience of love and has been recognised and seen, their anguish may be of a different order, perhaps of loss, making certain movements and behaviours unconsciously to avoid losing the love of those they admire and who have certain expectations of them.


However, I'm not dismissing the usefulness of diagnosis in interprofessional sharing, as well as in making it easier to indicate certain medicines when they appear necessary to alleviate suffering. But it is essential to identify and be aware of the reductionist aspect of reducing a clinical case to a nosography of biomedical identification. In psychotherapy, particularly in psychoanalysis, the first thing we try to do is assess the person's psychic development, i.e. what they have experienced and lived through in life, what their psychic maturity is, maturity not being a question of comparing childish and adult behaviour, but of how they manage to live a functional life without causing suffering to themselves or others, as well as their ability to regulate their own emotions and relate to people on the basis of reality.


Although there is no focus on diagnosis, in psychoanalysis we can talk about personality structures, which are profiles that ultimately indicate how a person relates to themselves, to others and the world. There are three main structures (this varies between authors): psychotic, borderline and neurotic. Very briefly, regardless of the symptoms, we can distinguish these personality structures (or, psychic development and maturity) by the nature of the distress, the way the person relates to others and the predominant defence mechanisms used.


The nature of existential anguish is often not just one, but there can be a predominance. These include the anguish of ceasing to exist (psychotic), the anguish of not existing in the eyes of another person and abandonment (borderline), and the anguish of knowing that one exists, but having the pain of losing the love of another (neurotic). As for how the person relates to themselves, to others and to the world, it depends a lot on how stable they have been in life, particularly the continuity of affective and secure relationships, with primary relationships with carers having a substantial weight here. Imagine a child who was born and is neglected, not having their needs met, nor being welcomed and cherished; how do they know they exist if no one looks at them? Without knowing how to exist for the other, without being represented internally to the other, they won't be able to realise representations of reality. In order to have an internal (mental) representation of something or someone, you must first have repeatedly related to them, being certain of their existence despite occasional absences. It's not because you're not in the presence of something (it could be anything from an object to a person, a relationship, a feeling...) or that you don't constantly have concrete proof of its veracity, that implies that it doesn't exist.


The absence of the ability to represent reality, combined with a dependence on the other, is characteristic of psychosis. Since there is no reality in which it is welcomed and makes sense to it, a neoreality is created. Psychosis is not only the result of neglect, but it can also be the result of constant terror, where it is unbearable to accept and deal with reality.

               In another case, a person may have a different experience, where they are welcomed and loved, but at other times rejected or treated badly. Their representation of themselves will be fragile, they will know they exist, but only partially, just like the other person. There will constantly be doubts about the other person's presence and love, resulting from an anguish of abandonment. This profile is characteristic of a borderline personality.


Finally, the predominant anxiety of neurotics is that of loss, fearing to lose the love and presence of those who have seen and valued them. They fear the loss of a bond, but this does not imply, as in the borderline case, the loss of self.


As for how they relate to others, this will depend on their ability to mentally represent the other, recognising them as someone different from themselves. In the case of psychosis, the relationship with this other is almost non-existent since there is a confusion between the boundaries of the Self and the Other. One doesn't relate, but absorbs the other, introjects them, or creates a reality for the other, projects them. For example, for some, a simple glance can be understood as a sign of persecution. In the case of the borderline personality, there is a relationship with the object, but a partial one. You don't see the other person and understand them in their own reality and as a total person, with both good and bad aspects, but you oscillate, with the other being either an idealised figure or a rejected one. There is no so-called object constancy. Finally, in the case of the neurotic, the natural failings of their carers having been tolerated by the contingency of love and care, they don't see the other as a persecutory object or as a saviour and idealised being, but as their real person, a total object, with both good and bad aspects, and confidence in continuity comes about because after every separation and difficulty, there has been reparation.


Finally, with regard to defence mechanisms, these are the ways that people use to better deal with their anguish and suffering. A person in the psychotic register will predominantly experience anguish of fragmentation or annihilation (fear of dying, fear of going mad, fear of losing oneself), largely due to the fact that they haven't had stable attachment relationships that they can trust. Without external support and welcome, it is difficult for a person to organise themselves in terms of their boundaries, what is the Self and what is the Other, and without the presence of someone to give voice to their experiences and help with their emotional understanding, they will not have the psychological structure to elaborate on their anxieties, in other words, to understand them in terms of language, thought and representation. Representation requires the knowledge and confidence that something that is not present exists, that something can be referred to by its representation. Psychotics therefore find it very difficult to understand the symbolic world, sticking to literal and concrete understandings. The most commonly used defence mechanisms would be of a more primary nature, with not only the escape from their distressing reality (creating a neo-reality such as hallucinations and delusions) but also the difficulty in differentiating between the Self and the Other, as well as between their own fantasies and reality. We're talking here about phenomena such as idealisation (projecting unrealistic characteristics onto something or someone, but admiring and desiring them), projective identification (attributing personal characteristics and desires to others, e.g. paranoia - a person who feels aggressive and wants to hurt others, but believes that others want to hurt them), denial, dissociation (unconsciously forgetting certain emotional experiences, putting them aside as if they didn't exist or were irrelevant), among others. On the other hand, a person in the neurotic register will have had the experiences necessary for trust in others and in the continued presence of the people and objects they relate to. They will be able to access and understand representations, elaborating their anxieties by making use of more organised defence mechanisms, such as sublimation (expressing oneself through art, poetry, creation), the use of humour, repression (unconsciously separating aspects from self-consciousness and reality that are not easily tolerated), rationalisation (creating argumentative networks to understand and modify the nature of one's emotions), intellectualisation, among others. The nature of the predominant anguish will be anguish of loss (fear of losing love) and guilt, only possible when you already know that you belong or belong to someone and have been loved by them. Finally, the borderline structure is somewhat in the middle of the other structures, presenting a great deal of inconstancy, stemming from the search to resolve the anguish of abandonment (the fear here is of losing oneself if one loses someone's love, there is always a distrust of the other person's intentions). The person is incessantly looking for someone's continuous and stable presence, in order to exist for the other and for themselves in a more integral way and not just in a partial way, as was once the case with insufficient carers, for example those who were sometimes present and sometimes very absent, and who, although they had positive attitudes, also had completely opposite ones. Here there are representations, but partial ones, so that there is great difficulty in analysing facts and people in their entirety, that is, in their ‘good’ and ‘bad’ aspects, oscillating between idealised and destructive views of significant people.


It is also important to point out that although a person may be organised predominantly in one of these structures, this does not imply that they do not have aspects of their personality that are characteristic of the other structures. For example, a person with a neurotic structure (accesses representations and symbolism, has an organised discourse and narrative of self, is able to conceive and experience others as containing both ‘good’ and ‘bad’ aspects in themselves - supports ambivalence, etc.) can have psychotic or borderline cores, such as having a tendency to excessively idealise a romantic partner, becoming dependent on them and denying negative aspects of the relationship.

 

               I won't go any further into explaining personality structures, as it's a complex subject that I'll get to later. But it is essential to realise that these personalities stem from the person's relationship with their environment and with the people they have lived with and live with. Psychopathology or suffering is relational, it's a process and it's not something that is in a person, but something that the person is experiencing. A person is never something, but is being according to multiple factors that underpin their reality. This applies not only to individuals, but to an entire society. After all, are many people anxious in themselves, or are they reacting and adapting to an anxiogenic world and society, which demands constant change, immediate pleasure and the achievement of certain idealised standards? Focusing on the diagnosis is not only reductionist but also unethical, as it ends up reducing the person to a stigma, a category, disregarding the fact that the pathology is an adaptation to an environment (family initially) and society with dysfunctional dynamics.

 

               Structures need to be deeply analysed and changed. Knowing these structures frees us; after all, being never is, but is being.

 

 

1 view0 comments

留言


bottom of page