This article introduces my English preprint, Reconstructing and Integrating Psychotic States. The paper was written from my position as a psychiatrist in Japan who has also lived through psychosis.
Reconstructing and Integrating Psychotic States (PDF)
This paper does not aim to reject standard psychiatric diagnosis or treatment. Rather, it attempts to complement them by describing psychotic states from the inside.
In conventional psychiatry, schizophrenia and delusion are often described from the outside, in terms of symptoms, diagnostic criteria, and treatment guidelines. These perspectives are indispensable. However, for the person concerned, the more urgent question is often different: What is happening within my own mind, and how can I understand the structure of my experience?
This preprint is an attempt to answer that question. It proposes that delusion should not be understood only as a false belief, but also as a mode of self–other relationality that harms both the self and others. It also reconsiders depression, bipolar disorder, neurosis, and thought disorder within a broader framework of psychotic states.
The conclusion is presented below as an entry point to the paper. The full argument can only be understood by reading the paper as a whole, but this section may help readers grasp its overall direction.
Conclusion
When patients confront a psychotic state, individual symptoms are often experienced not as appearing in isolation, but rather as an interrelated “cluster of symptoms”. In such a situation, the urgent issue for the person concerned is to grasp how their own condition, including its diagnostic name, is placed amid the confusion, and to discern the direction of treatment.
However, on the basis of this “cluster of symptoms”, it is not easy for the person concerned to recognize, in particular, a condition within the schizophrenia spectrum. To determine whether or not one has schizophrenia, it is necessary to discern whether one’s own thoughts correspond to delusion. Yet, as long as delusion is defined in current diagnostic systems as a “deviation from reality”, the person concerned cannot evaluate their own thoughts according to the same criterion. That is, under conventional operational concepts, self-diagnosis of schizophrenia, including self-judgment of delusion, is difficult in principle.
In light of this difficulty, this paper redefined delusion as a mode of thinking and a mode of relating that is expressed from self–other relationality that harms both the self and others. Furthermore, by drawing on the psychoanalytic concepts of consciousness and the unconscious, I repositioned delusion as a dynamic at the unconscious level, thereby strengthening the theoretical perspective for understanding delusion. In addition, as a direction of treatment, I introduced the concept of “love” (mutually sustaining self–other relationality) and presented a theoretical map in which delusional self–other relationality is transformed and the love that has begun to take shape becomes established at the unconscious level—that is, comes to operate unconsciously. Here, I emphasized the absence of temporality and self–other undifferentiation as characteristics of the unconscious.
This paper also redefined depression as an existential crisis, that is, as the loss of a sustaining ground, and explained the connection between delusion and “depression”. That is, while delusion may support the subject as a sustaining ground, when that ground becomes shaken, “depression” as an existential crisis may arise. Furthermore, from a psychoanalytic perspective, I showed the possibility that neurotic symptoms may be formed by psychic operations that attempt to avoid “depression” (existential crisis), and repositioned depression and neurosis as descriptions, at the levels of consciousness and the unconscious, of the same dynamics.
In addition, this paper organized the relationship between schizophrenia and bipolar disorder, as well as the position of thought disorder, under the above redefinitions. That is, I presented as hypotheses that schizophrenia and bipolar disorder may have continuous and structurally similar features, and that the loss of the ground from which thinking arises—the premises of judgment, criteria of value, and framework for meaning-making—may be experienced as thought disorder.
Finally, I will discuss the limitations of this paper and future issues. In clinical settings, patients’ narratives are not free from the influence of the norms and evaluative axes of contemporary society, and there is a possibility that the details of the psyche may not be sufficiently articulated. Moreover, insofar as the discussion includes the unconscious level, there remain domains that even the person concerned cannot grasp, and there may also be cases in which bringing unconscious contents into consciousness is not necessarily best for the person concerned. Therefore, the theory presented in this paper relies heavily on the self-experiential case and the hypotheses derived from it, and its validity in other cases requires future examination. Nevertheless, in light of the limitation that the operational concepts of current diagnostic systems are difficult to connect with the self-understanding of the person concerned, it would be fortunate if the redefinitions proposed in this paper could serve as an occasion for promoting the understanding of psychopathology and contribute to the person’s self-understanding and therapeutic orientation.
The author is a psychiatrist in Japan and the director of Yamashita Clinic. His work explores psychosis through clinical, theoretical, and first-person perspectives.
