CLINICAL CONTEXTS 临床环境 I would like to address a comment briefly at this time to the operation of the paranoid process specifically in regard to certain clinical entities: the nature of the specifically pathological manifestations of paranoia in the context of other diagnostic entities. This is an important point since my presumption is that paranoid elements enjoy a wide distribution in the general population, and that if one looks carefully enough and with sufficient intensity one can find paranoid manifestations with few exclusions in most human beings. 在此，我想简要地谈一下偏执过程的运作，特别是针对某些临床实体:在其他诊断实体的背景下，偏执的具体病理表现的性质。这是很重要的一点，因为我的假设是，偏执元素在一般人群中分布广泛，如果一个人足够仔细和足够强烈地观察，他可以在大多数人身上发现偏执的表现，几乎没有人幸免。 But I am focusing for the moment on the question of the extent to which identifiable clinical paranoia can be found in conjunction with other diagnostic categories. The first diagnostic category that I would like to consider is that of homosexuality. The connection between homosexuality and paranoid dynamics is a classic one, and was enunciated clearly, as we have seen, by Freud. As we have also seen, the inference that homosexuality and paranoia are always linked is also a questionable one. However, the dynamics of homosexuality can be and often are associated with the dynamics of paranoia. This is particularly the case where homosexuality reflects a feminine identification. Where homosexuality comes to mean passivity, submission to the power of the strong father, identification with the weak, passive, victimized, and powerless mother, the dynamics underlying homosexuality come to lie very close to those we have seen in reference to the paranoid process. 但我现在关注的问题是在何种程度上可以将临床偏执症与其他诊断类别相结合。我想考虑的第一个诊断类别是同性恋。同性恋和偏执动力学之间的联系是一个经典的例子，正如我们所看到的，弗洛伊德已经清楚地阐明了这一点。正如我们已经看到的，同性恋和偏执总是联系在一起的推论也是有问题的。然而，同性恋的动力学可以经常与偏执的动力学联系在一起。当同性恋反映了女性身份认同时尤其这样。当同性恋意味着被动，屈从于强大父亲的力量，认同软弱、被动、受迫害、无权无势的母亲时，同性恋背后的动力学与我们在偏执过程中看到的非常接近。 If paranoia can be a defense against underlying homosexual conflicts, it seems equally true that homosexuality can serve as a defense against underlying paranoid conflicts. What seems to me useful to keep in perspective is that both homosexuality and paranoia may be a response to similar underlying concerns. Thus they may be seen to function in conjunction, or be linked in reciprocal defensiveness, or may follow disparate paths both defensively and developmentally. It seems to me that, frequently enough, the breakdown of paranoid defenses is what brings the homosexual into treatment. Moreover, frequently enough, the paranoid defenses are what makes the treatment of homosexuality so problematic and difficult. 如果偏执可以用来防御潜在的同性恋冲突，那么同性恋也可以用来防御潜在的偏执冲突，这似乎也是正确的。同性恋和偏执都可能是对类似潜在问题的一种响应，在我看来，意识到这一点很有用。因此，它们可能被视为协同作用，或在相互防御中相互联系，或在防御和发展上遵循不同的路径。在我看来，通常情况下，是偏执防御的崩溃让同性恋者接受治疗。此外，偏执防御常常使同性恋的治疗变得困难重重。 Another important area in which the paranoid process can function is in relationship to phobias. We have had occasion to suggest that there may be some genetic relationship between childhood phobias and the development of paranoid personalities. Often it is difficult to draw the line between phobic states and more specifically paranoid processes. Both are forms of externalization. My experience is that paranoid patients tend to show phobic symptoms, often of a rather severe nature. It is difficult for example to draw the line between a severe agoraphobia and a frank paranoia. We will have occasion to discuss this question later on in our theoretical consideration, but in terms of diagnostic concerns it seems to me that phobic responses may often mask underlying paranoid concerns. 偏执过程运作的另一个重要领域是在与恐惧症的关系中。我们曾有机会提出，在儿童恐惧症和偏执型人格的发展之间可能存在某种发生学上的关系。通常很难在恐惧状态和更具体的偏执过程之间划清界限。两者都是外化的形式。我的经验是，偏执患者往往表现出恐惧症状，通常是相当严重的。例如，很难在严重的广场恐怖症和明显的偏执症之间划清界限。稍后我们将有机会在我们的理论思考中讨论这个问题，但是在诊断方面，在我看来，恐惧反应可能经常掩盖了潜在的偏执的担忧。 I recall one patient of mine who presented with a combination of phobic anxiety and depression that was relatively severe and resisted attempts at therapeutic intervention for a considerable period of time. It was only gradually that I became aware that the apparent agoraphobia, which became the focus for our therapeutic concerns, was covering a host of paranoid symptoms including ideas of reference and fears of attack and annihilation. It should be remembered that when Freud originally discussed the symptom of agoraphobia, he related it to identification with the prostitute in women and discussed the dynamics of the phobic condition in terms of the underlying wish to be violated. One can add at this point that in the same example there may also be a residual fear of vulnerability and violation which may underlie a specifically paranoid dynamic as well (Freud,1887-1902, pp.181-182). 我记得我的一个病人，他表现出一种结合了恐惧焦虑和抑郁的症状，后者相对严重，并在相当长的一段时间内抗拒治疗干预的尝试。直到后来，我才逐渐意识到，明显的广场恐怖症(这成为我们治疗关注的焦点)涵盖了一系列偏执症状，包括牵连观念[指将无关的外界现象解释为与本人有关，而且往往是恶意的，可成为妄想的先兆。]和对攻击和毁灭的恐惧。应该记住，当弗洛伊德最初讨论广场恐怖症的症状时，他把它与女性对妓女的认同联系起来，并从潜在的被侵犯的愿望的角度讨论了恐惧状态的动力学。在这一点上，人们可以补充说，在同样的例子中，可能还有一种对脆弱和侵犯的残留恐惧，位于特别的偏执动力学之下(弗洛伊德，1887-1902，页181-182)。 Another important diagnostic category is that of so-called psychopathic or the sociopathic personality disturbance. The DSM II describes this form of disorder under the rubric of antisocial personality. 另一个重要的诊断类别是所谓的精神变态或社会病态人格障碍。DSM II在反社会人格的标题下描述了这种形式的障碍。 As Cleckley has pointed out(1959), the psychopath typically demonstrates superior intelligence and other assets, and is able to succeed brilliantly for short periods of time in work, or study, or other human relationships, but inevitably and repeatedly fails in almost all the contexts of his endeavor. He proves himself inadequate, defective, and a failure. The lack of anxiety in such personalities, the tendency to displace blame to external forces, the inability to accept responsibility, and the antisocial tendencies begin to suggest ramifications of the paranoid process. The antisocial or psychopathic personality would seem to be a masked form of underlying paranoid dynamics. The paranoid process works in such a way as to set off such an individual from the rest of society, to endow him with certain special and narcissistic qualities, and to place him in a position that is inevitably in opposition to the social fabric. The sociopath stands in continuity with neighboring areas of psychiatric concern, specifically delinquency and criminal behavior. These also may express underlying paranoid dynamics. 正如Cleckley(1959)所指出的，精神变态者通常表现出卓越的智力和其他优势，能够在短期内在工作、学习或其他人际关系中取得卓越的成功，但不可避免地，并一再地，在所有他努力的情况下失败。他证明了自己的不足、缺陷和失败。人格中缺乏焦虑，倾向于把责任推给外部力量，无法承担责任，以及反社会倾向，开始暗示偏执过程的后果。反社会或精神变态人格似乎是潜在的偏执动力学的掩蔽形式。偏执过程是这样运作的:把这样一个人从社会的其余部分中隔离出来，赋予他某些特殊的自恋特质，并把他置于一个不可避免地与社会结构对立的位置。社会病态患者与邻近的精神病学关注领域保持一致，特别是违法和犯罪行为。这些也可能表现出潜在的偏执动力学。 The conjunction of paranoid manifestations and obsessional syndromes is, in my experience, not infrequent. This tends to be more so the case in the more severe obsessional states. It may in fact be seen with considerable regularity in borderline patients. Goldberg(1965) has reported a small series of four cases in which obsessional and paranoid mechanisms have coexisted over a considerable length of time without emerging into frank psychosis. It seems to me, in general, that there is a greater tendency for paranoid manifestations to be associated with obsessional syndromes than with hysterical syndromes. 根据我的经验，偏执症状和强迫症的结合并不少见。在更严重的强迫状态中，情况往往更严重。事实上，它在边缘型患者中经常出现。Goldberg(1965)报告了四个案例，其中强迫性和偏执性机制共存了相当长的一段时间，但没有发展成明确的精神病。在我看来，一般而言，偏执症状与强迫综合症的联系比与歇斯底里[即癔症型、表演型]综合症的联系更大。 However, as clinicians are well aware these days, more and more in analytic practice there is a tendency not to see relatively clear-cut neurotic syndromes, but rather complex personality organizations in which obsessional and hysterical features are combined in various proportions. My patient Jim J. represents a striking case of this congeries of personality characteristics. He suffered severely from anxiety and presented initially as a rather striking case of male anxiety hysteria. It gradually became clear, however, in the course of his analysis that he had a strong obsessional element in his personality which he was in many ways able to mobilize effectively as a defense against his underlying anxieties. We have discussed the rather significant role of paranoid manifestations in his overall personality functioning as well. 然而，如今临床医生都很清楚，在分析实践中，越来越多的人倾向于看到的不是相对明确的神经症状，而是复杂的人格组织，其中强迫性和歇斯底里的特征以不同的比例组合在一起。我的病人吉姆·J就是这种性格特征的一个典型例子。他患有严重的焦虑症，最初表现为明显的男性焦虑歇斯底里症。然而，在他的分析过程中，人们逐渐清楚地看到，他的人格中有一种强烈的强迫元素，他在许多方面都能有效地动员这种强迫因素来抵御他潜在的焦虑。我们已经讨论了偏执表现在他整体人格功能中的重要作用。 It should be noted that in relatively severe states of hysterical anxiety paranoid preoccupations may play a role in the clinical picture. It is also clear that paranoid manifestations may occur in varying combinations with hysterical manifestations.I am reminded of the excellent case discussion of Rycroft (1968), and more strikingly in the description of a case of hysteria by Jaffe(1971 a,b). The question remains as to whether both these cases might not have been borderline. The association between hysterical personality configurations and preoccupations and conflicts over homosexuality are a well established clinical phenomenon. We can only take note at this point of the links between feelings of feminine vulnerability, passivity, and penis envy, and the linkages between such concerns and what we have been describing here as paranoid dynamics. 值得注意的是，在相对严重的歇斯底里焦虑状态中，偏执先占观念可能在临床表现中扮演了某种角色。还可以明确的是，偏执的表现可能与歇斯底里的表现有不同的组合。这让我想起了赖克罗夫特(1968)的精彩案例讨论，更引人注目的是贾菲(1971 a,b)对癔病病例的描述。这两个案例是否还未到达边缘型，尚存疑。癔症型人格结构与同性恋的先占观念和冲突之间的联系是一个公认的临床现象。在这一点上，我们只能注意到女性脆弱感、被动和阴茎嫉妒之间的联系，以及这些担忧和我们在这里描述的偏执动力学之间的联系。 We might also note the relationship between the hysterical process and depression. A frequent linking of depressive dynamics with hysterical manifestations is a well-known clinical concern, one that raises specific problems for establishing criteria of analyzability. This general area of clinical concern was focused on by Zetzel (1968), who also provided a classificatory scheme of levels of hysterical organization in which one of the primary parameters was the depth of accompanying depression. It remains a moot question the extent to which paranoid mechanisms can be mobilized in the service of defending against such underlying depression, but at this point I can only suggest that the incidence of such paranoid responses may be more frequent than has otherwise been suspected. 我们也可以注意到歇斯底里的过程和抑郁之间的关系。抑郁动力学与歇斯底里表现的频繁联系是一个众所周知的临床问题，这为建立可分析性标准提出了具体的问题。Zetzel(1968)关注了这一普遍的临床关注领域，他还提供了一个歇斯底里组织水平的分类方案，其中一个主要参数是伴随抑郁症的深度。在何种程度上偏执机制可以动员起来，以防御这种潜在的抑郁症，仍然是一个有争议的问题，但在这一点上，我只能建议，这种偏执反应的发生率可能比被怀疑的更频繁。 A word should be said here about the so-called schizoid personality dis orders. If the incidence of paranoid manifestations must be regarded as questionable in the obsessional and hysterical disorders, that question would seem to be resolved in reference to schizoid disorders. My experience with schizoid characters has been limited, but in almost every case that I have had the opportunity to become familiar with there has been an identifiable paranoid core to the disorder. One is reminded inevitably of the so-called schizoid-paranoid positions described by Melanie Klein, a conjunction that we had occasion to discuss in relationship to Klein's contributions to the understanding of development. Guntrip(1969)attempts to separate the paranoid-schizoid position into its respective components. If the　"depressive position" is guilt-burdened, then the "paranoid position" must be regarded as fear-burdened. But Guntrip would regard the so-called schizoid position as lying still deeper than either the depressive or paranoid positions, thus representing a state in which the infantile ego has withdrawn from object-relations and seeks safety away from the anxieties of persecution or guilt. He writes: 这里应该说一下所谓的分裂样人格障碍。如果偏执症状的发生率在强迫型障碍和癔症型障碍中被认为是值得怀疑的，那么这个问题似乎在分裂样障碍中得到了解决。我对分裂样患者的经验是有限的，但在几乎每一个我有机会熟悉的案例中，都有一个可以识别的偏执内核。这不可避免地让人想起梅兰妮·克莱因)所描述的所谓分裂-偏执心位的观点，我们曾有机会讨论这个连接词与克莱因对理解发展的贡献的关系。Guntrip(1969)试图将偏执-分裂心位分成各自的部分。如果“抑郁心位”是负罪的，那么“偏执心位”一定是恐惧的。但是，Guntrip会认为所谓的分裂心位比抑郁或偏执心位位于更深的地方，因此代表了一种状态，在这种状态中，婴儿的自我已经从客体关系中撤退，寻求安全，以摆脱迫害或内疚带来的焦虑。他写道: The paranoid individual faces physical persecution(as in dreams of being at tacked by murderous figures) and the depressed individual faces moral persecution(as, for example, in feeling surrounded by accusing eyes and pointing fingers), so that Klein regards both positions as setting up a primary form of anxiety. In fact, most individuals prefer to face either depressive anxiety(guilt) or persecutory anxiety(amoral fear) or an oscillation between them, rather than face the extreme schizoid loss of everything, both objects and ego. Both persecutory anxiety and depressive anxiety are object-relations experiences while the schizoid position cancels object-relations in the attempt to escape from anxiety of all kinds(1969, p. 57) 偏执的个体面临着身体上的迫害(就像在梦中被凶残的人物所钉住)，而抑郁的个体面临着道德上的迫害(比如，被指责的眼神和手指所包围的感觉)，因此克莱因认为这两种情况都是焦虑的主要形式。事实上，大多数人宁愿面对压抑性焦虑(内疚)或被害性焦虑(非道德恐惧)或两者之间的振荡，也不愿面对极端的分裂的失去一切，包括客体和自我。被害焦虑和抑郁性焦虑都是客体关系体验，而分裂心位为了逃避各种类型的焦虑而取消客体关系(1969，第57页)。 What Guntrip describes is a relatively pure state of affairs relating to the dynamic configuration of infantile positions. However, clinically such pure positions are rarely seen in isolation. Klein's description may therefore be closer to the clinical basis. To my way of thinking the paranoid response may be seen as a defense against underlying depressive concerns, and the schizoid position may be envisioned as a defensive avoidance against both.　My own clinical experience suggests that the schizoid and paranoid manifestations seem to be clinically closely linked. The moot question which remains is whether or not the typical state of schizoid withdrawal and isolation is not in fact a manifestation of paranoid processes and a defense against paranoid anxieties. Guntrip所描述的是一种与婴儿心位的动力学配置相关的相对纯粹的状态。然而，临床上这种单纯的心位很少单独出现。克莱因的描述可能因此更接近临床基础。在我看来，偏执反应可能被视为对潜在的抑郁担忧的防御，而分裂心位可能被视为对两者的防御性回避。我自己的临床经验表明，分裂和偏执的表现在临床上似乎是紧密相连的。还有一个悬而未决的问题，那就是是否典型的分裂性退缩和孤立状态，实际上不是偏执过程的表现，以及对偏执性焦虑的防御。 We have had occasion already to discuss the overlap between paranoid symptoms and schizophrenic manifestations. Flagrant paranoid delusions are most frequently seen in the context of the schizophrenic process. Our attempt in the present study was to focus the paranoid dynamics as discernible and independent of the schizophrenic process, even though the overlap in clinical presentation was quite strong, and even though both the schizophrenic and paranoid process seemed to share a number of common etiological influences. The paranoid process can then be seen as independent of, although in many cases secondary to, the schizophrenic process. 我们已经有机会讨论偏执症状和精神分裂症状之间的重叠。公然的偏执妄想在精神分裂过程中最常见。我们在本研究的尝试聚焦于偏执动力学作为可识别的，与精神分裂过程独立的东西，即使重叠的表现在临床上非常强劲,尽管精神分裂和偏执的过程似乎共享一些共同的病因学的影响。偏执过程可以被视为独立于精神分裂过程(虽然在很多情况下次要于)。 In any number of cases, the paranoid resolution seems to function as adefensive bulwark against further schizophrenic deterioration. We have been able to identify the interplay of these respective processes in a number of cases we have analyzed above. The schizophrenic process has built into it a sense of inherent vulnerability, victimization, weakness, loss of autonomy and trust, and other factors which might precipitate a paranoid response.　The paranoia may be seen in terms of a restitutional response to the schizophrenic decompensation. Paranoid schizophrenics, then, may be seen as schizophrenics who have retained sufficient internal structure and capacity to mobilize their resources in a form of paranoid defense. Diagnostically, however, this particular group does not provide much difficulty, since the paranoid manifestations are usually of psychotic proportions and are therefore easily recognized. 在任何情况下，偏执的解决方法似乎都是防止精神分裂症进一步恶化的一种防御手段。我们已经能够在上面分析的许多案例中识别出这些各自过程的相互作用。精神分裂过程使人产生一种内在的脆弱感、受害感、软弱感、失去自主性和信任，以及其他可能引发偏执反应的因素。偏执症可以被看作是对精神分裂症失代偿的一种补偿反应。因此，偏执型精神分裂症患者可以被视为精神分裂症患者，他们保留了足够的内部结构和能力，以偏执型防御的形式来调动他们的资源。然而，在诊断上，这个特殊的群体并没有提供太多的困难，因为偏执的表现通常是精神病的比例，因此很容易被识别。[最后这句似乎是说偏执的程度，就是精神病的程度] The association of paranoia with hypochondriacal symptoms presents something of a problem. In a number of our case studies, the patients presented with hypochondriacal concerns. Without exception, when such concerns were in evidence, they could be seen to be related to the underlying self-image that was characterized by weakness, deficiency, inadequacy, and vulnerability. Hypochondriacal concerns, therefore, could be seen as linked to the underlying depressive core in the patient's personality. A study of the incidence of hypochondriacal manifestations in patients diagnosed with paranoid syndromes reveals that while the incidence of hypochondria in schizophrenic and depressive patients was relatively high, the incidence in cases of diagnosed paranoia was strikingly low(Stenback,1964). One could argue, therefore, that the manifestation of hypochondriacal and/or depressive symptoms would be a function of the effectiveness of the paranoid defenses. In cases of frank, psychotic paranoia, one might therefore expect a minimal manifestation of accompanying depressive and/or hypochondriacal manifestations. In cases where the paranoia is combined with either schizophrenic deterioration or a loosening of the paranoid defenses, one might expect to see a higher incidence of both depressive and hypochondriacal manifestations. In our own patients, we have noted that the depressive aspects of their illness did not become apparent—and in all cases did not become a predominant part of their symptomatology—until the paranoid defenses had been undermined in the course of the treatment. In some patients, there is a marked vacillation back and forth between paranoid and depressive aspects. 偏执与疑病症之间的联系是一个问题。在我们的一些病例研究中，患者表现出疑病症担忧。毫无例外，当这些担忧明显存在时，它们可以被视为与内在的自我形象有关，这种自我形象的特征是软弱、缺乏、不足和脆弱。因此，疑病症担忧可以被视为与患者人格中潜在的抑郁核心有关。一项关于被诊断为偏执症状患者的疑病症发病率的研究表明，虽然精神分裂症和抑郁症患者的疑病症发病率相对较高，但被诊断为偏执症状的患者的发病率明显较低(Stenback,1964)。因此，人们可能会认为，疑病症和/或抑郁症状的表现是偏执狂防御有效性的一个功能。在明确的精神性偏执的病例中，我们可能因此预期的伴随抑郁和/或疑病症的最小表现。在偏执与精神分裂症恶化或偏执防御放松相结合的情况下，人们可能会看到抑郁和疑病症的发生率更高。在我们的病人中，我们注意到他们的疾病的抑郁方面并没有变得明显——在所有的病例中也没有成为他们症状的主要部分——直到偏执的防御在治疗过程中被削弱。在一些患者中，在偏执和抑郁之间有明显的摇摆。