Paranoid States: Diagnostic Categorization 偏执状态：诊断分类 The traditional approach to paranoia, deriving from the influence of Kraepelin and Bleuler, has focused on a small number of paranoid states and has tried to establish these as diagnostic categories—even though the diagnostic stability of the categories has been quite variable(Lewis,1970). The focus in the present study is not on the problems of diagnosis and the establishment of illness categories. My emphasis here is on process—and in this sense the paranoid dynamics can be found in all of the paranoid states which will be described. They vary considerably in the degree, intensity, and extent to which the paranoid process is operative. 传统的偏执症研究方法，受到Kraepelin和Bleuler的影响，专注于一小部分偏执状态，并试图将这些状态确定为诊断类别——尽管这些类别的诊断稳定性变化很大(Lewis,1970)。本研究的重点不在于诊断问题和建立疾病类别。 我在这里强调的是过程——在这个意义上，偏执动力学可以在所有将要描述的偏执状态中找到。它们在程度、强度，以及偏执过程尊做的广度上有很大的不同。 The process point of view has validity not only in the specifically paranoid states, but also for the related toxic and organic states that produce paranoid symptoms. The description of these paranoid conditions offers a better sense of the variety and complexity of pathological forms through which the paranoid process expresses itself. It also makes it apparent, in the consideration of organic states in which paranoid symptoms are observed, that the function of the paranoid process bears a complex relationship to the integral functioning of the total organism. While the paranoid process does not depend on such organic factors for its operation, it is in no sense isolated from their influence. But we shall see more of this later. 该过程观点不仅适用于特定的偏执状态，而且适用于产生偏执症状的相关有毒和器质性状态。这些对偏执状态的描述，提供了对病理形式的多样性和复杂性更好的观念，通过这些病理形式偏执过程将自己表达出来。它还表明，在考虑偏执症状被观察到的器质性状态时，偏执过程的功能与整个有机体的整体功能有着复杂的关系。虽然偏执过程的运作并不依赖这些器质性因素，但它在任何意义上都离不开这些因素的影响。但是我们稍后会看到更多。 Leading the parade of paranoid states is the so-called true or classic paranoia. It can be questioned whether this diagnostic entity ever really occurs. The Diagnostic and Statistical Manual(1968) labels it "an extremely rare condition." The constellation of symptoms involved in paranoia was one of the first to emerge from the diagnostic preoccupation of Kraepelin. Blueler, writing in 1911, offers the following description: 在偏执状态中排在最头里的是所谓的真偏执或经典偏执。这种诊断实体是否真的发生过是值得怀疑的。《诊断与统计手册》(1968)将其列为“极其罕见的疾病”。与偏执有关的一系列症状是最早从Kraepelin的诊断中出现的症状之一。布鲁勒在1911年的著作中给出了如下描述: The construction, from false premises, of a logically developed and in its various parts logically connected, unshakeable delusional system without any demonstrable disturbance affecting any of the other mental functions and, therefore, also without any symptoms of "deterioration" if one ignores the paranoiac's complete lack of insight into his own delusional system(Blueler, 1950). 不可动摇的妄想系统，逻辑上从假前提发展出来，各部分在逻辑上相连。如果你忽略偏执者对他自己的妄想系统完全缺乏洞察这点，可以说这个偏执系统没有任何可论证的扰动会影响其他的心理功能，因此，也没有任何“恶化”的症状。(Blueler, 1950)。 While it remains possible that such an isolated and sequestered delusional system can function in the context of an otherwise integral personality, my own experience has not found this to be the case. Usually—even in patients who present an apparently isolated delusional system, without other apparent personality impairments—on more careful examination they prove to be schizophrenic. There is sufficient diagnostic variability to make the status of classic paranoia a moot question, but I suspect that most contemporary clinicians would tend to diagnose such patients as paranoid schizophrenics. 虽然这样一个孤立和隔离的妄想系统仍然有可能在一个完整人格的环境中发挥作用，但我自己的经验却没有发现这种情况。通常情况下，即使病人表现出明显孤立的妄想系统，没有其他明显的人格缺陷，经过更仔细的检查，他们也被证明是精神分裂症患者。有足够的诊断变异性，使经典的偏执状态成为一个有争议的问题，但我怀疑，大多数当代临床医生倾向于把这样的患者诊断为偏执型精神分裂症。 Paranoid schizophrenia is perhaps the most serious of the paranoid disorders. The paranoid schizophrenic demonstrates the characteristics of the paranoid process as we have described them above—but these characteristics are imbedded in a personality structure which is quite primitive and disorganized. Paranoid characteristics are frequently seen in schizophrenic disorders, both in acute episodes and in chronic cases. The delusional system in such cases tends to be bizarre and somewhat disorganized, with a considerable element of grandiosity. The delusions are often persecutory, and auditory hallucinations are often incorporated as part of or an expression of the delusional content. 偏执型精神分裂症可能是最严重的偏执型障碍。偏执型精神分裂症表现出了我们上面所描述的偏执过程的特征，但这些特征根植于一种相当原始和无组织的人格结构中。偏执的特征经常出现在精神分裂障碍中，无论是急性发作还是慢性病例。在这种情况下，妄想系统往往是奇怪的，有点杂乱无章，有相当大的夸大成分。妄想通常是被迫害，而幻听通常是妄想内容的一部分或表现形式。 The paranoid aspects of schizophrenic breakdowns are not often apparent, although by far the great majority of acute schizophrenic episodes have a strong paranoid flavor. Consequently the large majority of initial diagnoses of the schizophrenic process take the form of paranoid schizophrenia. Again based on my own clinical experience, the overlap between paranoid and schizophrenic manifestations is considerable, and in fact it is a rare schizophrenic patient who does not manifest some paranoid content. This may be flagrant or it may be deeply embedded in the patient's psyche, and it may form an aspect of his illness which he keeps well hidden. Frequently patients who have carried a label of chronic undifferentiated schizophrenia over the course of many years prove on deeper probing to have a latent paranoid core. 精神分裂症的偏执方面并不明显，尽管到目前为止绝大多数急性精神分裂症发作都有很强的偏执特色。因此，绝大多数精神分裂症的初期诊断都是偏执型精神分裂症。再一次，根据我自己的临床经验，偏执和精神分裂症的表现有相当大的重叠，事实上，一个精神分裂症患者没有表现出一些偏执的内容，很罕见。这可能是公然的，也可能深植于病人的精神中，这可能是他隐藏得很好的疾病的一个方面。通常情况下，那些多年来被贴上慢性未分化精神分裂症标签的患者，在更深入的调查中被证明有一个潜在的偏执内核。 I have a suspicion, in reading many of the attempts to attain diagnostic clarity in dealing with these states, that distinctions are often made on the basis of degree, rather than of any significant qualitative difference between categories of patients. It is also quite possible that the historical differentiation of these categories may have been a function of the manner, depth, and sophistication of psychological investigation. In the large custodial institutions of the early part of this and the preceding century, there was little opportunity for careful and time-consuming diagnostic evaluation. 在阅读了许多试图在处理这些状态时获得诊断清晰度的尝试后，我怀疑，区别往往是基于程度，而不是类别患者之间的任何显著的质的差异。这些类别的历史区分也很可能是心理调查的方式、深度和复杂性的结果。在本世纪早期和上个世纪的大型监护机构中，几乎没有机会进行仔细和费时的诊断评价。 A term that has caused considerable confusion—a confusion that was not helped by its use in the DSM II—is the term paraphrenia. Kraepelin's original use of the term was meant to imply that the delusional content was not as rigidly systematized as in full-blown paranoia. Freud, however, used the term as roughly equivalent to our meaning of paranoid schizophrenia, particularly in his discussion of the Schreber case. The term probably does not have much diagnostic utility—particularly in attempts to distinguish it from paranoid schizophrenia. It would seem to represent a group of less disorganized and decompensated paranoid schizophrenics. Despite recent attempts to shore up the distinction(Frost,1969), the usefulness of the distinction is not readily apparent. 有一个术语引起了相当大的混乱——一个在DSM II中没有得到帮助的混乱——那就是妄想痴呆。Kraepelin最初使用这个术语是为了暗示妄想性的内容不像成熟的妄想症那样被严格系统化。然而，佛洛伊德使用这个术语大致相当于我们对偏执型精神分裂症的理解，尤其是在他对史瑞伯案例的讨论中。这个术语可能没有太多的诊断价值，尤其是在试图将它与偏执型精神分裂症区分开来的时候。它似乎代表了一群较无组织和失代偿的偏执型精神分裂症患者。尽管最近有人试图支持这种区分(Frost,1969)，但这种区分的有效性并不明显。 The next important category is that of the involutional paranoid state. This is a counterpart to the more frequent involutional depressive condition. The onset is usually gradual, coming on in the involutional period late in life and often without any apparent precipitating stress. The delusional system usually presages death, along with a fear of abandonment. The fear of death may often be somewhat diffuse and vague, making a diagnostic discrimination between involutional paranoia and involutional depression somewhat difficult at times. The concerns of such patients often focus around the loss of physical capacity, the approaching end of active and useful life and career, and the encroachment of physical disability and increasing loss of function. Often the delusional content will be markedly hypochondriacal. As with involutional melancholia, agitation may be a marked aspect. 下一个重要的类别是更年期偏执状态。这是一种与更常见的更年期抑郁症相对应的疾病。发病通常是渐进性的，在更年期晚期发病，通常没有明显的诱发压力。妄想系统通常预示着死亡，伴随着对被抛弃的恐惧。对死亡的恐惧往往是模糊而弥散的，因此有时很难对更年期偏执症和更年期抑郁症做出诊断。这些病人所关心的往往是丧失身体能力，即将结束活跃和有用的生活和职业，以及身体残疾的侵犯和功能的日益丧失。妄想的内容通常是明显的疑病症。与更年期忧郁症一样，躁动可能是一个显著的方面。 The preceding categories of paranoid states are psychotic in their level of functioning. But there is one major paranoid category which involves a more basically characterological personality distortion. The paranoid personality is characteristically hypersensitive, argumentative, suspicious—constantly maintaining a guarded and defensive attitude toward other people in his environment and the world around him. He is constantly on guard against being taken advantage of, constantly expecting attacks and injury from those around him. He may be quite tense or hostile, but often enough is quiet and receding—in either case maintaining a rigid guardedness and control of his environment and his relationships. 上述类型的偏执状态在其功能水平上属于精神病。但有一个主要的偏执类别涉及到一个更基本的性格上的人格扭曲。偏执型人格的特征是极度敏感、好辩、多疑——对周围的人和环境总是保持一种警惕和防御的态度。他时刻警惕着被利用，时刻等待着周围人的攻击和伤害。他可能很紧张或充满敌意，但通常都很安静和内向——在任何一种情况下都保持着对环境和人际关系的严格控制。 The rigidity and suspiciousness of these personalities make their personal relationships extremely difficult and trying, particularly on people around them. They avoid close involvement and are quite prone to jealousy and angry outbursts. When their intelligence is high and their reality testing intact, they use these capacities in a strenuous and inflexible attempt to control things and people around them. A frequent presentation of such cases in my own experience has been through a somewhat masochistic and depressed wife who comes seeking treatment because of her inability to tolerate the strain of what is happening at home. As it turns out, the husband is a rather paranoid individual who makes the home situation extremely difficult, full of tension, and makes difficult and troublesome demands on the wife as a means of bolstering and supporting his paranoid fears. Such paranoid husbands are almost universally resistant to any suggestion of treatment. I would see the paranoid personality, then, as one in which the paranoid process has become highly structuralized and embedded in the organization of the personality, so that it dominates the inner workings of the personality without necessarily impeding the structural and functional organization of the personality. While it is thus clear that the paranoid process can dominate personality organization without necessarily leading to psychotic disorganization, it is also quite clear that that process can be incorporated into personality organization with varying degrees and in varying ways. This sometimes gives rise to diagnostic difficulties. But we shall see more of this later. 这些人的顽固和多疑使他们的人际关系极其困难和艰难，尤其是对他们周围的人。他们避免亲密接触，很容易嫉妒和发脾气。当他们的智力很高，他们的现实测试完好无损时，他们就会用这些能力进行艰苦而不灵活的尝试来控制周围的人和事。在我自己的经历中，经常出现这样的情况，一个有点受虐和抑郁的妻子来寻求治疗，因为她无法忍受在家里发生的事情的压力。事实证明，丈夫是一个相当偏执的人，他使家庭情况极其困难，充满紧张，并对妻子提出困难和麻烦的要求，作为强化和支持他偏执恐惧的手段。这种偏执的丈夫几乎普遍拒绝任何治疗建议。那么，我认为偏执型人格是这样一种人格，在这种人格中，偏执型过程已经高度结构化，并嵌入到人格的组织中，因此它支配着人格的内部运作，而不必阻碍人格的结构和功能组织。虽然很明显，偏执过程可以支配人格组织，但不一定导致精神错乱，但也很明显，这个过程可以以不同程度和不同方式纳入人格组织。这有时会导致诊断困难。但是我们稍后会看到更多。