Adolescence, Indifferentiation, and the Onset of Psychosis

ADOLESCENCE, INDIFFERENTIATION, AND THE ONSET OF PSYCHOSIS Henri Grivois Hôtel-Dieu, Paris The onset of psychosis happens, by definition, only once. The first psychotic episode is unforeseeable and risks being overlooked. Left to itself its future is uncertain, and the prognosis is potentially unfavorable. The variety of its manifestations as well as its thymic and cognitive instability explains why so little is written on this subject. The psychiatric literature, by its almost exclusive reference to evolved psychoses, has not distinguished the qualities peculiar to the onset of psychosis (nascent psychosis). Yet recent research reflects an interest in early diagnosis of psychosis to secure qualitative improvements and the chance ofa favorable outcome for patients. A special approach must be used for patients during the stage of nascent psychosis. Something must be done, but early treatment is not enough. Psychotropic medication has no more than a sedative effect and there are few specifics at this stage (Swain 175). Further, one risks obliterating the patient's lived experience. The entire battery of interventions, above all the first consultations, must follow from a rigorously organized and intensive strategy to directly engage with this subjective experience. For many years at l'Hôtel-Dieu, a general hospital situated in the center of Paris, we have harnessed ourselves to this task. First I shall describe the existence of centrality. It constitutes the most characteristic and permanent trait of the onset of psychosis. From the concept of concernment, I propose a phenomenological morphogenesis of the initial sequence of psychosis. Next I turn to the state of indifferentiation that overcomes the subject, and then to the vulnerability peculiar to adolescents. I shall end with some fundamental epidemiological data. Henri Grivois1 05 Centrality To be mad is not only the feeling of being uniquely in contact with all humanity, whether as alienated from it or as uniting all of it in oneself conceived as the only member of the species. It is this certainly but also more than this. It is to infer that one occupies a unique place in the human world. It is the feeling of being encircled by everyone. Without being responsible, the patient is placed in the forefront of some grandiose project. His centrality, whatever the mode ofexpression, orients him towards a form of mental disorder. As a general rule, at the beginning, centrality is never explicit and passes unnoticed. The physical and verbal behavior of the patient suffice to accuse him, without any further investigation, of unintelligibility and incoherence. Centrality is above all an emotion about which we should admit that we know almost nothing. People with nascent psychosis are the prey of intuitions impossible to comprehend. Like Rimbaud's drunken boat, they flee, drifting or hiding themselves, coming back and taking offagain. They are therefore incapable, wherever they go, of living an instant of unconcern. Incapable of expressing their singular rapport with the world, they keep silent. Very soon nevertheless centrality engenders a torrent of questions. Silently, voicelessly, patients apprehend in an almost automatic manner the responses to these questions in the verbal and gestural behavior of others. Since Esquirol (Gauchet and Swain 464) identified hallucinatory phenomena as the cause of psychosis, they have occupied a disproportionate place in mental science for 200 years. This construction of the concept of hallucination in psychiatry, key to the orthodox vision of psychosis, assures a watchful vigilance to rule out every non-symptomatic treatment ofpatients. Hours or perhaps days later, no longer capable of abstaining from interpretation, patients begin to sketch out an explanation ofthe prodigious situation which they have experienced. They interrogate their relation to others and the intentions and the degree of unanimity of people towards them. Invoking demons and monsters often gives their explanations a first coherence which is in harmony with the scale of their experience. On their side the psychiatrists, to facilitate verbalizing the experience, suggest paraphrases of a general order: influence, mental automatism, exterior action, xenopathia, etc. To mask centrality, to get away from it, or in response to the gravity of the event, the patients, in search of some responsibility, envisage more elaborate scenarios: mission, conspiracy, trial, condemnation. A political vocabulary, more plausible but less universal than a...