THE PROBLEM OF LATENT PSYCHOSIS'

GUSTAV BYCHOIVSKI, M.D.

T h e title of this communication may be misleading, since i n

reality there is not just one but many problems related to latent
psychosis. Moreover, it should be pointed out from the very out-
set that what is meant by latent psychosis is by no means a merely
dialectical psychotic potentiality of every individual. According
to such a definition we are all virtual psychotics just as we are all
potential criminals.
On the contrary, we deal with a clinical reality. Bleuler (1,
p. 239) spoke of latent schizophrenia as:

T h e most frequent form, although admittedly these people

hardly ever come for treatment. . . . In this form we can see
in nuce all the symptoms and all the combinations which are
present in the manifest types of the disease. Irritable, odd,
moody, withdrawn or exaggeratedly punctual people arouse
among other things, the suspicion of being schizophrenic.
Often one discovers concealed catatonic or paranoid symp-
toms, and exacerbations occurring in later life demonstrate
that every form of this disease may take a latent course.

As to the disposition for a depressive psychosis, it has been even

less sharply defined by descriptive psychiatry.
A comparison of these early concepts with our present ideas
shows a line of development based on the ever wider use of tools
provided by psychoanalysis. It was especially the progress of our
knowledge of the ego with the developmen't of such concepts as
ego strength and ego weakness and the relative resilience of its de-
fensive measures that helped us to understand the dynamics of
1 Read at the Annual Convention of the American Psychoanalytic Assodation in
Atlantic City, May. 1952.
484
 THE PROBLEhf OF LATENT PSYCHOSIS 485

the psychotic breakdown. However, before we attempt a dynamic

interpretation, we must first suggest a tentative descriptive defini-
tion of latent psychosis. I personally use this concept in the fol-
lowing sense:
(a) Character-neurotic difficulties which, at an appropriate
provocation, may burst into psychosis;
(b) Neurotic symptomatology with the same outcome;
(c) Deviant behavior, for instance, delinquency, perversion,
addiction;
(d) An arrested psychosis, posing as psychopathy and, like in
former groups, likely to reveal some day its true nature.
Finally, as a group of particular importance
(e) Psychosis provoked by therapeutic or didactic psychoanaly-
sis.
Obviously all these groups are largely overlapping and cannot
be strictly separated from each other.
T h e problem of diagnosis is the first to arrest our attention,
since the descriptive criteria mentioned above are obviously too
vague and inadequate to arouse in us more than a suspicion.
Further clarification can be provided by two sources: clinical ob-
servation in a therapeutic situation and psychological testing. Ad-
ditional problems of considerable interest arise when we confront
these two sources of information.
As to the clinical observation, first rank belongs to features in-
dicative of increased communication between the mental systems
or even of their partial and temporary reversal. Thus, primary
processes may prevail in the patient’s productions and, when en-
couraged by the analytic situation, he may display features of a
rapidly growing regression. His thinking may become scattered
and show many displacements and condensations, and, above all,
lie may impress the observer with his unusual understanding of
symbolism. JVith all this it is only natural that our patient will
oblige us with his most willing acceptance of our interpretations,
and he may even become rapidly astute in offering interpretations
himself. I t is then as though his resistances were melting from
hour to hour, leaving bare his repressed unconscious. Thus he
486 GUSTAV BYCHOWSRI

may show an unusual aptitude for the understanding of his dreams

and of his symptoms.
Another group of symptoms is related to specific characteristics
of the prepsychotic ego. It reveals its weakness in many ways. Its
poor resilience is indicated by its vulnerability to the slightest
frustration, as experienced in the therapeutic situation. Reactions
of disappointment and depression may be provoked by a postpone-
ment of the session or by the “cold and unfeeling” attitude of the
analyst. Such attitudes are particularly characteristic of a latent
depression or what may be called a depressive disposition.
We note in passing that in this description we omit at first any
reference to the deepest dynamic implications.
T h e narcissistic hypercathexis of the ego manifests itself by per-
sistence of primitive megalomania with the characteristic features
of irritability, boundless impatience and primitive defense
mechanisms such as rapid blocking and quick withdrawal into
complete silence and detachment covering up intense daydream-
ing. T h e quality of primitive, unsublimated and nonneutralized
aggression is revealed by reactions of rage at the slightest provca-
tion.
Magical thinking, even if not manifest directly in conscious
productions, comes to the surface as though its emergence from
the system of the preconscious depended merely on the removal
of very slight resistance, that is, weak countercathexis.
Ideas of reference, massive projections, and beginning paranoid
reactions color the transference situation and bear witness to poor
development of ego boundaries.
All the above-mentioned phenomena may be related to the
persistence of former ego states which coexist with an actual ego
more u p to date in its functioning and organization. This idea, in
view of its basic significance for our problem, will be discussed
later on.
At this point I would like to devote some time to the diagnostic
help which we can derive from psychological techniques. T h e
comparison of the clinical and psychological data and an attempt
at their relative evaluation poses many complex problems which
would deserve and require a special discussion. IVhat follows is
 THE PROBLEM OF LATENT PSYCHOSIS 487

a brief presentation of my personal point of view based on data

for which I am greatly indebted to a few clinical psychologists, in
particular, Dr. Fred Brown who ,gave me the benefit of his large
experience. Upon my request, the latter formulated his own
opinion in a personal communication. T h e characteristics of
schizophrenia as manifested mainly in the Rorschach, but also i n
the drawing test (Machover) and in the IVechsler-Bellevue intel-
ligence test, are all well known and per se do not allow a differ-
entiation between an active, manifest and a latent psychosis. How-
ever, according to Brown, a comparative analysis of the total test
material allows the psychologist to evaluate

the extent to which the individual is able to counterbalance

schizophrenic ideation. T h e degree of latency and its close-
ness to the surface then becomes a matter of estimating the
individual’s ego strength in relation to deviant ideation and
affects which thrust against the ego barrier. A careful differ-
entiation must take into consideration the patient’s function-
ing on completely structured tests such as the Wechsler-
Bellevue where maximal cue utilization is possible and
functioning in an unstructured situation where cues are very
vague or nonexistent.
I n addition to other criteria, one may say that the better
the performance on a structured test in contrast to poor func-
tioning on an unstructured test such as a Rorschach, the
greater the likelihood of latency, especially if the Rorschach
reveals underlying potentialities for adaptation if and when
the individual finds himself in a well-structured social setting.
T h e poorer the structured performance in conjunction with
a bizarre Rorschach the greater the likelihood of a n overt
reality-distorting psychosis.
Prevalence of introjective mechanisms, especially when re-
lated to love objects lost in some remote past, as well as other
signs of increased orality, seem-characteristic of latent depres-
sion or of a depressive disposition. Other familiar character-
istics of depression such as absence or paucity of color and
movement reactions, restriction and coarctation are generally
present in both active and latent form.
Moreover, in a latent depression productivity is relatively
high, with a high number of Dd, and F but a relatively low
number of F+. Characteristically, one may find just one M as
488 GUSTAV BYCHOWSKI
a flickering vestige of the obsessive-compulsive aspect of ego
defenses. [Personal communication from Dr. Fred Brown.]
I found that in most cases the psychological data coincided with
my clinical impressions and observations. In a number of cases my
impression, which was at first vague and crystallized only after a
period of therapeutic observation, could be confirmed and sub-
stantiated by the psychological data collected at the very begin-
ning of my acquaintance with the patient. Thus, the value of
projective techniques for an immediate and sharp evaluation of
psychotic potentialities of our patients seems well established.
Yet, I would like to emphasize two important points of disagree-
ment which, I am sure, will be clarified in the course of further
study. These points seem contradictory. T h e first concerns pa-
tients where the psychologist made the diagnosis of a schizophrenic
process, a diagnosis not confirmed by clinical observation. T h e
opposite error lay in the psychologist not recognizing the psychotic
potentialities which were revealed by clinical observation.
I start with the discussion of the latter point. I n all fairness
I must admit that I observed this occurrence in two cases only;
moreover, both of them were tested by a different psychologist,
while the former e r r o r - o r I should rather say disagreement-was
due to another investigator. All this would, of course, point to
the importance of the personal element in psychological testing.
It seems indispensable to give you a brief characteristic of the
two cases in question, since both have a direct bearing on our
problem.
I n one case a medical student was referred for treatment of
symptoms of anxiety hysteria. This diagnosis was confirmed by
clinical observation and a very good result of one year of analysis.
T h e findings of the psychologist pointed in the same direction,
emphasizing the mild character of the neurosis and being ex-
tremely optimistic about the prognosis.
T h e first stretch of analysis did not reveal any untoward signs
except a considerable amount of latent homosexuality and mas-
ochism. Although obviously neither of these constellations could
be fully resolved in the span of one year (the patient made an
excellent improvement and wished to return to school which was
 THE PROBLEM OF LATENT PSYCHOSIS 489
in another city) it was felt that he would be able to get along.
Unfortunately, after a year of well-being his panic returned, pre-
cipitated this time by examinations for the National Board.
H e returned for treatment which at first developed along famil-
iar lines but after several months became unexpectedly and un-
pleasantly enlivened by frankly paranoid reactions. These were
worked through and after a year of interruption the patient
returned to school.
However, panic of mostly homosexual character with paranoid
elaboration developed again and became so intense that he felt
forced to interrupt his studies, this time definitely. I referred him
to a woman analyst who was successful in helping him to work
through his homosexual transference. As a result of this last
stretch of analytical work he became free of symptoms but gave up
his medical studies.
I n this case the psychologist saw no more than the clinician.
None of us could foresee that at some point the patient’s ego
would take recourse to paranoid defenses. Furthermore, one may
argue that the psythotic episode was provoked, or at least made
possible, through psychoanalysis. T h e psychoanalytic process, hav-
ing removed the character defenses, laid bare a core of ego weak-
ness so that the defense reaction of anxiety hysteria was no longer
a sufficient protection against the challenge of a competitive,
predominantly masculine environment.
Incidentally, all the unfortunate clinical transformation oc-
curred despite a very successful marriage which the patient was
able to achieve in the course of the first stretch of his analysis. It
is significant that this complete heterosexual gratification did not
help to diminish the impact of his homosexual libido.
I n a second case of this group a young college student was
brought for treatment by his mother. Clinically he presented a
severe depression with features of a latent schizophrenia and, for
some time, had been close to suicide.
In this case the psychologist found an unusual intelligence
(I.Q. 146) extraordinary creative fantasy but otherwise no un-
toward signs, although he concluded that “his assets in themselves
may create many of his difficulties. H e is so unusual that he will
490 GUSTAV BYCHOWSKI
withdraw into himself, finding satisfaction and pleasure in his
own fantasies.”
Here again, psychological exploration failed to reveal the core
of ego weakness with primitive narcissism and megalomania and
the persistence of split-off ego states with co-ordinated fantasies of
almost concrete character.
T h e uncertainty of psychological diagnosis in this sort of case
was best illustrated by the results obtained by submitting the data
of the Rorschach and TVechsler-Bellevue tests for evaluation to
nine experienced psychologists. Six of these considered the patient
as highly gifted but schizoid, two as normal, and only one as
schizophrenic.
T h e conclusion seems inevitable that certain clinical constella-
tions may elude present methods of psychological investigation. I n
particular, the delicate interplay between the psychotic potentiali-
ties and the constructive resources of the ego-an essentially dy-
namic probIem--cannot always be detected by the psychological
techniques which after all, despite all their refinement, remain
static.
This formulation would explain the second area of disagree-
ment between the clinician and the psychologist. I n several cases
the latter diagnosed a schizophrenic process, a diagnosis which
could not be confirmed by clinical observation. Here then the
psychologist was impressed by the core of ego weakness but under-
estimated the reconstructive resources of the ego. I n one of these
cases the clinical picture did not display any schizophrenic fea-
tures and was that of a cyclothymia with depressive reactions. In
other cases the conclusion imposed itself that the psychotic con-
stellation prevalent in the testing situation changed rather rapidly
under the impact of therapy. This response could not be predicted
on the basis of psychological exploration, which explained the
pessimistic conclusions of the psychologist.
With all these reservations in mind I wouId not forego the
benefit of psychological exploration in all somewhat doubtful
cases. We shall see that it offers a substantial help in our planning
of therapy.
I come now to what, from the psychoanalytic point of view, I
 THE PROBLEM OF LATENTPSYCHOSIS 491

consider the most interesting point of the entire problem. What

is the dynamic structure of the latent psychosis?
As a general answer, I would be satisfied wit11 the following
formulation: I n the course of early development the splitting
mechanism comes into action, so that early ego States remain
untouched under the cover of later ego formations. Accordingly,
archaic constellations remain fixated and preserved, as it were,
for future reference. They form then the psychotic germs which,
under the impact of various dynamic and environmental factors,
can cause the psychotic breakdown of ego defenses and sever what-
ever reality contact and testing have been built up in the course
of later development.
As an illustration I shall present to you some data from a clinical
observation, while invoking your indulgence for its necessary
incompleteness.
T h e patient is a professional man of forty who, in the course of
years, has had two periods of analytical treatment of many months’
duration, with two different analysts. H e came for help mainly
because he was afraid of “paranoia.” H e felt that the F.B.I. might
be after him because of his past association with the Communist
Party.
I n addition to the slightly paranoid attitude, clinical observa-
tion revealed many other abnormalities. T h e patient, married for
ten years and father of one child, had been avoiding sexual con-
tacts with his wife for two years and was instead masturbating and
peeping through windows into the apartments .across the street.
He was isolating himself more and more socially and was handi-
capped in his professional career by not taking a degree. H e had
stopped any efforts in this direction many years before. Although
on the surface neat and well groomed, he disclosed that he could
go for months without taking a bath (or a shower). There were
also many somatic complainp with a distinctly hypochondriacal
coloring: among them I would single out gastrointestinal symp-
toms which were particularly disturbing and which form the core
of my clinical illustration. They were (a) most obdurate constipa-
tion and (b) attacks of excruciating pain in the stomach, mostly
following a meal or defecation.
492 GUSTAV BYCHOLVSKI
T h e patient finds it extremely difficult to take a bath: he is
afraid that something may happen to him, that he may die. H e
remembers that his mother used to say rather apologetically:
“Excuse me for mentioning it; I have just had a bath.” Then his
next association deals with that period of his childhood when he
used to lie in bed waiting for his parents to have intercourse.
When he would hear the characteristic sounds he would mastur-
bate. At a somewhat later time he refused to move his bowels
unless he felt forced to do so. At night when he felt his feces stick
out of his rectum, he would remove them and throw them behind
his bed. At other times his mother had to give him an enema.
H e comments that since he could not possess his mother as a
sexual object he would “give the thrill” to himself in being both
the mother and the sexually aggressive father. I n this way he
would no longer need his parents as sexual objects. Thus his
retention of feces served as a protective device against his passive
homosexual wishes.
T h e patient describes his gastric pains as the feeling of having
a stone i n his stomach. This was one of the standing complaints of
his hypochondriacal mother. He feels these pains after meals. His
next associations pertain to the copious Sabbath meals in his
childhood and to his parents retiring afterwards for an afternoon
rest. H e thought, of course, of their having sexual relations.
As to his gastric symptoms which he experiences after elimina-
tion, he brings up the following material. According to his own
private anatomic notions the stomach is protected by a cushion of
bowels filled with their contents. If the intestines are empty then
the stomach is suspended in a vacuum.
Moreover, the stomach, when empty, can be filled by the bad,
dangerous stuff which mother has to offer. I n this way he may be
poisoned. H e connects it with his fear of food prepared by his
wife who, like his mother, is not “clean” enough. H e prefers to
avoid too close bodily contact with his wife (and little daughter).
As long as he is filled up by his own products he is protected
against his mother’s (and wife’s) aggression.
Striking memories emerge dealing with a female cat he had
loved as a little boy and had treated as his doll, baby, and bed
 T H E PROBLEhI OF LATENT PSYCHOSIS 493
companion. Once, in fascination, he saw her giving birth. I t was
like little balls of feces coming out. His mother forced him to give
the cat away which hurt him deeply.
Now, when afflicted by his mother’s illness and the fear of losing
her, he reaffirms the process of introjection and as a defense de-
velops nausea. O n the other hand, experiencing any new “rejec-
tion” by his mother who, according to him, prefers now, like i n
the past, his older brother, makes him feel that she tries to expel
him. I n order to restore the original unity lie tries to be both the
mother and the infant. Thus, at first through introjection and
identification, he becomes the mother and then he takes himself
in as the baby.
H e feels the sphincter active, contracting and relaxing in his
stomach. This he compares with the vagina contracting i n inter-
course and in the act of birth. Thus, within his.bodily ego, proc-
esses of retention alternate with expulsion, both dealing with the
introjected breast, baby, and fecal penis. I n this way he tries to
achieve complete self-suficiency and at the same time, while filled
up from inside, secure his protection against any outside attack.
Similar mechanisms could be detected in the dealing of his
archaic ego with his late father and brother. T h e latter, i n partic-
ular, was connected with “laryngeal” introjection, resulting i n
compulsive clearing of the throat and occasional vocal blocking.
It is only natural that primitive defense mechanisms prove in-
sufficient to protect the ego against further attacks from intro-
jected love (and hate) objects, especially in view of the fact that
the primitive instinctual drives persist unabated. Thus, the patient
continues both to fear and to desire sadistic homosexual attacks
and acts this out in the daily drama of his somatic symptoms. In
these symptoms and in the underlying fantasies he is an object of
various forms of imminent threat .and persecution.
H e who, like a primitive cannibal, had “devoured” his father’s
strength, fears that his own heart will be torn out of his chest like
the heart of human victims sacrificed by the old Aztecs. It is only
natural that he included the analyst in the group of executioners
chosen for this sinister design. Thus, one day, after I kept him
waiting a few minutes and he saw the-reason for this delay i n the
494 GUSTAV BYCHOWSKI
person of the handyman emerging with his tools from my office
(he had to fix the radiator), his fleeting and only reluctantly ad-
mitted fantasy was: I have had a dictaphone installed in secret i n
order to record data against him and for his destruction. This will
be the result of his opening all his heart to me.
I n one of his anal fantasies a three-edged knife penetrates his
rectum. In his recent masturbation fantasies he was doing this to
a woman. Rich associative material connects the raping fantasy
with his father who functions both as a subject and as an object.
H e believes that his constipation can be removed only by knife,
and, generally speaking, all his bodily orifices can be opened up
only by violence. Thus the analytic cure itself is seen as a rape by
the analyst who in this way only can remove all his blocks, includ-
ing the intellectual and verbal inhibition. In this way analysis
would make true the injunction of the prayer about bodily ori-
fices: “You can remove mucous from my throat only with dyna-
mite- hly mother did it to me with enemas,” said the patient.
However, when he tries to improve his physical condition by
exercises, he feels overwhelmed by the impact of his magic nar-
cissism. While he “straightens himself out” (unbends the curva-
ture of his spine) he is afraid that “the spirits from below” may
flow inside his brain and harm him. This may happen along the
“pipes” (channels) mentioned in the childhood prayer which the
patient had learned as a little boy from his orthodox Jewish father
and which he had to recite after his morning defecation.

Blessed art Thou, Lord our God, King of the universe, who
has fashioned man with wisdom and created in him many
openings and channels that are known before the seat of your
glory [i.e., that are known to you.] If a single one of these is
opened u p or sealed u p [i.e., when it should not be], then it
is impossible to exist and‘stand before Thee. Blessed art
Thou, 0 Lord, who heals all flesh and performs wonders.

Thus, all his bodily orifices are under special guard and control.
At times he felt a real anxiety as to what his fate might be if God
did not take care of them.
Preservation of archaic forms of ego organization seems a n indis-
 THE PROBLEM O F LATENT PSYCHOSIS 495

pensagle basis for the persistence of such primitive fantasies.

Since the frame of this brief communication precludes a more
detailed presentation, I shall limit myself to a few illustrations of
his persistent magic narcissism.
T h e patient’s middle name is identical with the name of one of
the old Hebrew Kings. Although he never uses it, it has for him
the meaning of his being destined, one day, to play a very im-
portant role. Thus, his present personal and professional frustra-
tions are of no consequence, since in some future his greatness
will become manifest. This attitude, by the way, allows him to
sneer at all the enviable successes of his colleagues. They pale
when confronted with his future greatness. However, any prepara-
tion for the fulfillment of this great role is accompanied by deep
anxiety. H e finds it impossible to study the classics of his profes-
sion, since in so doing he would absorb elements of future power
which he may misuse for his own selfish and destructive objectives.
I n this way he becomes as trembling with fear and overawed by
influx of knowledge as he had felt when as a little boy, he studied
the chapters of the Torah, dealing with the garments and the sacri-
fices to be performed by the High Priest: these were, so he felt,
indications and preparations for his own mission. Later on in his
college years, he had similar experiences while writing poetry:
here he was creating greatness out of nothing and, trembling, was
expecting some fantastically great results. H e even used the words
priest and sacerdotal: as a poet he was not made for this world.
Sacred vessels are reserved for the Holy.Days and should not be
mixed with everyday apparel. A sacred and secret function is
going on inside him and he resents talking about it with the
analyst who is one of the hoi-polloi.
Such moments of insight help the patient to reactivate his primi-
tive ego states. However, he may also experience them spon-
taneously or between sessions. Then, in passing, for instance, by
Carnegie Hall, he sees and feels himself exactly like i n those
bygone days of poetry, when he believed in his special mission,
and felt so incomparably superior to others.
T h e aggressive aspect of magic narcissism accounts for a host of
fears which the patient feels while trying to absorb knowledge.
496 GUSTAV BYCHOIVSKI
As a protection against these fears phobic and counterphobic
mechanisms are put into operation, notably self-destructive ges-
tures and activities serve to deflect aggression toward the ego and
forestall some more serious retribution. It is quite understandable
that as long as aggression means primitive hostility of the archaic
ego it is as dangerous, or even more so, for the self as it is for the
outside world. Thus, in transference, the process reduces itself
among other things to the conflict between the wish of the primi-
tive ego wanting to rob the father of his superior power and the
fear of self-destruction resulting from the introjection of such
great power. On a different level this conflict presents itself as a
strife between the desire to attack and the wish (and fear) of pas-
sive homosexual assault.
This is a part of what the patient had to say about his reading:
“Chaucer said: ‘I sat and read like a stone.’ I sat like a leaf, had
no solidity. I can never forget my body, some movement is going
on all the time. If I sit and read without moving I may explode or
die. If I was that relaxed and off my, guard it would lead to death.
It would be either self-destruction or destruction by others. I
would become so absorbed by reading that I might lose contact
with reality, lose my mind.”
TVe might expect other characteristic reactions from an ego
fixated on such a primitive level. Indeed, one cannot help being
impressed by the wealth of manifestations related to the magic
omnipotence either in the positive sense or in phobic fear of evil
magic of others. Some of these ideas emerge into the system of
preconscious and can be elicited under slight pressure, while
others belong to the unconscious and require more elaborate ana-
lytic work. I n a similar way, reactions of primitive rage correlated
with the archaic ego remained dissociated from the rest of the
personality only to emerge in a-nalysis with great vehemence. I n
the course of analytic work the introjected love-hate objects may
become extrajected and assume the role of persecutors. This hap-
pens either in dreams or in the process of analytic working
through.
I n a dream the patient is being pursued by murderers. H e arms
himself with a very long and thick stick but feels powerless to
 THE PROBLEhI OF LATENT PSYCHOSIS 497
strike. Finally he hears a whisper, “Now I got you,” and finds him-
self lying in the mud like the hero of Le Feu, the famous First
TVorld TVar novel by Barbusse.
I n an analytic session, in the course of working through his
deeply ambivalent relationship toward his brother, as one of the
main love-hate objects, he sees him emerging from nowhere and
posting himself before his eyes, as if unwilling to leave. “He is
. .
opaque . . refuses to budge . . it is ridiculous.” On the day
preceding this session the stomach pains became particularly
violent. “I was so infuriated,” reports the patient, “that I wanted
to put a knife into him . . . to kill him.”
Abundant clinical material shows that to this patient his stom-
ach has become a meeting ground of various conflicting introjects.
Were it not for the fact that these extremely vivid fantasies have
been elicited during psychoanalytic sessions one would unques-
tionably consider them as indicative of blossoming schizophrenic
symptomatology. How else would one qualify the following pro-
ductions forming an extract of a number of sessions?
“IVords of wisdom which I have absorbed stick in my stomach.
There is a saying in my family, ‘He has i t in his stomach,’ meaning
that one knows something but cannot express it. There is a small
animal in my stomach. It is friendly, pawing. It has white skin
like my father , . . it makes me think of my father fumbling i n
my mother’s chest drawer.” This fragmentic introjection of his
father makes him think of the paternal penis enclosed in his
stomach which remains stretched. H e speaks of himself as self-
impaled instead of being impaled by his father.
“TVhen my father tvas belching he used to make a terrific
sound . . . . this makes me think of the awe-inspiring sound of the
Shofar. TVlien I was a little boy I was allowed to blow the Shofar
and my father admired me for it.’-’
T h e patient had felt that his mother had usurped all the power
by having at times the father’s penis inside her; in his fantasy he
would beat her by keeping it inside his stomach permanently. His
gastric symptoms showed considerable deterioration after his
father’s death which occurred in .his adolescence. H e then re-
affirmed and reactivated the process of introjection as a substitu-
498 GUSTAV BYCHOWSKI
tion for this loss and for what he called the disruption of his unity
with his father.
T h e patient felt that i n accepting him for treatment the analyst
signed the death warrant for both of us.
I have given away my secret-my stomach-I never gave it
to another analyst. JYhen you take away the penis I have in
my stomach then I have to replace it by emasculating you.
For you to try to cure me is a dangerous and mad enterprise.
I refuse to give up anything. Little David slew Goliath, the
giant. T h e little man inside me does not want to get out. I
feel that my heart is beating inside my stomach. In my ado-
lescence a doctor told me that I had the heart of a lion. This
makes me think of Richard the Lion-Hearted. When I was
thirteen I read in a physical culture magazine about a little
boy who was trained by his father to be an athlete like him-
self bulging with muscles. This little boy of nine, this heroic
figure I have inside myself. I have also an Indian face. This is
one of the Indians about whom I read as a little boy. [In this
moment the patient comments, look at all my fervor in relat-
ing all this to you.] I have to feed the little man inside myself
to keep him strong. Strong men have to eat a lot. I n my
childhood I heard stories about gastronomic feats performed
by men in my father’s youth. H e himself boasted of his big
accomplishments in eating and of his great strength when he
was a soldier in his old country. Mother used to stand by
when I ate and encourage me. Food played a tremendous part
in family life. Since food was being eliminated [enemas were
a frequent ceremony] the stomach had to be filled up again,
could not remain empty.
After the last session I felt pain in my stomach right under
the ribs. Lionel is in the stomach. I felt the sphincter quiver-
ing. Lionel was trying t o push his fist through the sphincter
like through the vagina. I was telling him, “All right go
ahead,” and to the vagina inside myself I was saying, “Open
up, let Lionel in.” T h e n there was some easing of pain. This
damn penis inside cannot sit still, it quivers. It wants to get
control of everything.
I have inside myself both the lion and the lioness, mother
as a big cat and father as the lion of Judah. I have the whole
zoo inside, even the unborn baby. I was once fascinated by
. seeing a man putting his head i n the lion’s mouth but I went
even further, I swallowed’the lion. When we eat meat we
 THE PROBLEM OF LATENT PSYCHOSIS 499

swallow the animal. I went through a period of vegetarian-

ism, apparently I didn’t want to swallow the cow, as my
mother.
I come to the third point of my discussion. Obviously our
deepening knowledge of a potential psychosis must have an im-
portant bearing on our therapeutic approach.
Primum non nocere, the first principle of medical ethics, applies
no less to our work than to somatic medicine. My own interest in
the entire problem goes back to a patient I analyzed as a young
analyst without any awareness of the impending danger. She was
a woman in her early thirties, keeping a household with her
bachelor brother and well-nigh isolated from other social contacts.
She was brought for treatment because her obsessive-compulsive
features increased to the point of seriously interfering with her
daily existence. Obsessive avoidance and isolation were focused on
oral functions and indicated deep anxiety and preoccupation with
danger, threatening both her and her brother. I n view of my
ignorance of the problem of latent psychosis, I analyzed her in the
classical, prescribed way in which I have been trained. Analysis
proceeded and progressed according to a mode which I have de-
scribed in the first part of this presentation. I was thoroughly
pleased with myself and the patient and proud of my work until
she broke down suddenly with an acute schizophrenic episode.
She had to be hospitalized immediately, and the psychotic episode
was eventually cured by insulin shock therapy.
TVhile such an event could not be foreseen nor prevented at
that time, it could hardly be excused in the present state of our
knowledge. And yet, time and again, we see a psychosis developing
as a result of a prolonged, systematic and relentlessly pursued
psychoanalysis, certainly a poor outcome when this happens to a
patient who came seeking help for his neurotic or character diffi-
culties. However, it is no more desirable when the psychotic fate
befalls a young physician who, as a prospective psychoanalyst, is
subjected to didactic analysis.
After this warning, I come to the positive part of my therapeutic
conclusions. It is clear from all that precedes that analytic tech-
pique with the patients in question ought to be distinguished by
500 GUSTAV BYCHOWSKI
its flexibility. This means that only in stretches can it assume all
the exact characteristics of classic psychoanalysis. For the rest of
our work we have to introduce modifications aiming at protecting
and strengthening the ego. Much of what I have to say on the sub-
ject has been emphasized elsewhere, at first by Federn (6) and later
on, by myself (2, 3,4).
T h e necessity to protect the ego forces us to avoid procedures
which may endanger its precarious security. Too deep and too
rapid interpretations, especially when not accompanied by certain
reassuring explanations may expose the ego to the onrush of id
impulses as well as to the implacable sadism of the superego. Some
resistances have to be respected, at least for the time being, and
therapy ought to be shifted to other areas. T h e latter remark
implies that therapy in our cases ought to be much more con-
sciously directed than in “normal” analytic patients. T h e analyst
has to chart his course like the captain of a ship embarked on a
perilous journey.
T h e integrative (synthetic) function of the ego may be further
impaired by too much insistence on free associations. T h e ego may
find the ensuing looseness of thinking too much to its liking, a
factor which may contribute to a general regression of the level
of functioning.
T h e latter factor gains in importance the more the clinical pic-
ture approaches a manifest psychosis. However, in most cases
belonging to our group, free associations can be used, yet with
some circumspection and moderation.
Frequency of sessions and the position of the patient-reclining
on the couch, seated and facing or not facing the analyst, are
further factors which can be used to bring the patient closer to
actual reality or to encourage his regression in therapy. I n this
way the analytic process may be slowed down or speeded up
according to our view of the relative strength of the ego.
T h e general regressive tendency of the ego has to be watched
and stopped whenever necessary. Patients should not be allowed
to indulge in regression for too long a time. I n particular it may
be imperative like with a frank psychotic, to structure the session
 THE PROBLEM OF LATENT PSYCHOSIS 50 I
in such a way as to call back the patient to reality before ter-
minating.
Mounting anxiety should be detected as early as possible and
approached as a direct therapeutic objective. These are the mo-
ments when incisive interpretation should be combined with firm
reassurance and when our active kindliness should make it clear
to the patient beyond any doubt that he can count on his analyst
under any circumstances.
This brings me to a brief discussion of the handling of trans-
ference. Generally speaking, it should follow the well-known prin-
ciples of psychoanalytic therapy-however, with emphasis on some
special points.
Greater flexibility of the analyst will allow him to maintain the
usual attitude of analytic detachment, yet, at a given moment,
approach the patient with more warmth and active participation.
Incidentally, the more secure the analyst and the better he is
trained in the classic technique, the less will he feel bound to
maintain an attitude of rigid aloofness as a kind of reaction
formation against his own insecurity and unconscious or semi-
conscious countertransference.
Further indications for the handling of transference can be
inferred from the essential characteristics of the ego. Persistence
of dissociated primitive ego states accounts at times for transfer-
ence assuming special features. It may consist either in infantile
leaning and predominantly oral dependence with derivative prim-
itive identification or, negatively, in defensive hostility culminat-
ing in destructive rage. Yet, in view of the rest of the ego
remaining on a more adult level, such reactions are only tempo-
rary and may be covered up by more mature transference forms.
T h e dissociation between these various attitudes of the ego
toward the analyst as a temporary love-hate object may be so
blatant as to make for a true split in the object relationship. I n
this way, in the transference, the ego repeats the cleavage by the
archaic ego which in its deep ambivalence had split parental
images into bad and good objects. It is of great therapeutic value
to work through this peculiar situation and to demonstrate it to
the patient with absolute ciarity.
502 GUSTAV BYCHOWSKI
IVhen detected, all primitive transference reactions have to be
worked through carefully and at an early stage. T o allow for a
prolonged accumulation of infantile dependence may be just as
detrimental as to leave untouched reactions of bristling hostility.
Moreover, any psychotic reaction and defense mechanisms, espe-
cially when observed in the transference situation, should be no-
ticed and made a direct object of immediate analytic scrutiny. I n
this way the mode of action of the primitive ego states can be
reached directly. I n addition, we should by no means disregard
the total life situation of the patient, since it may offer many
opportunities for the manifestation of significant reactions of
the ego.
All this material offers ample occasion for the training of the
ego in reality testing, which is certainly one of the essential factors
of analysis of this group of patients. T h e reinforcement of the
prepsychotic ego remains one of the main objectives of analytic
therapy, and it is the more imperative the more we expose the ego
to the bombardment of the repressed id derivatives. Therefore,
every new step in analytic insight should be followed up by an
interval needed for assimilation of the new material and for the
further growth of the immature ego formation.
Certainly reassurance and therapeutic friendliness do not con-
tribute to any permanent strengthening of the ego but they help
it over particularly difficult spots. It seems to me that the most
important part of the process of reinforcement is achieved through
analysis of primary narcissism and archaic megalomania. I n this
way narcissism may be led toward new outlets and sublimation.
Thus, instead of weakening the ego, narcissistic libido may serve
to strengthen its structure and to attune it better to reality.

Conclusion: I n this paper the problem of latent psychosis was

discussed from the point of view of diagnosis, dynamics and ther-
apy. As to the diagnosis, the writer tried to establish clinical
criteria for suspecting psychotic potentialities beneath a faqade of
neurosis, perversion, addiction or other deviant behavior. I n addi-
tion I discussed the usefulness of psychological testing as an ad-
juvant for establishing the correct diagnosis.
 THE PROBLEhI OF LATENT PSYCHOSIS 503

As to the dynamics of the latent psychosis, I postulated the exist-

ence of a dissociated primitive ego core with its characteristic
attitudes and constellations. Clinical material was presented to
illustrate the reactions produced by such dissociated primitive ego
organizations. In discussing the problem of therapy I pointed out
the necessity of modification and flexibility of psychoanalytic tech-
nique when applied to this group of patients. TVitliout such cau-
tion the treatment may upset the precarious balance of the
neurotic fasade and provoke a psychosis.

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