DIAGNOSTIC CRITERIA 诊断的标准
So how does the analyst actually arrive at a diagnosis? In ‘On Beginning the Treatment’, Freud was not very forthcoming about how to distinguish practically neurosis from psychosis, yet he did warn his readers about the deceitfulness of the clinical picture:
所以，精神分析家实际上获得诊断没有？在“论治疗的开始”，弗洛伊德并没有直接提出如何实践时区别神经症与精神病。可是，他确实警告他的读者，关于这个临床画面的欺骗性。
Often enough, when one sees a neurosis with hysterical or obsessional symptoms, which is not excessively marked and has not been in existence for long—just the type of case, that is, that one would regard as suitable for treatment—one has to reckon with the possibility that it may be a preliminary stage of what is known as dementia praecox (‘schizophrenia’, in Bleuler’s terminology; ‘paraphrenia’, as I have proposed to call it), and that sooner or later it will show a well-marked picture of that affection.
经常地，当我们看见一位神经诊者具有癔症或妄想症的症状时，这并不是过分明显，并且并没有长久存在。它仅是这种个案，换句话说，我们将会认为这位神经症是适合于治疗。我们必须考虑这个可能性：这可能是一个初期的阶段，对于众所周知的“精神病”（精神分裂症schizophrenia，用布鲁尔的术语，paraphrenia，依照我对它的建议称呼）。迟早，它将会显示一个属于那种情感的明显的画面。
(Freud 1913c:124) 8 Jacques Lacan and the Freudian practice of psychoanalysis Freud contended that ostensibly neurotic symptoms (such as elusive bodily pains and compulsive behaviours) should not be taken as unambiguous signs of an underlying neurotic illness, however conspicuous they may be.
弗洛伊德主张，夸张的神经症的症状（譬如，难以捉摸的身体的疼痛与强迫性的行为），应该被视为是并不模糊的迹象，属于潜在的神经症疾病，无论它们可能很明显。
A psychosis can hide under the mask of a neurosis, and the analyst should not be misled by the colours of the clinical guise.2 To many of his contemporaries, Freud’s admonition must have seemed odd, used as they were in privileging strict relationships between certain symptoms and certain disorders. Yet it may also surprise those contemporary clinicians who still believe that hallucinations are sufficient for diagnosing psychosis or that persistent offending is pathognomonic for psychopathy.
精神病有时隐藏在神经症的面具之下。精神分析家不应该被临床时的伪装模样所误导。对于许多他的当代的人们，弗洛伊德的警告当时一定显得奇怪。虽然它们被用来让某些的症状与某些的疾病之间的严谨的关系具有特权。可是，那些当代的临床医生可能也会大吃一惊，因为他们依旧相信，光凭幻觉就足够诊断精神病，或是他们相信，持续的冒犯是属于精神病的特殊病症。
None the less, Freud’s first, negative diagnostic rule read that one should not take symptoms at face value. Mental organization had to be dislodged from observable phenomena, and analysts were urged to suspend their judgement and to look for more reliable criteria. Defining such criteria proved more onerous than exposing the misleading ones though.
现在仍然是如此，弗洛伊德的最初，负面的诊断的规则写著：我们不应该将症状就表面看待。精神病的组织必须跟可被观察到现象驱离开来。精神分析家被建议要悬置他们的判断，并且寻找更多可靠的标准。定义这些标准证明更加的繁重，比起揭露那些误导的标准。
Freud was adamant that the psychoanalytic process is unpredictable and that the analyst’s initial diagnosis can always be disproved by the vicissitudes of the treatment, in which case analysts should be willing to change their minds about the patient’s psychic economy. Paradoxically, the most correct analytic diagnosis would be that which the analyst is able to formulate at the end of the treatment, which is unfortunately a point of no return. The whole diagnostic enterprise reminded Freud (1933a[1932]:155) of the medieval ordeal by water, albeit with the analyst rather than the patient in the position of the victim.
弗洛伊德坚决主张，精神分析的过程是无法被预测的，精神分析家的最初的诊断有时能够被反驳，由于治疗的起伏。在治疗的情况，精神分析家应该愿意改变他们的心意，关于病人的心灵的活动。悖论地，即使是最正确的精神分析的诊断都将会是精神分析家能够说明的东西，在治疗的结束时。很不幸地，那是没有回转的时刻。整个的诊断的企业让弗洛伊德想起中世纪的用水的磨难，虽然处于受害者的立场的是精神分析家，而非病人。
Despite these problems, and despite his advocacy of a ‘dynamic diagnosis’, Freud did suggest at least two positive diagnostic criteria. The first criterion can be inferred from his alternative tabulation of neuroses and psychoses as transference neuroses and narcissistic neuroses respectively. On the one hand, Freud classified anxiety hysteria (phobia), conversion hysteria and obsessional neurosis as transference neuroses, because the emotional tie connecting the patient to the analyst acquires in these cases an ‘extraordinary, and for the treatment, positively central, importance’ (Freud 1916–17a[1915–17]:445).
尽管这些难题，尽管弗洛伊德主张“动态的诊断“，他确实建议至少要有两个正面的诊断的标准。第一个标准能够被推论，根据神经症者与精神病者的替换的表格，分别作为移情的神经症与自恋的神经症。在一方面，弗洛伊德将焦虑的癔症（恐惧症），转化的癔症与妄想的神经症，分类为移情的神经症。因为情感的关系，连系病人跟分析家，在这些个案里，获得”特殊的重要性，对于治疗而言，是非常核心的重要性“。
On the other hand, patients suffering from a narcissistic neurosis—dementia praecox, paranoia or melancholia—‘have no capacity for transference or only insufficient residues of it’ (ibid.: 447). When faced with the task of distinguishing between neurosis and psychosis, the analyst should thus investigate whether the patient is capable of developing and maintaining an emotional tie, the absence of such an ability indicating psychosis and giving the analyst enough reason to rule out psychoanalytic treatment.
另一方面，遭受自恋的神经症痛苦的病人—精神分裂症，妄想症或忧郁症—他们“并没有移情的能力，或仅是移情的不充足的残渣“。当他们面对区别的工作，区别神经症与精神病，精神分析家因此应该研究病人是否能够发展或维持情感的关联。缺乏这样的能力指示精神病，并且给予精神分析足够理由来排除精神分析的治疗。
Here Freud exchanged the objective diagnosis based on ‘symptoms interpreted as signs’ for an intersubjective diagnosis, resting on the evaluation of a relationship.
在此，弗洛伊德将客观的诊断，以被解释为迹象的症状作为基础的客体的诊断，交换为互为主观性的诊断。这个诊断依靠关系的评估。
However, transference was not the only and perhaps not even the most significant criterion Freud employed to discriminate between neurosis and psychosis. In his metapsychological paper ‘The Unconscious’ (1915e), he opposed schizophrenia to hysteria and obsessional neurosis on no other grounds than the patient’s speech. According to Freud, a schizophrenic patient’s speech bears witness to a remarkable meticulousness, with expressions often displaying a degree of artificiality, sentences becoming disorganized and words getting strangely mixed up with the body.
可是，移情并不是唯一，或许甚至并不是最重要的标准，弗洛伊德使用来区别神经症与精神病。在他的后设心理学的论文，“无意识”，他将精神分裂症跟癔症与妄想症相提并论，根据的理由仅是病人的言词。依照弗洛伊德，精神分裂的病人的言词见证到明显的讲究细节，表达经常展示矫揉造作的程度，句子变得散乱，文词跟身体奇怪地混合一块。
Schizophrenic patients appear to be using ‘condensed speech’, because whole series of thoughts find an outlet in single words, which consequently acquire massive meaning and become linked to a bodily organ or process.3 Freud attributed these extraordinary schizophrenic speech characteristics to the prevalence of wordconnections over thing-connections in psychosis. In psychotic patients, the relationship between what Freud called ‘word-presentations’ (Wortvorstellungen) and ‘thing-presentations’ (Sachvorstellungen) has been severed, resulting in a closed circuit of symptomatic wordconnections. Patients are no longer concerned about the actual ‘things’ that words represent in a particular language; they merely relate to their verbal content.4
精神分裂症的病人似乎使用“浓缩的言词”，因为思想的整个的意义就在这些字词里找到发泄。这些字词结果获得重大的意义，并且跟身体的器官或过程连接一块。弗洛伊德将这些特殊的精神分析的言词特征，归属于精神病的字词连接压倒过事物的连接。在精神病的病人，这个关系已经比分割，弗洛伊德所谓的“字词-表象”与“物表象”之间的关系。结果形成症状的字词的一个封闭的迴圈。病人不再关心现实的事物，那是字词用特殊的语言所代表。它们仅是跟它们的文词内容有关系。
A clear illustration of this radical inertia of thing-presentations in psychosis is offered by a girl who complains that her eyes have been twisted—an example Freud borrowed from Victor Tausk (1919) — because her lover is a genuine eye-twister (Augenverdreher). In German, an Augenverdreher is an arrant deceiver, and although the woman is aware of this meaning (the thing-presentation), she is unable to assimilate it. She can only relate to the literal meaning (the word-presentation) of Augenverdreher, through which she is forced to conclude that her lover has twisted her eyes physically.5 The woman’s conviction that she is suffering from twisted eyes (her symptom) is determined by the broken connection between the word-presentation and the thing-presentation. Although she knows the thing-presentation, it is impossible for her to use this meaning in order to relativize the literal one.
在精神病，物表象的这个强烈的贯性，有一个清楚的例子，由一位女孩提供。她抱怨她的眼睛已经被障眼—弗洛伊德从维克多 陶斯特借用的一个例子—因为她的爱人是一位真诚的障眼术者。在德文，障眼术者是一位声名狼藉的欺骗者。虽然这位女人知道这个意义（物表象），她不能够接受它。她仅是描述障眼术者的字面意义（词表象）。通过这个意义，她被迫下结论说，她的爱人已经在生理方面障眼她的眼睛。这位女人确信，她正在遭受被障眼的痛苦（她的症状），是由于字词表象与物表象之间的关联度中断所造成。虽然她并不知道物表象，她不可能使用这个意义，为了将字面意义相对化。
Another example of this linguistic mechanism, reported to me by a colleague, concerns a man who threatens to sabotage the central heating of the psychiatric clinic where he was based, and even to set the whole building on fire, in order to take revenge on those members of staff who have left him out in the cold. Like the female patient, this man is incapable of assimilating the thing-presentation of the expression ‘to be left out in the cold’, i.e. to be left behind, although he is perfectly aware of it. To him, ‘to be left out in the cold’ means that some people have tried to lower his body temperature, and therefore he feels that these scoundrels deserve tit for tat.
这个语言的机制的另外一个例子，一位同事跟我报导，关于一个人。他威胁要破坏精神病诊所的中央冷气系统，他以那里作为基地。他甚至要放火烧掉整栋建筑物，为了报复那些将他排除在外的成员。就像那位女性病人，这位男人无法接受“被冷落在外”的这个表达的物表象，也就是被抛弃一旁，虽然他完全知道它。对于他，“被冷落在外”意味着，某些人们尝试降低他的身体的温度，因此，他感觉，这些坏蛋应该被以牙还牙。
On the surface, neurotic patients can suffer from the same kinds of symptoms (twisted eyes, physical coldness) as psychotics, which is exactly what Freud intended to demonstrate, but the neurotic symptoms respond to an entirely different psychic economy. In neurosis, the wordpresentation has not been cut off from the thing-presentation, but the word-presentation has been repressed. It has been driven out of the patient’s consciousness into the unconscious. The upshot is that the wordpresentation exercises its influence without the patient being aware of what has produced the symptoms.
表面上，神经症的病人会遭受相同种类的症状的痛苦（眼睛被障眼，生理感到寒冷），当作是精神病。这确实是弗洛伊德打算要证明的。但是，神经症的症状回应一个完全不同的心灵的活动。在神经症者，字词表象并没有跟物表象隔离开来。而是字词表象已经被压抑。字词表象已经从病人的意识驱赶进入无意识。结果是，字词表象运用它的影响，而病人却不知道是什么产生这个症状。
In neurosis, symptoms are determined by a repressed, unconscious representation and it is the analyst’s task to bring the patient to the point where this hidden factor can be retrieved. Put differently, neurotic patients somehow suffer from a ‘lacking word’, which the analytic process can help to recover. In psychosis, matters are completely different. Although symptoms are also determined by wordpresentations, the latter are not repressed and neither are the thingpresentations.
在神经症，症状被决定，根据被压抑的无意识的表象。精神分析家的工作就是要将病人带到这个时刻，这个被隐藏的因素能够被重新获得的时刻。换句话说，神经症的病人有些遭受“文词欠缺”的痛苦，精神分析的过程能够帮忙他重新获得。在精神病，事情完全不同。虽然症状被决定，也是由于字词表象，字词表象并没有被压抑，物表象也没有。
Whereas a neurotic patient fails to find the building blocks of her symptoms, a psychotic patient has nothing to hide. All the materials are out in the open. This is why Freud, talking about the schizophrenic woman, observed: ‘The patient’s comments…have the value of an analysis…They throw light at the same time on the meaning and the genesis of schizophrenic word-formation’ (Freud 1915e:198). Of course, the drama is that in psychosis the ‘analytic’ value of the patient’s utterances has no bearing whatsoever on the destabilization of the symptoms.
虽然神经症的病人无法找到她的症状的建筑方块，精神病的病人却是没有什么东西可让他隐藏。所有的材料都暴露在外面。这就是为什么弗洛伊德谈论关于精神分裂症的女人时，他观察到：「这位病人的评论具有精神分析的价值。这些评论同时让我们明白精神分裂症者的字词形成的意义与戏剧。当然，戏剧是，在精神病，病人的表达的“精神分析的价值”，跟症状的不稳定，并没有丝毫的关系。
Freud’s considerations on differential diagnostics form the nucleus of Lacan’s distinctions between neurosis, psychosis and perversion. Within a Lacanian orientation, psychic structures do not differ as far as the clinical picture is concerned, but on the basis of speech and language, and with respect to the subject’s relationships with his peers, family members, colleagues, lovers, therapists, etc.
弗洛伊德对不同的诊断的考虑，形成拉康的区别的核心，区别神经症，精神病与倒错症。在拉康的定向里，心灵的结构并没有差异，就临床的画面而言。而是，根据言说与语言的基础，关于主体跟他的同侪，家庭成员，同事，情人，治疗师等等的关系。
Lacan had already drawn attention to both these criteria in his earliest writings on paranoia (Lacan 1975a[1931]; 1975b[1932]; 1988d[1933]), but they did not start to gain momentum until the 1950s, as part of his ‘return to Freud’ and his aspiration to restore the value of speech and language in psychoanalysis. Perhaps as a result of his own training as a clinical psychiatrist working with psychotic patients, Lacan detailed these criteria most emphatically for the psychic structure of psychosis and he was least explicit concerning perversion.
拉康已经注意到这两个标准，在他的早期探讨妄想症的著作。但是，直到1950年代，这些著作才开始获得重视，作为他“回到弗洛伊德”的部分。拉康渴望恢复言说与语言在精神分析的价值。或许，由于他自己作为临床精神病医生的训练的结果，他研究精神病人。拉康因此强调地详细列举这些标准，作为精神病的心灵的结构。关于倒错症，他则是没讲得那么明确。
Moreover, in his discussion of the various psychic structures he usually highlighted the speech and language features, the nature of the transference being regarded as an effect of these characteristics. In the subsequent sections of this chapter, I will follow a similar trajectory, from psychosis to neurosis and perversion, and from speech to transference. As Lacan’s comments on perversion are less elaborated and coherent than those on psychosis and neurosis, the section on perversion will necessarily be more tributary to others’ and my own interpretations of Lacan’s works than the preceding ones.
而且，当他讨论各色各样的心灵结构时，他通常强调言说与语言的特征。移情的特性则是被认为是这些特征的影响。在这个章节的随后的部分，我将遵循类似的途径，从精神病到神经症与倒错症，并且从言说到移情。因为拉康评论倒错症，并没有像评论精神病与神经症那么精细与一致性。讨论倒错的部分将必然更加枝枝节节，比起其他两个，以及我自己对于拉康的著作的解释，比起前面的那些解释。
雄伯译
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