Regarding the last point raised whether lithium is an antidepressant which prevents suicide, I am not in a position to answer it. I would suggest, if possible, that Tom Ban, Jules Angst or Paul Grof answer this question.

Regarding the use of the term agnosia to denote lack of reality testing or lack of insight into the illness (in this case a manic episode), I can understand Barry’s point of view.  He admits that the use of the word agnosia is beyond the Oxford English Dictionary definition.  He further states: “the defect is clearly a biochemical pathology of the brain... the patient is given a false and futile message that the problem (lack of reality testing into his illness)” has to be fixed or surmounted presumably by a ‘psychoanalyst who followed this totally ineffective line of reasoning”. At this point, we depart because the use of the word agnosia has been independently given a precise meaning and the lack of reality testing is also independent of  the current psychoanalytic jargon as shown below.

I don’t know what Barry means regarding my example of Anton’s syndrome as quoted in the Psychiatric Dictionary written by Robert Jean Campbell as ‘the lay one’. Please, note that visual anosognosia and denial of loss of vision with confabulations (caused by an occipital brain lesion) has been widely accepted as a bona fide entity and at times is associated with the Charles Bonnet syndrome (visual loss plus visual hallucinations) (G. Anton “Über die Selbswahrnehmung der Herderkrankungen des Gehirns durch den Kranken bei Rindenblindheit und Rindentaubeheit” Arch. Psychiatrie Nervenkrankh. Vol.32, pp 86-27, 1899).

I am sorry to tell Barry that Freud was the first one to introduce the word agnosia in the neurological literature in his widely quoted (by neurologists) work on the aphasias: “I use the term ‘asymbolia’ in a sense other than that in which it has been ordinarily used since Finkelnburg, because the relation between word presentation and object-presentation seems to me to deserve to be described as a ‘symbolic’ one. For disturbances in the recognition of objects, which Finkelnburg classes as asymbolia, I should like to propose the term ‘agnosia’. It is  possible that agnostic disturbances (which can only occur in cases of bilateral and extensive cortical lesions) may also entail a disturbance of speech, since all incitements to spontaneous speaking arise from the field of object-associations. I should call such disturbances of speech third-order aphasias or agnostic aphasias. Clinical observation has in fact brought to our knowledge a few cases which required to be view in this way...” (p. 215 Appendix C ‘Word and Things´ The Standard Edition, vol. XIV).  This use of the word agnosia still prevails among all neurologist.  William Alwyn Lishman in his masterful book Organic Psychiatry, second edition, Blackwell Scientific Publications, 1987 also acknowledges, on page 52, Freud’s priority in using the term agnosia and ‘related defects of perception’. Lishman uses the term as currently used in neurology. On page 61, he writes on anosognosia which “implies lack of awareness of disease, and is most commonly shown for left hemiplegic limbs. It may occur along with unilateral neglect, hemisomatognosia, or with the illusions of transformation and displacement (reduplication) which are considered below”. Further, Lishman listed the unawareness or denial of amnesic defects seen in Korsakoff’s psychosis and  Anton’s syndrome.  Probably you are aware that Freud was a prominent neurologist for about 10 years before he embarked in his new field of psychoanalysis. Further, in the chapter of differential diagnosis, Lishman writes: “Agnosic and apraxic defects, disturbances of the body image and of spatial orientation, like- wise should raise suspicion of focal cerebral disorder...” (p. 129).  I have seen two cases of prosopagnosia. The patient could not recognize familiar faces or even her own face in a mirror.

Freud, just like Henry Ey, were greatly influenced by the British neurologist Hughlings Jackson and Freud, in particular, was close to Meynert (who was a pupil of Wernicke). Probably you would approve of a sentence written by Freud in the same paper: “the psychical is a process parallel to the physiological” - a ‘dependent concomitant’ (a term used by Jackson himself) (p. 207).

Freud  elaborates on the difference of psychosis and neurosis in the following sentence: “In Meynert’s amentia - an acute hallucinatory confusion which is perhaps the most extreme and striking form of psychosis - either the external world (reality) is not perceived at all, or the perception of it has no effect whatever” (p. 150,  vol. XIX of the Standard Edition).  Reality has two components: one perceptions and the other the store of memories of earlier perceptions (the internal or psychic reality). In amentia the ego is overpowered by the internal world with the id’s wishful impulses (e.g., megalomania) and further:  “the motive of this dissociation from the external world is some very serious frustration by reality of a wish - a frustration which seems intolerable. The close affinity of this psychosis to normal dreams is unmistakable. A precondition of dreaming, moreover, is a state of sleep and one of the features of sleep is a complete turning away from perception and the external world” (p. 151). Henry Ey has elaborated this relationship between dreaming and psychopathology extensively.  Contrary to the defense mechanism of repression seen in neurotics, the psychotic is dissociated, loses its unity and a clear cleavage, a splitting or a division is established.  A similar line of observation was used by Wernicke’s use of the word ‘sejunktion’ when the boundaries between memories images and real perception are blurred or extinguished, hence the associative system is disrupted.  Freud wrote another paper on the loss of reality in neurosis and psychosis in 1924 (Der Realitatsverlust bei Neurose und Psychose) published in volume XIX of the Standard Edition, pp. 183-187.

The results of psychoanalytic treatment in manic-depressive illnesses or bipolar disorder were disappointing, indeed, since Karl Abraham’s and Melanie Klein’s earliest bold attempts to treat this disorder. Nevertheless, since Kraepelin, psychological or environmental triggering factors were often described which culminated with Freud’s masterpiece Mourning and Melancholia in 1915  (Standard Edition volume XIV, pp. 239-243).

I am grateful that Barry makes me think about basic issues in psychopathology which I have been teaching for over half a century, namely the concept of reality and reality testing.  The classical textbooks, such as Mayer-Gross, Slater and Roth, Clinical Psychiatry, Cassel and Co. London, 1960) are not biased towards psychoanalysis when they write on examining the patient: “Insight and Judgement. What is the patient’s attitude to his present state? Does he regard it as an illness, as ‘mental’ or ‘nervous’, as needing treatment?” (p. 49). Writing about the onset of schizophrenia Mayer Gross, Slater and Roth stated (p. 284): “if these musing, in the adolescent,  continue for long, or if they lead to a break with reality, they will not be transient phases of adolescence but will be due to schizophrenia”. The use of the term break with reality is independent of psychoanalytic enquiry but it has been used in psychopathology, phenomenology and psychoanalysis all the same.

Biology and ethology has contributed to phenomenology and has shown us since Jakob von Uexhküll that there are three modes of reality of the world (Umwelt, Mitwelt and Eigenwelt). Reality becomes shattered if one of these modes is emphasized to the exclusion of the other two.

I would agree with Barry that with the great advances of neurosciences we can literally be able to map psychopathological changes in brain images at biochemical or molecular levels. Therefore we must conclude that endogenous psychoses are not functional psychoses but ultimately they are organic psychoses. We are back to Wernicke’s and Kleist’s viewpoints which were in disagreement with Kraepelin’s. Wernicke and Kleist were able to pinpoint areas of the brain which control or mediate certain behavioral changes such as Trieb-Ich, Gefühls-Ich, Selbst-Ich and Welt-Ich. Each Ego State is controlled by neuronal circuits of particular areas of the brain.

Finally, I would add that reality is perceived by the senses and validated by objective  physical and verifiable measures. The shared sense of reality by the majority of people (in greek Koinocosmos) is what determines whether somebody is psychotic or not.

Hector Warnes
January 7, 2016