There are, of course, many diagnoses in the DSM-4,1 various categories and gradations of psychopathology based on the clinical material - signs and symptoms - which can be easily and quickly grouped. This type of diagnostic system is best understood as a descriptive approach to nosology, where a diagnosis is based on easily observable or obtainable bits of information. In its modern form it is best attributed to Kraepelin and with the elaboration of the DSM has resulted in an expansive system of matrices and algorithms combining bits of information in a manner well suited for the dominant metaphor of our time, that of information technology. With the exception of the division between Axis 1 and Axis 2,1 however, there are no major or essential distinctions among the diagnoses. Most American schools of psychoanalysis - ego psychology, object relations, and self psychology, which as a group I will henceforth term traditional psychoanalysis - have followed this categorization or descriptive nosological approach. Jacques Lacan and those adherent to the work of Freud as elaborated and expanded by Lacan, however, hold fast to a different orientation to the question of diagnosis. For Lacanians, there are only three major diagnostic categories: that of psychosis, neurosis, and perversion. Given the relative rarity of perversion and the fact that the therapeutic approach to the patient with perversion is quite similar to that of neurosis, the key diagnostic issue becomes one of establishing whether the patient presents with psychosis.
Now: why would this seemingly archaic question of neurosis versus psychosis be important, especially to a clinician without interest in psychoanalysis - Lacanian or otherwise. After all, neurosis disappeared from standard psychiatric diagnoses in 1980 with the publication of the DSM-3.3
There are two main reasons. The first is that the Lacanian theory of psychosis allows one to absolutely differentiate the presence or absence of psychosis, useful in situations where the clinician is unable to determine whether a "voice" represents a hallucination; or whether a particular disorganized thought process represents psychosis, or an acute hysterical crisis; or whether an odd or unusual thought represents a delusion; or whether the very sick and troubled patient before us - manifesting intense pathology - is extremely sick in a psychotic or non-psychotic manner. The importance of this degree of diagnostic precision, however, may not be immediately obvious. After all, a very sick patient, one might say, needs to be treated as a very sick patient and, well, voices are voices and the question may seem rather to be one of naming: are they psychotic versus non-psychotic hallucinations, or hallucinations versus perceptual abnormalities Not Otherwise Specified, perceptual abnormalities NOS, to use our current jargon? All of these distinctions, many would argue, are semantic and have no bearing on the clinical decisions - hospitalization, medication, type of therapy - we need to make in our approach to the patients. My second main assertion is that this is absolutely wrong. Our therapeutic approach to the patient must take a certain form - we must position ourselves to occupy a certain role or place in our work with psychotics - else we precipitate or exacerbate the psychosis and set up the conditions for a failure in treatment. Certain attitudes to take towards the patient, which may be necessary in the establishment of the transference in our work with neurotics - for example, taking a certain position or role of authority which physicians often do in dealing with patients - will be quite destructive in our relationships with psychotics.
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