Psychopathology
Adult patients
The various psychoses involve deficits in the autonomous ego functions (see above) of integration (organization) of thought, in abstraction ability, in relationship to reality and in reality testing. In depressions with psychotic features, the self-preservation function may also be damaged (sometimes by overwhelming depressive affect). Because of the integrative deficits (often causing what general psychiatrists call “loose associations,” “blocking,” “flight of ideas,” “verbigeration,” and “thought withdrawal”), the development of self and object representations is also impaired. Clinically, therefore, psychotic individuals manifest limitations in warmth, empathy, trust, identity, closeness and/or stability in relationships (due to problems with self-object fusion anxiety) as well.
In patients whose autonomous ego functions are more intact, but who still show problems with object relations, the diagnosis often falls into the category known as “borderline.” Borderline patients also show deficits, often in controlling impulses, affects, or fantasies – but their ability to test reality remains more or less intact. Adults who do not experience guilt and shame, and who indulge in criminal behavior, are usually diagnosed as psychopaths, or, using DSM-IV-TR, antisocial personality disorder.
Panic, phobias, conversions, obsessions, compulsions and depressions (analysts call these “neurotic symptoms”) are not usually caused by deficits in functions. Instead, they are caused by intrapsychic conflicts. The conflicts are generally among sexual and hostile-aggressive wishes, guilt and shame, and reality factors. The conflicts may be conscious or unconscious, but create anxiety, depressive affect, and anger. Finally, the various elements are managed by defensive operations – essentially shut-off brain mechanisms that make people unaware of that element of conflict. “Repression” is the term given to the mechanism that shuts thoughts out of consciousness. “Isolation of affect” is the term used for the mechanism that shuts sensations out of consciousness. Neurotic symptoms may occur with or without deficits in ego functions, object relations, and ego strengths. Therefore, it is not uncommon to encounter obsessive-compulsive schizophrenics, panic patients who also suffer with borderline personality disorder, etc.
This section above is partial to ego psychoanalytic theory “autonomous ego functions.” As the “autonomous ego functions” theory is only a theory, it may yet be proven incorrect.
Childhood origins
Freudian theories point out that adult problems can be traced to unresolved conflicts from certain phases of childhood and adolescence. Freud, based on the data gathered from his patients early in his career, suspected that neurotic disturbances occurred when children were sexually abused in childhood (the so-called seduction theory). Later, Freud came to believe that, although child abuse occurs, not all neurotic symptoms were associated with this. He realized that neurotic people often had unconscious conflicts that involved incestuous fantasies deriving from different stages of development. He found the stage from about three to six years of age (preschool years, today called the “first genital stage”) to be filled with fantasies of having romantic relationships with both parents. Although arguments were generated in early 20th-century Vienna about whether adult seduction of children was the basis of neurotic illness, there is virtually no argument about this problem in the 21st century.
Many psychoanalysts who work with children have studied the actual effects of child abuse, which include ego and object relations deficits and severe neurotic conflicts. Much research has been done on these types of trauma in childhood, and the adult sequelae of those. On the other hand, many adults with symptom neuroses and character pathology have no history of childhood sexual or physical abuse. In studying the childhood factors that start neurotic symptom development, Freud found a constellation of factors that, for literary reasons, he termed the Oedipus complex (based on the play by Sophocles, Oedipus Rex, where the protagonist unwittingly kills his father Laius and marries his mother Jocasta). The shorthand term, “oedipal” — later explicated by Joseph Sandler in “On the Concept Superego” (1960) and modified by Charles Brenner in “The Mind in Conflict” (1982) — refers to the powerful attachments that children make to their parents in the preschool years. These attachments involve fantasies of sexual relationships with either (or both) parent, and, therefore, competitive fantasies toward either (or both) parents. Humberto Nagera (1975) has been particularly helpful in clarifying many of the complexities of the child through these years.
The terms “positive” and “negative” oedipal conflicts have been attached to the heterosexual and homosexual aspects, respectively. Both seem to occur in development of most children. Eventually, the developing child’s concessions to reality (that they will neither marry one parent nor eliminate the other) lead to identifications with parental values. These identifications generally create a new set of mental operations regarding values and guilt, subsumed under the term “superego.” Besides superego development, children “resolve” their preschool oedipal conflicts through channeling wishes into something their parents approve of (“sublimation”) and the development, during the school-age years (“latency”) of age-appropriate obsessive-compulsive defensive maneuvers (rules, repetitive games).