THE TRANSITION TO DELUSION 向妄想的转变 One of the critical phases of the process underlying the development of paranoia is the transitional phase in which the inner mental processes shift from a preparanoid organization to a more frankly paranoid form. Sullivan (1953) referred to the paranoid transformation of the personality: This transformation refers to the shifting of blame to others for what previously had to be maintained as a dissociated and intolerable aspect of one's own personality. The patient begins to elaborate personifications of specific evils. He can begin to ascribe to his enemies everything he has felt in himself to be a weakness, defect, or other inadequacy. He can rid himself of those impairments of his own personality from which he has suffered so long. 偏执发展过程的关键阶段之一是过渡阶段，在这个阶段内，内部的心理过程从前偏执组织转变为一种更明确的偏执形式。沙利文(1953)提到了人格的偏执型转变:这种转变指的是将以前必须作为一个人自身人格的分离和不可容忍的方面而被维持的东西归咎于他人。病人开始详细描述具体的罪恶。他可以把自己内心的一切感觉(软弱、缺陷或其他不足)都归因于他的敌人。他能使自己摆脱长期遭受的人格缺陷。 Sullivan describes a quality of illumination about this transformation. The patient gains the sudden insight which allows him suddenly to make sense out of it. The sense of inner defect is suddenly reversed and he begins to see that the others are really to blame. This transforming illumination is usually preceded by a suspicion and a sense of uncanniness which then flowers into the renovating realization—the cognitive reorganization which achieves the transfer of blame. The world becomes active, personified, blameworthy, malignant, and the patient is absolved of his weakness. Arieti(1961) describes the clearing of confusion and ambiguity and obscurity in terms of the dawning of a lucid realization. Things suddenly fall together and are assembled into a pattern that has meaning and relevance to the patient. The pieces of the jigsaw puzzle fit together in what Arieti calls a "psychotic insight."The psychotic insight establishes the paranoid psychosis. Will describes this process in the following terms: 沙利文描述了这种转变的启发性质。病人获得了突然的洞察力，这使他突然明白了其中的道理。内心的缺陷感突然逆转，他开始意识到其他人才是真正的罪魁祸首。这种转化的启发之前通常是怀疑和一种神秘的感觉作为先导，然后开花结果变为革新的实现——认知重组，实现了责备的转移。这个世界变得活跃起来，人格化了，该受责备的，恶性的，病人的弱点得到了宽恕。Arieti(1961)用意识清醒的黎明，来比喻这种对混淆、模糊和晦涩不明的清除。突然间，所有的东西都聚集在一起，组成了一个模式，这个模式对病人来说是有意义的和相关的。拼图的各个部分在Arieti所谓的“精神病洞察力”中组合在一起。精神病洞察力建立了偏执型精神病。Will将这个过程描述如下: As communication fails isolation increases, and the sufferer finds himself caught in a nightmare, driven by a feeling of urgency to make sense of the incomprehensibles with which he is involved. He seeks a simple formula to make all clear, and if he is unfortunate he may elaborate the paranoid solution with its grandiosity, apportioning of blame, and chronic reformulation of the past and present to refine and protect a "system" that will reduce anxiety(1961b,p.22). 当沟通失败时，孤立感就会增加，患者会发现自己陷入了一场噩梦，一种紧迫感驱使着他去理解自己所涉及的那些不可理解的事情。他寻求一个简单的公式来解释清楚，如果他不幸的话，他可能会用它的夸大、责任的分摊和对过去和现在的长期重构来制订偏执的解决方案，以精炼和保护一个将减少焦虑的“系统”(1961b，第22页)。 The process has been described more in detail by Searles (1965). He suggests that the emergence of the paranoid delusion may represent the terminal point of a process in which the patient struggles to defend himself against his anxiety by a variety of mental states—perplexity, bafflement, uncertainty, confusion, and suspicion. Such defensive states develop an increasing intensity of pressure which seeks relief in the simplification of thought processes. The delusion provides such simplification and such relief. The process is analogous, according to Searles, to dream formation or development of a conversion symptom. Both involve complex determinants which are condensed into the conscious expression. The sense of intolerable complexity of thought from which relief is sought is in the subject's awareness. Searles(1965)更详细地描述了这个过程。他认为，偏执妄想的出现可能代表了一个过程的终点，在这个过程中，患者通过各种心理状态——困惑、迷惑、不确定、混乱和怀疑——努力保护自己免受焦虑的困扰。这种防御性状态发展出越来越大的压力，这种压力寻求在简化思维过程中得到缓解。妄想提供了这样的简化和这样的解脱。Searles认为，这个过程类似于梦的形成或转化症状的发展。两者都涉及到复杂的决定因素，这些因素被浓缩成意识表达。寻求解脱的思想的难以忍受的复杂性的感觉存在于主体的意识中。 As Searles sees him, the suspicious person is unable to tolerate, freely and spontaneously, in awareness the full intensity of his affective responses to both internal and external stimuli. Instead he delays and dilutes his response—anger in response to a provocative remark, for example—by focusing his attention in an intellectual way on the remark, searching for nuances and implications of what was meant, and why the remark was made. The inexorable flow of life will sweep more stimuli on him before any one has been processed. The normal person can allow himself to flow with the influx of stimuli and respond appropriately and proportionally to each. For the suspicious person the unavoidable influx of external stimuli and the constant pressure of internal stimuli become increasingly difficult, and the pressure involved in maintaining defenses against these emotions becomes increasingly intense and intolerable. He cannot bring himself to seek relief by admitting these affects into consciousness—they are simply too threatening. Searles认为，多疑的人无法自由地、自发地容忍自己对内部和外部刺激的全部情感反应。相反，他通过以一种理智的方式将注意力集中在这句话上，寻找其中的细微差别和含义，以及为什么要说这句话，来拖延和稀释他的反应——例如，对挑衅言论的愤怒反应。在他处理完一个刺激之前，无情的生命之流会在他身上扫过更多的刺激。正常人可以让自己随着刺激的涌入而流动，并对每一种刺激做出适当而成比例的反应。对于多疑的人来说，不可避免的外部刺激的涌入和内部刺激的持续压力变得越来越困难，而维持对这些情绪的防御所涉及的压力变得越来越强烈和无法忍受。他不能让自己通过承认这些影响进入意识来寻求解脱——它们简直太危险了。 The delusion brings relief from this increasing intensity and complexity. The delusion brings a reorganization of meaning which makes sense out of everything—or nearly so. It provides a focus for previously fragmented attention so that the influx of external and internal stimuli now can be related to this new formation. We have noted the characteristic selectivity of attention in paranoid states—stimuli that do not fit with the delusion are simply disregarded or discounted as irrelevant. The transformation is achieved by way of the paranoid construction. The increasing pressure which Searles describes has to do with the subject's inner needs and insecurity. The cognitive reorganization which is part of the paranoid construction is determined not so much by the logical force of available evidences, but by the inner subjective needs which the subject finds increasingly stressful and intolerable. 这种妄想从这种日益增长的强度和复杂性带来了解脱。这种妄想带来了意义的重组，使每件事都变得有意义——或者几乎有意义。它为以前分散的注意力提供了一个焦点，因此外部和内部刺激的流入现在可以与这个新形成的联系起来。我们已经注意到偏执状态下特有的注意力的选择性——不符合妄想的刺激被简单地忽略或认为无关紧要。这种转变是通过偏执建构来实现的。Searles所描述的不断增加的压力与主体的内在需求和不安全感有关。认知重组是偏执建构的一部分，其决定因素与其说是现有证据的逻辑力量，不如说是主体日益感到压力和难以忍受的内在主观需求。 The paranoid transformation often serves as a resolution of an underlying process of schizophrenic disorganization. The perplexity, bafflement, uncertainty, confusion, and suspicion that Searles describes are frequently aspects of schizophrenic fragmentation and disintegration. Such aspects of depersonalization, however, can also occur at less pathological levels, but must always be seen as defensive operations. We can also add that the defenses are directed not to underlying feelings of anxiety alone, but also against underlying depressive affects. The shift from such unstable defensive patterns toward a paranoid resolution is an attempt to achieve cognitive closure and affective relief. To the extent that it achieves these objectives, the paranoid transformation becomes inflexible and relatively irreversible. To that extent the prospects for successful therapeutic intervention are diminished (Will,1961a). 偏执的转变通常作为精神分裂症紊乱的一个潜在过程的解决方案。Searles描述的困惑、迷惑、不确定、混乱和怀疑是精神分裂症分裂和瓦解的常见方面。然而，人格解体的这些方面也可以发生在较不病态的水平，但必须始终被视为防御性的行动。我们还可以补充说，这些防御措施不仅针对潜在的焦虑情绪，还针对潜在的抑郁影响。从这种不稳定的防御模式向偏执的解决方案的转变，是一种实现认知封闭和情感解脱的尝试。在达到这些目标的程度上，偏执型转变就会变得僵化，而且相对不可逆转。在这种程度上，成功的治疗干预的前景被削弱(Will,1961a)。 The emergence of clinical paranoia is an end stage of a developmental course which, at psychotic levels of severity, may extend back to the first year of life. The central theme of this development is the subversion of the child's will by a parent to believe that one's will can be unconditionally influenced by another person(Kovar,1966). Through the years of childhood and adolescence, the patient may maintain himself in a prepsychotic state of uneasy equilibrium by avoiding situations in which the dictatorial parent or surrogate is not present. The presence of such a figure serves to organize and direct the preparanoid's life and activity. Kovar (1966) feels that, when such an authoritarian figure becomes unavailable, the delusional structure emerges. Its function is to provide the needed external influence. This observation is important, since it reemphasizes the fact that the paranoid defense is not only derived from inner uncertainties, disillusionments, and depressive anguish, but it has determinants which derive from the patient's environment as well. The inner dynamic determinants permit us to see the inner necessity of defense, but they do not help us to understand fully how it is that the pattern and style of defense becomes paranoid, rather than, for example, manic. 临床偏执的出现是一个发展过程的最后阶段，在严重程度的精神病水平上，可以追溯到生命的第一年。这种发展的中心主题是父母对孩子的意志的颠覆，他们认为自己的意志可以无条件地受到另一个人的影响(Kovar,1966)。在儿童和青少年时期，患者可能通过避免出现独裁父母或代理人不在场的情况，使自己保持在一种平衡不稳定的前精神病状态。这样一个形象的存在是为了组织和指导前偏执者的生活和活动。科瓦尔(1966)认为，当这样一个威权人物变得不可用时，妄想结构就会出现。它的作用是提供必要的外部影响。这种观察很重要，因为它再次强调了这样一个事实:偏执的防御不仅来自于内心的不确定性、幻灭和抑郁的痛苦，而且还有来自患者环境的决定因素。内在动力学决定因素允许我们看到内在防御的必要性，但它们不能帮助我们充分理解防御的模式和风格是如何变得偏执而不是狂躁的。 Some of the initial probing in this direction was done by Sullivan. He describes the paranoid transformation as passing from the feeling that one is the victim of one's own defects to the realization that one is the victim of a devilish environment. "It is not that I have something wrong with me, but that he does something to me." There is a passage from unhappy sanity to a relatively more comfortable paranoid psychosis. As he views the process, the self is built out of interactions—adjustments, expectations, compromises—with the culture. Our own inner security or insecurity is built on the recurrent evaluations of significant persons around us. We are blamed by others who may take out on us their sense of frustration with their own shortcomings. If we have a sense of this unfairness, we learn to blame them in turn for our own discomfort. The sources of our real discomfort date back to infancy and childhood and to our empathic ties to significant objects, before we could determine who was to blame for how bad we felt. 在这个方向上的一些初步探索是由沙利文完成的。他把这种偏执的转变描述为，从自我缺陷的受害者，到意识到自己是邪恶环境的受害者。“不是我有什么毛病，而是他对我做了什么。”从不快乐的神志正常人到相对舒适的偏执型精神病有一段路要走。在他看来，自我是建立在与文化的互动之上的——调整、期望、妥协。我们自己内心的安全感或不安全感是建立在对我们周围重要人物的反复评估之上的。我们会受到他人的指责，他们可能会在我们身上发泄他们对自己缺点的挫折感。如果我们有这种不公平的感觉，我们就学会反过来把自己的不适归咎于他们。我们真正感到不舒服的根源可以追溯到婴儿期和童年时期，以及我们与重要客体之间的移情关系，那时我们还无法确定对于我们的糟糕感觉该责备谁。 But the transfer of blame, while it saves us for the moment, is still open to question, and becomes even less secure when we subject it to consensual validation. In fact the real roots of feelings of insecurity and inadequacy are often hidden from us. To support his transference of blame, the paranoid provides an explanation,a context which gives meaning to, and substantiates, his blaming operation. The paranoid construction thus emerges in the service of completing, supporting, substantiating, and justifying the transference of blame which is the essential aspect of the paranoid transformation. The inner exigency to maintain the transfer of blame is the driving force behind the pressure to confirm the paranoid construction. The greater the insecurity, the more insistent the need to misinterpret or reinterpret every event to bring it into congruence with the basic construction. Thisdelusional distortion may well reach schizophrenic proportions(Sullivan, 1956). 但是，责备的转移虽然暂时挽救了我们，但仍存在疑问，当我们将其置于双方同意的确认之下时，这种做法就更不安全了。事实上，不安全感和不足感的真正根源往往对我们隐藏起来。为了支持他的责备转移，偏执者提供了一个解释，一个上下文，给他的责备行动赋予意义，并使之具体化。因此，偏执建构是为完成、支持、证实和证明责任转移而服务的，这是偏执转变的基本方面。坚持责任转移的内在迫切性是确认偏执建构的压力背后的动力。不安全感越大，就越迫切地需要曲解或重新诠释每一件事，使其与基本结构相一致[基本结构指偏执建构]。这种妄想扭曲很可能达到精神分裂症的程度(沙利文，1956)。 It is apparent that the transformation from preparanoid to paranoid thinking involves both a cognitive reorganization and a defensive realignment of the personality. Underlying both these aspects, there are genetic influences which determine the pattern of response and set the stage for the emergence of the paranoid defense. There are, therefore, genetic aspects of the problem which have to do with the painful aspects of the inner sense of inferiority, worthlessness, inadequacy, and a lack of a sense of autonomy and self-esteem—elements of the perception of oneself which are intolerable and require defensive maneuvers so that they can become bearable. There are also genetic aspects which have to do with the pattern and organization of defensive operations. Given the underlying need for defenses, what are the influences that mold the ego's resources to deal with such painful pressures in the direction of the paranoid defenses and mechanisms? When we talk about paranoid style, it is this cluster of influences that are most pertinent. However, we must not lose sight of the fact that the underlying necessities, to which the paranoid operation is a response, are also in their way determinants of the response. They are the irritants for which the paranoid position is a specific rejoinder. In this manner the several genetic currents interact and in a sense determine each other. 很明显，从前偏执到偏执思维的转变包括认知重组和人格的防御性重组。在这两个方面的基础上，起源的影响决定了反应的模式，并为偏执防御的出现奠定了基础。因此,还存在起源方面的问题，这些问题与痛苦的方面有关，这些方面包括内心的自卑感,毫无价值,不足,缺乏自主权和自尊——也就是自我感知中无法忍受,并要求防御策略(这样他们就可以成为可以承受的)的元素。还有起源因素与防御行动的模式和组织有关。考虑到对防御的潜在需求，是什么影响塑造了自我的资源，使其朝着偏执防御和机制的方向来应对这种痛苦的压力?当我们谈论偏执风格时，这一系列的影响是最相关的。然而，我们决不能忽视这样一个事实，即偏执行动是对底层必须性的一种反应，这些必须性也是反应的决定因素。他们是一种刺激物，偏执的心位是一种具体的反驳。以这种方式，几个起源的洋流相互作用，并在某种意义上决定彼此。