The Strasbourg Visual Scale: A Novel Method to Assess Visual Hallucinations

The experience of oneself in the world is based on sensory afferences, enabling us to reach a first-perspective perception of our environment and to differentiate oneself from the world. Visual hallucinations may arise from a difficulty in differentiating one's own mental imagery from externally-induced perceptions. To specify the relationship between hallucinations and the disorders of the self, we need to understand the mechanisms of hallucinations. However, visual hallucinations are often under reported in individuals with psychosis, who sometimes appear to experience difficulties describing them. We developed the “Strasbourg Visual Scale (SVS),” a novel computerized tool that allows us to explore and capture the subjective experience of visual hallucinations by circumventing the difficulties associated with verbal descriptions. This scale reconstructs the hallucinated image of the participants by presenting distinct physical properties of visual information, step-by-step to help them communicate their internal experience. The strategy that underlies the SVS is to present a sequence of images to the participants whose choice at each step provides a feedback toward re-creating the internal image held by them. The SVS displays simple images on a computer screen that provide choices for the participants. Each step focuses on one physical property of an image, and the successive choices made by the participants help them to progressively build an image close to his/her hallucination, similar to the tools commonly used to generate facial composites. The SVS was constructed based on our knowledge of the visual pathways leading to an integrated perception of our environment. We discuss the rationale for the successive steps of the scale, and to which extent it could complement existing scales.

Pre-Reflective Self-Awareness in Psychotic Disorders

Disorders of the self figure prominently in psychotic experiences. Subjects de­scribe that “alien” thoughts are inserted in their mind by foreign powers, can sometimes hear their thoughts aloud or describe complex voices interacting with each other. Such experiences can be conceptualized in the framework of a Philosophical Anthropology, which suggests that human experience is characterized by centric and excentric positionality: subjects experience their environment centered around their enlived body and at the same time can reflect upon their place in a shared lifeworld from an excentric point of view. Pre-reflective self awareness has been suggested to ensure that subjects can identify their own thoughts or actions as belonging to themselves, even when they reflect upon them from an excentric point of view. This pre-reflective self awareness appears to be impaired during psychotic experiences, when subjects no longer identify thoughts in their own stream of consciousness as belonging to themselves and instead attribute them to an outside agent. Among several potential causes, it is suggested that such impairments can be due to discrimi­natory or traumatic experiences, which affect the enlived (centric) position of a person and make her feel encircled and deeply threatened by aversive powers. As a consequence, the afflicted individual may fundamentally distance herself from her current centric position in a hostile environment, at the price of experiencing her own thoughts or actions as alien. Philosophical Anthropology may thus help to explain how social exclusion, discrimination and traumatization can promote psychotic experiences and why social support is of primary importance for any treatment of psychosis.

Narcissistic Disorders of the Self as Addictions

Pathological narcissism is an addiction to Narcissistic Supply, the narcissist’s drug of choice. It is, therefore, not surprising that other addictive and reckless behaviours – workaholism, alcoholism, drug abuse, pathological gambling, compulsory shopping, or reckless driving – piggyback on this primary dependence. The narcissist – like other types of addicts – derives pleasure from these exploits. But they also sustain and enhance his grandiose fantasies as “unique”, “superior”, “entitled”, and “chosen”. They place him above the laws and pressures of the mundane and away from the humiliating and sobering demands of reality. They render him the centre of attention – but also place him in “splendid isolation” from the madding and inferior crowd. Such compulsory and wild pursuits provide a psychological exoskeleton. They are a substitute to quotidian existence. They afford the narcissist with an agenda, with timetables, goals, and faux achievements. The narcissist – the adrenaline junkie – feels that he is in control, alert, excited, and vital. He does not regard his condition as dependence. The narcissist firmly believes that he is in charge of his addiction, that he can quit at will and on short notice. The narcissist denies his cravings for fear of “losing face” and subverting the flawless, perfect, immaculate, and omnipotent image he projects. When caught red handed, the narcissist underestimates, rationalises, or intellectualises his addictive and reckless behaviours – converting them into an integral part of his grandiose and fantastic False Self

Cold Therapy and Narcissistic Disorders of the Self

For well over a century, since the publication of Freud’s seminal “On Narcissism” in 1914, pathological narcissism was widely considered to be a disorder of the “character” or the personality. This culminated in the 1980s and 1990s with the inclusion of Narcissistic Personality Disorder (NPD) in the third, fourth and text revision editions of the Diagnostic and statistical Manual (DSM). Cold Therapy is based on two premises: (1) That narcissistic disorders are actually forms of complex post-traumatic conditions and not disorders of the personality; and (2) That narcissists are the outcomes of arrested development and attachment dysfunctions. Consequently, Cold Therapy borrows techniques from child psychology and from treatment modalities used to deal with PTSD. Cold Therapy consists of the re-traumatization of the narcissistic client in a hostile, non-holding environment which resembles the ambience of the original trauma. The adult patient successfully tackles this second round of hurt and thus resolves early childhood conflicts and achieves closure rendering his now maladaptive narcissistic defenses redundant, unnecessary, and obsolete. In the process, both transference and countertransference are encouraged in order to most closely recreate the roles of the original “perpetrator” of abuse (abuser) and his or her victim (the patient or client). Cold Therapy makes use of proprietary techniques such as erasure (suppressing the client’s speech and free expression and gaining clinical information and insights from his reactions to being so stifled). Other techniques include: grandiosity reframing, guided imagery, negative iteration, other-scoring, happiness map, mirroring, escalation, role play, assimilative confabulation, hyper vigilant referencing, and re-parenting.

The Broken Self: Injured States in The Transference-Countertransference Matrix

Themes of injury and injuredness reverberate throughout the treatment of patients categorized as having disorders of the self. Aspects of the various identifications that these patients may make with clinicians who are visibly physically handicapped from the outset of treatment are explored. Vignettes from psychoanalytically informed psychotherapies conducted at frequencies of up to three times weekly reveal how these identifications are used to externalize a sense of internal psychic impairment and to shed defective introjects in an attempt to preserve a faltering self. Themes of injury and defectiveness resonate throughout the transference-countertransference matrix, leading either to a working through of the injured state or, in unfortunate cases, to the disabling of the treatment itself. Particular attention is paid to patients who reveal during treatment that they were raised by a physically ill or handicapped parent and are therefore particularly vulnerable to castrative or disintegrative anxiety. Implications for the use of the able-bodied clinician by such patients are also considered, as well as the use of the clinician’s injuredness by less primitively organized patients. The limitations of these treatments are also addressed.