The Clinical Picture 临床表现 Fred was subsequently able to finish his high school requirements and be accepted in a large eastern university. We have already recounted his subsequent disappointments and the schizophrenic decompensations that brought him to our hospital and into therapy with me. I would like to turn at this point to my own experience working with him and to some of the material related to his treatment course. That material, placed against the background of his family problems and past experiences, raises some difficult and perplexing problems both for the treatment of paranoid patients in general, and for the understanding of the role of psychiatry vis-a-vis the patterns of social disorganization and disruption that swirl about us in contemporary society. 弗雷德后来终于完成了他的高中学业，并被东部一所大型大学录取。我们已经讲述了他后来所经历的失望和精神分裂症的失代偿，这些情况导致他来到我们的医院并接受了我的治疗。现在，我想谈谈我自己与他工作的经历，以及与他治疗过程相关的一些材料。这些材料，结合他的家庭问题和过去的经历来看，不仅给一般意义上偏执患者的治疗带来了一些困难和令人困惑的问题，而且也给理解精神病学在当代社会中围绕我们的社会混乱和破坏模式所扮演的角色带来了一些挑战。 After his admission to the hospital, Fred began to slowly calm down and became increasingly less agitated, hostile, and assaultive. It took somewhat longer for his thought processes to become more organized. For several weeks his thought was rather tangential and he seemed to have difficulty holding a single line of thought for any length of time. He continued to have difficulty concentrating for a considerable period of time. Gradually he was able to become comfortable with the therapeutic situation and more and more able to recall parts of his history and to recount them to me. The substance of much of what was expressed in this early period of his treatment had to do with his intense disappointment and rage in relation to his parents. This would alternate with angry tirades against a wide spectrum of authority figures. The feeling connected with this material was intense. When he would get into these angry diatribes, it seemed that he had all he could do to keep the rage under control and to keep himself from simply exploding. He would clench his fists, pound on the desk furiously, twist his face into a tight, tense knot, shout out explicatives expressing his rage—and the furious intensity of it. 弗雷德入院后，开始慢慢平静下来，逐渐变得不再那么激动、充满敌意、具有攻击性。他的思维过程变得更有条理则花费了更长的时间。几个星期以来，他的思绪相当发散，他似乎很难在任何一段时间内保持一种单一的思路。在相当长的一段时间里，他仍然难以集中注意力。渐渐地，他能够适应治疗环境，越来越能够回忆起自己的部分经历并向我讲述。在他治疗的早期阶段，所表达的大部分内容都与他对父母的极度失望和愤怒有关。这会与他对各种权威人物的愤怒斥责交替出现。与这些材料相关的感觉是强烈的。当他开始这些愤怒的斥责时，他似乎竭尽全力控制愤怒，不让自己爆发出来。他会紧握拳头，愤怒地捶打桌子，把脸扭成一个紧绷的结，大声喊出表达愤怒的理由，以及这种愤怒的狂暴烈度。 He was given a battery of tests at this point and the findings give us a fair representation of his inner turmoil. During the testing he was superficially friendly, but maintained a guarded and suspicious posture. During the intelligence test he became quite angry and defensive, and actually refused to continue the testing. He accused the psychologist of trying to control his mind, as he thought the other doctors were doing. After a lengthy discussion of his feelings about the testing and his illness, he agreed to continue the testing. But he remained quite guarded and would become very upset and defensive whenever he failed a test item. His performance was quite uneven: the full scale WAIS IQ was 99, but verbal was 108 and performance IQ 86. This reflected his reliance on verbal skills to cover his inadequacies and occasional inner confusion. I would like to quote from the psychologist's report: 此时，他接受了一系列测试，测试结果充分反映了他的内心混乱。测试过程中，他表面上很友好，但保持着一种戒备和怀疑的姿态。在智力测试中，他变得非常生气且有抵触情绪，甚至拒绝继续测试。他指责心理学家试图控制他的思想，就像他认为其他医生所做的那样。在长时间讨论他对测试和疾病的感受后，他同意继续测试。但他仍然非常戒备，每当他测试不及格时，就会变得非常沮丧且有抵触情绪。他的表现相当不稳定：全面WAIS智商为99[WAIS是Wechsler Adult Intelligence Scale的缩写，意为韦克斯勒成人智力量表]，但言语智商为108，操作智商为86。这反映了他依赖言语技能来掩盖自己的不足和偶尔的内心困惑。我想引用心理学家的报告： He made an effort to be quite intellectual in his responses, but his responses were quite empty and pretentious. He had markedly impaired comprehension, concentration, and attention. Besides being easily distracted, his associations were quite loose and the logic of some of his reasoning is quite odd. His abstracting ability is low. He tends to be either concrete or overly abstract. His general manner was suspicious and he readily projected responsibility and blame. Mr. F. clearly seems to have a thought disorder that interferes greatly with his ability to think clearly and to function at his appropriate level. He finds it very difficult to think on a secondary process level as he is quite vulnerable to the intrusion of primary process material.... He is under a great deal of instinctual push at this time. He feels quite anxious. agitated, and threatened. At times he feels as if he might lose control of his sexual and aggressive impulses. He feels that he is quite helpless and vulnerable to attack, especially at the hands of other males. Males are seen as being perpetually in conflict and quite aggressive. In the face of the aggression of male authority figures, he readily regresses to quite primitive levels of functioning. His own sexual identity is quite confused in that he sees himself as weak like a woman. His perception of women is that they are damaged and defective. He has partially identified with his mother yet feels rejected by her. Because of his mixed identity he vacillates between displacing the father and seeking his mother as a love object, and competing with her for the love and affection of his father. He feels that he has been unloved and neglected by his parents and other adults, and sees himself as somewhat of a needy orphan child. His own dependency needs are reminders to him of his own vulnerability, and he finds them extremely frightening. The content of some of his Rorschach responses was interesting as well. He tended to see a variety of struggling and fighting male figures in the blots. He described a number of faces and skulls—with staring eyes and biting, tearing mouths and teeth and claws. On the fourth card he saw a giant monster looking down at him and threatening him. There were several other monsters as well—each seen as powerful and destructive. In seeing the monster on card IV he became quite anxious and laughed nervously. At one point he became rather disturbed and complained, "Wow! I'm getting sick. I don't know if I want to do any more of these. I'm really finding these incredible things in my subconscious. All these monsters and stuff! It makes me nervous and crazy—Wow! Like not being in your own head! You get into these things and you never know what you' re going to find. It's ridiculous!" Again, after seeing a monster's head with a biting jaw on card VII, he commented, "Whoever made these up had a freaky mind. Mr. Rorschach had better be careful when he goes around making up these god-damned inkblots—if they came out of his head, then he had monsters in his head. It's like my nightmares—they make me nervous!" 他的回答努力表现得很有智慧，但实际上却很空洞和矫揉造作。他的理解力、专注力和注意力都有明显受损。除了容易分心外，他的联想也相当松散，一些推理的逻辑也很奇怪。他的抽象能力很低。他要么过于具体，要么过于抽象。他通常表现得很多疑，很容易推卸责任和指责别人。F先生的思维明显紊乱，这极大地干扰了他清晰思考和在适当水平上发挥能力的能力。他很难进行二级过程的思考，因为他很容易受到一级过程材料的干扰......他此时承受着巨大的本能冲动。他感到非常焦虑、激动和受到威胁。有时他觉得自己可能会失去对性和攻击冲动的控制。他觉得自己很无助，很容易受到攻击，尤其是在其他男性的攻击下。男性在他看来是永远处于冲突中，相当具有攻击性。面对男性权威人物的攻击，他很容易退回到相当原始的功能水平。他自己的性身份相当混乱，他觉得自己像女人一样软弱。他认为女性是有缺陷的。他部分认同自己的母亲，但又感到被她拒绝。由于他的身份混淆，他在取代父亲和寻找母亲作为爱的客体之间摇摆不定，并与母亲争夺父亲的爱和感情。他觉得自己没有被父母和其他成年人爱过，感到自己被他们忽视过，他觉得自己有点像一个需要帮助的孤儿。他自己的依赖需求提醒他自己的脆弱，他发现这非常可怕。他的一些罗夏墨迹测验的反应内容也很有趣。他倾向于在墨迹中看到各种挣扎和战斗的男性形象。他描述了许多面孔和头骨——瞪着眼睛，咬着、撕扯着的嘴巴、牙齿和爪子。在第四张卡片上，他看到了一个巨大的怪物俯视着他并威胁着他。还有其他几个怪物——每一个都被视为强大和具有破坏性的。在看到第四张卡片上的怪物时，他变得相当焦虑，并紧张地笑了起来。有一次他变得相当不安并抱怨道，“哇！我要生病了。我不知道我是否还想再做这些。我真的在我的潜意识里发现了这些不可思议的东西。所有这些怪物之类的东西！这让我紧张和疯狂——哇！就像不在自己的头脑里一样！你进入这些东西，你永远不知道你会发现什么。这太荒谬了！”同样，在第七张卡片上看到一个长着咬合下颚的怪物头后，他评论道，“创造这些东西的人头脑一定很怪异。罗夏先生最好在制作这些该死的墨迹时小心一点——如果它们是从他脑子里出来的，那他脑子里就有怪物了。这就像我的噩梦一样——它们让我紧张！” The test data reflected the inner turmoil and disorganization that Fred was experiencing at the time. They also reflected his markedly paranoid posture and his tendency to resort to mechanisms of denial and projection in the face of failure or stressful anxiety. More importantly for our consideration, however, we were able to catch a glimpse of his inner world. It was flooded with destructive rage and hostile, aggressive impulses. His inner perception of himself was as a powerful, monstrous, and destructive force. He saw interpersonal contexts in terms of hostility, anger, destructive competitiveness, and vicious sadism. We were struck by the tearing, biting, primitive oral destructiveness that Fred felt to be within him. These are due to the destructive introjects that form the internal basis for his pathology. The primitive organization of these introjects is reflected in the susceptibility and vulnerability to instinctual pressures, as well as the resulting regressive pulls. 测试数据反映了弗雷德当时内心的混乱和无序。它们还反映出他明显的偏执姿态，以及在面对失败或压力性焦虑时倾向于采取否认和投射的机制。然而，对我们来说更重要的是，我们能够窥见他的内心世界。它充斥着破坏性的愤怒和敌对、攻击性的冲动。他内心对自己的认知是一种强大、可怕且具有破坏性的力量。他以敌意、愤怒、破坏性的竞争和恶毒的虐待狂来看待人际关系。弗雷德内心那种撕扯、咬合的原始口腔破坏欲给我们留下了深刻印象。这些都是由于构成他病态心理内部基础的破坏性内摄物所致。这些内摄物的原始组织结构反映在对本能压力的敏感性和脆弱性，以及由此产生的退行性拉力上。