Violence and the Paranoid Process 暴力和偏执过程 The problem of violence in paranoid patients is of particular interest, since it involves such a high degree of destructiveness and potential danger. The destructive potential is high in the paranoid syndromes that we have discussed—particularly in those which show a psychotic level of functioning or have a capacity for psychotic decompensation. It is readily understandable that the persecutory delusions would lead the patient to defend himself by destructive counterattacks. This is particularly true insofar as the patient's underlying sense of vulnerability and helplessness may create acute levels of rather intense persecutory anxiety. The destructive counterattack is a way of relieving this anxiety. The patient's delusions may also allow for a rationalization or justification of the destructive activity. This is particularly true where paranoid grandiosity comes into play. 偏执患者的暴力问题特别值得关注，因为它涉及如此高的破坏性和潜在的危险。在我们讨论过的偏执综合症中，破坏性的潜在性是很高的，特别是在那些表现出运作的精神病水平或有精神病失代偿能力的症状中。被害妄想症会导致病人采取破坏性的反击来保护自己，这是很容易理解的。当病人潜在的脆弱感和无助感可能会造成严重程度的被害焦虑时，这种情况尤其严重。毁灭性的反击是缓解这种焦虑的一种方式。患者的错觉也可能使破坏性活动合理化或正当化。这一点在偏执夸大发挥作用时尤为明显。 One of the important points that needs to be made in this connection is that the expression of violence is not limited to paranoid syndromes as such. Nonetheless, a cogent case can be made that, where violence is found as a part of the clinical picture, it is very likely to serve as an expression of underlying paranoid dynamics. This can be seen, for example, in violent patients who present themselves as the psychiatric emergency room(Lion et a1,1969). Such patients often presented with fears of loss of control or sudden destructive impulsivity, running "amok"—often with diffuse anxiety states and paniclike reactions. The breakthrough of destructive impulses was often without any clear-cut precipitant. Low frustration tolerance and poor work and marital histories were characteristic, along with superimposed paranoid elements. Self-esteem was low, and any narcissistic injury was dealt with by projection and an outburst of rage. Past histories often reflected a triat of enuresis, pyromania, or sadistic behavior to animals—a sadistic triad which has been found to be related to adult criminality (Hellman and Blackman,1966). 在这方面需要指出的重要一点是，暴力的表现并不限于偏执症状本身。尽管如此，一个令人信服的案例可以被证明，当暴力被发现是临床表现的一部分时，它很可能是潜在的偏执动力学的一种表达。例如，这可以在表现为精神急症室的暴力患者身上看到(Lion et a1,1969)。这类患者常常表现出对失去控制的恐惧或突然的破坏性冲动，“发狂”——通常伴有弥漫性焦虑状态和类似恐慌的反应。破坏性冲动的突破往往没有明确的诱因。较低的挫折忍耐力、糟糕的工作和婚姻史，以及附加的偏执因素是其特征。自尊很低，任何自恋的伤害都是通过投射和愤怒的爆发来处理的。过去的历史往往反映了遗尿、纵火或虐待动物行为的三联症——虐待三联症已被发现与成人犯罪有关(Hellman和Blackman,1966年)。 Even when the violent impulses were directed toward particular objects, the violence was a form of reaction to dependency conflicts, and against the threat of diminished masculinity or physical weakness. The most frequent object of attack for these men was the wife. Such men seemed quite threatened by their dependency on their wives and their unconscious need for support from them—while the wives often manifested a masochistic need for punishment which responded to the husband's sadism. Some of these patients also had associated temporary lobe pathology or alcoholic pathology. (The association between these states and the paranoid process will be discussed in a later section.) 甚至当暴力冲动指向特定客体时，暴力也是对依赖冲突的一种反应形式，是对男子气概减弱或身体虚弱的威胁的一种反应。这些男人最常攻击的客体是他们的妻子。这样的男人似乎被他们对妻子的依赖和对支持的无意识需求所威胁——而妻子往往表现出一种需要被惩罚的受虐欲，来回应丈夫的虐待。其中一些患者还伴有暂时性脑叶病变或酒精性病变。(这些状态和偏执过程之间的联系将在后面的章节中讨论。)