2. Lack of sleep, as Paul Federn has pointed out,18 is another factor which may produce a psychotic break in predisposed individuals. It has been shown that sleep deprivation produces hallucinatory phenomena even in normal individuals. Lack of sleep weakens the mind's control of the body. A breakdown may occur in a schizoid individual who spends his nights studying for exams.
3. Emotional situations which the schizoid individual cannot handle may produce a break-down. Schizoid patients have been known to crack up in the face of an impending marriage, a financial crisis, or following the birth of a child. One of my patients attempted suicide after rejection by a young man.
4. Critical periods of life: adolescence and menopause. Adolescence with its surging sexual impulses is a particularly difficult period for the schizoid personality. Indeed, schizophrenia was formerly called dementia praecox because it occurred most frequently in early adulthood. Menopause is another period when inadequate ego adjustments collapse under the impact of strong emotions, often plunging the individual into an emotional crisis.
A nervous breakdown is a loss of control over feelings and behavior. Its manifestations differ, however, from one patient to another. In some patients it appears as an overwhelming anxiety and confusion. Others become wildly destructive and have to be restrained. Still others develop paranoid delusions. And some become progressively withdrawn and unresponsive. Each reacts according to the dynamics of his personality structure, that is, according to the relative strength of the repressed impulses and the defenses against them. In all cases the experience contains common elements which show that a similar process is at work. These elements are:
1. Confusion and feelings of anxiety verging on terror.
2. Estrangement—a state of partial unreality in which one cannot tell if one is dreaming or awake. In this situation one pinches oneself to tell the difference. Estrangement occurs when a person is overwhelmed by sensations.
3. Depersonalization—the loss of the feeling of self.
4. Finally, schizophrenia—a withdrawal and regression to infantile or archaic levels of functioning as a means of survival.
The person going through a breakdown is not aware that repressed feelings have broken through his defenses. Such an awareness would require self-knowledge and ego strength that the schizoid doesn't have. When he acquires these through therapy he is in a position to release the repression without danger to himself or others. The incident which sets off the breakdown may be almost insignificant. If conditions are right, it acts like the fuse which explodes the dynamite. The catastrophic result can only be explained in terms of the terror which is buried within the personality. On no other basis can one understand the extreme steps that the person will take if the terror continues.
The schizophrenic state is a denial of reality. If the denial is complete, the terror vanishes. Since one aspect of his terror is the fear of being destroyed, the schizophrenic's condition is a refuge. He can hardly be destroyed if he is not “here,” that is, not existing in present time and space. He cannot be punished if he is not himself, that is, if he is really Napoleon or Jesus Christ or some god in disguise. On the other hand, if his terror stems from his fear that he will destroy someone else, then a paranoid mechanism removes his fear. He has no reason to reproach himself, since, by means of the paranoid delusion, he is convinced that others are scheming to destroy him. It is amazing how little anxiety the paranoid individual shows when he recounts his story of imagined persecutions. Finally, not to feel and not to think dispels all fear.
4
The Forsaken Body
SELF-POSSESSION
There is something about the physical appearance of the insane individual that strikes us as strange and bizarre. We sense that he is out of contact with things around him. This impression is conveyed by certain physical signs that distinguish the schizophrenic from the normal.
I saw a girl in my office some time ago who was in an obvious psychotic state. She carried her head to one side, as if her neck were bent at an angle. Her eyes had a wild, distraught look. Her face had an expression of fear and agony. She tore at her hair with both hands, moaned and muttered. Her speech was slurred and I could not understand her. I sensed, however, that she understood what I was saying.
She was the patient of one of my associates who was on a hospital call at the time. Although she had no appointment with him, her desperation brought her to the office. She would not quiet down. Any attempt to calm her was resisted forcibly. She continued to moan and tear at her hair. When her doctor was reached he spoke to her on the phone and she became more tractable. Finally, his arrival ended the episode, for he was able to calm her and drive her home.
The appearance of this patient indicated such an evident disturbance that a glance was sufficient to reveal the diagnosis. However, no diagnosis of schizophrenia should be based simply upon a person's state of agony and torment, for it can be shown that similar agonizing emotions may occur in response to a tragic event. For example, a mother might react in like manner to the death of her child. She would moan, tear her hair, and refuse to move. The agony and torment of the insane is no less real because we are unaware of the reason for their suffering. The two situations differ, of course, in their causative factors. In the case of the mother, the anguish is related and proportionate to a known and accepted cause; the behavior of the insane person appears disproportionate to the apparent stresses of his immediate situation. The observer cannot perceive the cause of his actions; and the insane person, whether he knows the cause or not, cannot communicate it to us.
The opposite situation can also exist in insanity. The cause may be known or visible, but the psychotic person's reaction seems to bear no relation to this cause. The simplest example is the lack of reaction to an obvious loss or injury, as in the case of a schizophrenic parent who kills a child but shows no grief. Thus, the lack of meaningful response to the events of the external situation is an accepted indication that “something is off.”
When we say that the psychotic is out of contact with reality, we do not necessarily mean that he is unaware of what is happening around him. The catatonic, for example, is fully aware of what one says or does to him. And the girl in the above illustration, I am sure, knew what I was doing and heard my questions. I asked her what was troubling her. But she couldn't answer this question. She was reacting to a situation inside herself, that is, to certain feelings and body sensations which she did not understand and which were overwhelming her. It is not a question of the intensity of the feeling. The grief of a mother who has just lost a child would be equally intense. She, too, could ignore her environment temporarily. But she would be capable of describing her feelings and of relating them to an immediate cause.
The psychotic person is out of contact with his body. He does not perceive the feelings and sensations in his body as his own or as arising from his body. They are alien and unknown forces acting upon him in some mysterious way. Therefore, he cannot communicate them to us as meaningful explanations of his behavior. He feels terrified, and his behavior expresses this feeling, but he cannot relate it to any specific event.
The schizophrenic acts as if he were “possessed” by some strange force over which he has no control. Before the advent of modern psychiatry it was customary to regard the insane as being “possessed by a demon,” or “devil”—for which he was to be punished. We have rejected this explanation of his illness, but we cannot avoid the impression that the schizophrenic is “possessed.” No matter what the outward expression of the psychotic—whether comic, tragic, delusional or withdrawn—this impression is always present. It still serves as a valuable indication of the illness for today's observer.
It is significant that we use the concept of “possession” in our language
