1. 1
CLINICAL NOTES
ON NEUROSIS AND PSYCHOSIS
Sigmund Freud (1924). ‘Neurosis and Psychosis,’ On Psychopathology, translated by
James Strachey, edited by Angela Richards (London: Penguin Books, 1987), pp. 209-
218.
Sigmund Freud (1924). ‘The Loss of Reality in Neurosis and Psychosis,’ On
Psychopathology, translated by James Strachey, edited by Angela Richards (London:
Penguin Books, 1987), pp. 219-226.
These clinical notes summarize the main points raised by Sigmund Freud in the two
papers cited above.
These are by no means the only papers that Freud wrote on this topic, but they have
been chosen here because they bring out the main points effectively.
Readers who find the analytic distinction between neurosis and psychosis
interesting can then read further on this topic.
The first thing to note that is that Sigmund Freud had invested more in the study of
the psychoneuroses than in the psychoses.
There are a number of reasons for this.
The most important reason is that it was easier to generate a positive transference
with the neuroses than with the psychoses.
Most psychotics were narcissistic to a point where it was not possible to generate the
kind of positive transference that would make analytic interventions possible in the
clinic.
That is not to say that analysts avoid psychotics.
It is more a case of being wary of the limitations of their method with psychotics as
opposed to psychiatrists who focus on the latter.

2. 2
‘Neurosis and Psychosis’ was written in 1923 and translated into English in 1924.
‘The Loss of Reality in Neurosis and Psychosis’ was written and translated into
English in 1924.
Both papers were featured in the Standard Edition in 1961.
Freud starts with a formula that differentiates between the neuroses and the
psychoses.
A neurosis is characterized by ‘a conflict between the ego and the id, whereas
psychosis is the analogous outcome of a similar disturbance in relations between the
ego and the external world.’
So, for instance, in Meynert’s amentia the external world is either not perceived by
the ego at all or not taken seriously by the ego. In its place the ego conjures up its
own internal and external reality.
This happens because the ego feels that some wish of it was thwarted by reality. That
is why reality becomes intolerable to the ego. There is an affinity then between loss
of reality in dreams and the loss of reality in amentia.
Likewise, in schizophrenia, the subject suffers from a form of ‘affective hebetude’ –
this leads to the unwillingness to participate in external reality.
What is really at stake in such a situation is whether the ego remains in touch with
external reality or not when it experiences a state of conflict.
Freud states that there are three forms of conflict:
‘Transference neuroses correspond to a conflict between the ego and the id;
narcissistic neuroses, to a conflict between the ego and the super-ego; and psychoses,
to one between the ego and the external world.’
Not only, argues Freud, does the ego fall ill because it is not able to cope with the
demands made by a number of ruling agencies; it is also important to identify the
circumstances in which the ego can emerge unscathed from a situation that is
characterised by conflict.
The two circumstances in which this is possible include economic factors and the
splitting of the ego.
Nonetheless, in both neuroses and psychoses there is a loss of reality albeit with a
difference.
A neurosis is more responsive to reality whereas a psychosis is subject only to the
domination of the id.

3. 3
This difference however exists only in the beginning phases of a neurosis.
But sooner or later both the neuroses and the psychoses represent a withdrawal from
external reality into a world of the subject’s own making.
This libidinal withdrawal from external reality is what Freud terms ‘the loss of
reality’ in the title of the second paper.
In terms of the causative mechanism however Freud maintains the distinction
between ‘repression’ in the neuroses and ‘disavowal’ in the psychoses.
In the neuroses, the subject seeks recourse to fantasy whereas in the psychoses, the
subject substitutes external reality with his own version of internal reality.
In both instances, the id is not able to come to terms with anake – i.e. the ‘exigencies
of reality.’ The neurosis avoids an intolerable piece of reality; the psychosis remodels
the reality in a form that is acceptable to the id.
Hallucinations help the id to conjure up mental images that correspond to the wishes
of internal reality while repudiating those of external reality.
Paramnesias and delusions also further the same function; they remodel reality as
the psychotic sees fit.
However neither in a neurosis nor in a psychosis can external reality be eluded in its
entirety. The rejected piece of reality threatens to force its way back into the
consciousness of the subject; this induces anxiety.
In other words, neither neurotic fantasy nor psychotic hallucinations can do away
with the ‘upward flow’ of the unconscious or find an effective substitute for that
portion of reality which is repudiated by the subject’s ego.
Freud’s conclusion therefore is that ‘both in neurosis and psychosis there comes into
consideration the question not only of a loss of reality but also of a substitute for
reality.’
SHIVA KUMAR SRINIVASAN