DESCRIPTIVE versus DYNAMIC CONCEPTS OF
PSYCHOPATHOLOGY by Robert M. Young We need to keep some quite fundamental distinctions in mind. The first
is that between the descriptive and the dynamic. The reason I have put
descriptive in quotes is that there really is no such thing as the purely
descriptive. One of the most important ideas in recent philosophy of science is that there
is no theory-neutral descriptive language. All descriptions occur inside explicit or
implicit frameworks of ideas. One way this can be put is that all facts are theory-laden;
all theories are value-laden; all values exist and have meaning inside an ideology or
world-view. In the domain of psychological, psychotherapeutic and psychiatric language
there is a special danger in the use of technical terms. They can lead one to squeeze the
life out of experience, leading to complacency and fatalism, the conversion of lived
experience and relations among people to something dead, as if the relations between
people were relations between things. This is called reification or
thingification. There has been an important protest against the use of objectifying
technical terms in the psyche professions. The use of labels can easily lead to treating
people as if their diagnosis is a straightjacket which exhausts the meaning of their
lives. It can also carry the implication that their case is hopeless. This is most evident
in the use of the diagnostic category schizophrenic, but it applies to all
such labels. It is as if the person so labelled has thereby become de-mented, without a
mind, and as if their experience is no longer part of the human community, meaningless (Barham, 1984; Barham and Hayward, 1995; I have
reflected on the relations between the personal, the psychotic and the psychodynamic in Young, 1996). Dynamic language is less prone to these dangers. It is designed to
remain in contact with the dialectic of experience to be evocative and redolent of
peoples feelings and subjectivity. Dynamic language involves emotions, mechanisms,
defences, valences. It is closer to prose, narrative, ordinary language. I am not saying
that the dynamic terminology in psychoanalysis involve no technical terms, only that those
terms are designed to be part of a living language and to grow out of and make contact
with what people feel. Dynamic terminology also acknowledges its theory-dependency. The other distinction I want to stress is that between thinking in
terms of a fairly sharp distinction between the normal and the pathological, on the one
hand, and what I want to call the all-in vicissitudes model, on the other.
This is an awkward phrase and is intended to be so. The normal/pathological model conjures
up an ego which keeps irrationality at bay with defence mechanisms which act like
guardians of rationality or, perhaps, antibodies against invasion, eruption or infection.
The vicissitudes framework conveys an ever-shifting set of impulses and
counter-impulses based on an ongoing unconscious phantasy life. In particular, that
language of Kleinian psychoanalytic theory places a double-headed arrow linking the
paranoid-schizoid position with the depressive position (PS
DESCRIPTIVE versus DYNAMIC CONCEPTS OF PSYCHOPATHOLOGY
by Robert M. Young
We need to keep some quite fundamental distinctions in mind. The first is that between the descriptive and the dynamic. The reason I have put descriptive in quotes is that there really is no such thing as the purely descriptive. One of the most important ideas in recent philosophy of science is that there is no theory-neutral descriptive language. All descriptions occur inside explicit or implicit frameworks of ideas. One way this can be put is that all facts are theory-laden; all theories are value-laden; all values exist and have meaning inside an ideology or world-view. In the domain of psychological, psychotherapeutic and psychiatric language there is a special danger in the use of technical terms. They can lead one to squeeze the life out of experience, leading to complacency and fatalism, the conversion of lived experience and relations among people to something dead, as if the relations between people were relations between things. This is called reification or thingification.
There has been an important protest against the use of objectifying technical terms in the psyche professions. The use of labels can easily lead to treating people as if their diagnosis is a straightjacket which exhausts the meaning of their lives. It can also carry the implication that their case is hopeless. This is most evident in the use of the diagnostic category schizophrenic, but it applies to all such labels. It is as if the person so labelled has thereby become de-mented, without a mind, and as if their experience is no longer part of the human community, meaningless (Barham, 1984; Barham and Hayward, 1995; I have reflected on the relations between the personal, the psychotic and the psychodynamic in Young, 1996).
Dynamic language is less prone to these dangers. It is designed to remain in contact with the dialectic of experience to be evocative and redolent of peoples feelings and subjectivity. Dynamic language involves emotions, mechanisms, defences, valences. It is closer to prose, narrative, ordinary language. I am not saying that the dynamic terminology in psychoanalysis involve no technical terms, only that those terms are designed to be part of a living language and to grow out of and make contact with what people feel. Dynamic terminology also acknowledges its theory-dependency.
The other distinction I want to stress is that between thinking in terms of a fairly sharp distinction between the normal and the pathological, on the one hand, and what I want to call the all-in vicissitudes model, on the other. This is an awkward phrase and is intended to be so. The normal/pathological model conjures up an ego which keeps irrationality at bay with defence mechanisms which act like guardians of rationality or, perhaps, antibodies against invasion, eruption or infection. The vicissitudes framework conveys an ever-shifting set of impulses and counter-impulses based on an ongoing unconscious phantasy life. In particular, that language of Kleinian psychoanalytic theory places a double-headed arrow linking the paranoid-schizoid position with the depressive position (PS÷D) and involves constant, sometimes instantaneous, movement back and forth from splitting and projective identification to integration, concern for the object and depressive anxiety. According to Kleinian psychoanalysis, the paranoid-schizoid and depressive positions are two absolutely fundamental modes of mental functioning. I offer here John Steiners brief characterisations of the two positions which have come to be seen as the basic modes of feeling between which peoples inner worlds oscillate:
As a brief summary: in the paranoid-schizoid position anxieties of a primitive nature threaten the immature ego and lead to a mobilisation of primitive defences. Splitting, idealisation and projective identification operate to create rudimentary structures made up of idealised good objects kept far apart from persecuting bad ones. The individuals own impulses are similarly split and he directs all his love towards the good object and all his hatred against the bad one. As a consequence of the projection, the leading anxiety is paranoid, and the preoccupation is with survival of the self. Thinking is concrete because of the confusion between self and object which is one of the consequences of projective identification (Segal, 1957).
The depressive position represents an important developmental advance in which whole objects begin to be recognised and ambivalent impulses become directed towards the primary object. These changes result from an increased capacity to integrate experiences and lead to a shift in primary concern from the survival of the self to a concern for the object upon which the individual depends. Destructive impulses lead to feelings of loss and guilt which can be more fully experienced and which consequently enable mourning to take place. The consequences include a development of symbolic function and the emergence of reparative capacities which become possible when thinking no longer has to remain concrete (Steiner, 1987, pp. 69-70; see also Steiner, 1994, pp. 26-34).
According to this way of thinking our inner worlds are in a constant state of flux, moving back and forth between these positions and prey to all sorts of unconscious phantasies. The mind has available to it a variety of ways of avoiding being overwhelmed by the psychotic processes anxieties, wishes, cravings which are going on all the time in the unconscious. Every defence has a normal and a virulent version, but there are no hard and fast lines. Projective identification the unconscious process of putting of feelings into others or into parts of ones own mind is the basis of all communication, all empathy and all loving feelings, but in its malignant forms is the mechanism of prejudice, racism and hatred of others. Meltzer noted that Kleins understanding of the paranoid-schizoid and the depressive positions moved from being fixation points for psychoses to being developmental stages to her final understanding of them as positions involved in the moment by moment functioning of the mind. Similarly, Wilfred Bion drew our attention to the distinction between the normal and the psychotic parts of the personality (Bion, 1967, pp. 43-64). In both cases what is putatively psychotic in the theory of the mind maintained by the normal/pathological dichotomy of traditional psychiatry is seen as part of the vicissitudes of the normal in children and adults. Instead of carefully policed boundaries there are permeable ones, with an ongoing kaleidoscope of feelings, splits, projections, imaginings, hallucinations, delusions, reintegrations, slips, recoveries all moment by moment. My life is like that, and I am rarely psychotic for long.
However, there are important caveats to bear in mind. Whatever we may wish to say about the social construction of disease categories, if you have ever been in the presence of a psychotic breakdown your own or someone close to you or a patient you will feel that something qualitatively different is going on. I have in mind, from my own personal and clinical experience, manic-depressive psychosis (sometimes called bipolar disorder), schizophrenia, psychotic depression, and so-called true paranoia. These are, for the most part, of unknown aetiology, which is why they are called functional disorders, i.e., disorders where no structural pathology in the nervous system has been discovered. When you are up against these disorders, they feel wired in. As a lovedone or carer or just as a passer-by, one feels in the presence of something qualitatively different from the day-by-day forms of irrationality I have sketched above. One way of distinguishing the psychotic from the vicissitudes of the normal is to distinguish between praxis and process. Praxis is a word for the best state of being in control of oneself, leading a life which consists for the most part of willed, planned pursuit of sensible purposes, amenable to advice, alteration, self-critical reflection. Process, on the other hand, implies being in the grip of something which is implacable, not amenable to counsel, driven by an inner compulsion. Psychotic people often say that their voices convey an inner necessity which brooks no opposition, an irresistible impulse: I had to do it. People in the midst of a psychotic episode are in important respects sometimes unreachable. If you have ever treated or loved or even sought to be neighbourly to a psychotic person, you will know what I mean. It can break your heart to give love and/or extended therapy to someone who cannot take it in, benefit from it and make it food for thought, just as it is often heartbreaking to make interpretations to a patient who experiences what you say as what Bion calls beta-elements, unassimilable bits - rather than alpha elements, experiences which provide food for thought.
It is a dreadful pity that the patients and domains which have, perhaps, contributed most to advances in the understanding of primitive processes and which have led to much more searching and beneficial analysis, come from work with people who have not benefited much from psychoanalysis and psychotherapy, though work with them has pointed the way to greater understanding and to ways of helping less disturbed patients. A number of psychoanalysts have worked closely with psychotics and have thereby led us to a deeper understanding of the inner world. I am thinking, in particular, of the work of Klein, Bion, Donald Winnicott, Herbert Rosenfeld, Hanna Segal, Donald Meltzer and Harold Searles. Yet they would be the first to say that you cannot cure a psychotic person with analysis or psychotherapy. You may well shift them along a line from very disturbed to less so, but you will not eliminate the psychotic parts of their personalities. This is no reason for not undertaking such work. As the work of certain specialised centres such as the Arbours Crisis Centre (Berke et al., 1995) and as some recent conferences such as those on psychosis at the University of Essex have emphasized, it is challenging and important work (Ellwood, 1995). Even so, one must accept limited goals. This is not to say that the experiences of psychotic people are not as meaningful or as amenable to understanding as the experience of others. In some ways they are more intensely and obviously meaningful. The problem is that it is very hard to get a line on them and decode them and make them part of a give-and-take dialogue. Nevertheless, illuminating efforts have been made. In particular, Peter Barham has attempted to decode the conversation of a psychotic person (Barham, 1984, ch. 4).
Being in the presence of a psychotic person as a lovedone, friend or therapist means that one feels up against it. Where psychological treatments are appropriate (as they are not in certain organic conditions such as dementia), the work is slow and uncertain. I was once supervised on a case which eventually went wrong in the sense that after a period of promising psychotherapeutic work the patient had a psychotic breakdown. My supervisor, a psychoanalyst, said as a consolation that she had never treated anyone anywhere near that crazy. Indeed, in some parts of America it is illegal to use psychotherapy with psychotic patients. Even so, as I have said, much has been learned about the inner worlds of all of us from psychoanalytic work with people who are schizophrenic (Searles, Bion, Segal, Rosenfeld, Laing), autistic (Meltzer, Tustin) or with autistic parts (S. Klein), suffering from borderline states (Searles, Rosenfeld, Kernberg).
In addition to the major functional disorders I have mentioned, there are others diseases which do have demonstrable organic correlates and which are intractable. I am thinking of Alzheimers disease (pre-senile dementia), general paresis (an advanced stage of untreated syphilis), drug-induced mania or psychosis (of various types). These are all organic, and damaged tissues can be seen at autopsy. They are not so puzzling, but they can be as distressing as the major functional psychoses. For example, a person with pre-senile dementia may look his or her old self, but the brain is deteriorating, and the mind and personality are simply much less there. This is heart-rending to family and friends.
Then there is a class of psychosomatic disorders where unresolved unconscious conflicts are thought to have been projected into somatic processes. The line between psychological causation and other factors is unclear in these diseases, but there is an acknowledged psychic component in them: bronchial asthma, rheumatoid arthritis, ulcerative colitis, essential hypertension, peptic ulcer, neurodermatitis, thyrotoxicosis. Subsequent research has focused less on specific disorders and more on multiple causation of diseases formerly regarded in purely physical (Gelder et al., 1996, pp. 345-47). Important psychological causation has also been implicated in certain disorders where there is no inflammation or lesion, but function is impaired, e.g., hysterical conversion, anorexia, bulimia, frigidity, impotence.
I have so far attempted to convey two models, one the traditional one with a sharp dichotomy between the normal and the pathological, the other with a much more permeable boundary between psychotic and non-psychotic processes. I have also indicated that much can be learned from treating people whom one may not be able to change as much as neurotic patients may often be changed.
I now want to turn to psychotic symptoms and diagnoses per se. I do not want my reason for doing so to be misperceived. I am not offering a highly-condensed textbook of psychiatry. I am making short descriptions of diagnostic categories for the purpose of reflecting on the sort of accounts which are being offered in diagnostic manuals such as the American Psychiatric Associations Diagnostic and Statistical Manual (DSM-III-R, 1987; DSM-IV, 1994). I am reflecting on the meanings of the concept of psychopathology, in this case as applied and exemplified in the most recent nosology.
All of the characteristic psychopathological symptoms of psychosis involve extreme distortions of reality as experienced by others, though they are utterly real to the sufferer. It is pointless to contradict or confront the patient in the grip of a full-blown delusion or hallucination: they know what is real. A definition of psychosis is being out of touch with reality, but this is too simplistic. The patient is in intimate and overwhelming contact with reality but has lost the ability to discriminate between the inner and the outer worlds.
Delusions typically involve a profound misperception of pheenomena, events or other people, usually in a persecutory way, but one can also be deluded in a way that is idealising. People who approach one are experienced as out to get me, telling lies about me, blaming me for the situation, thinking Im a whore being in love with me. The same can be true of objects. I had a patient who expected garden hoses or electrical cords to jump up and strangle her, offal to be thrown into her car window. Black men whom she passed on the street were expected to attack her. Another patient was sure she was surrounded at her place of work by a lesbian ring, that it was my intention to seduce her and that her cousin had tried to do so. You cannot be quite sure that a delusion has no external foundation. Indeed, it does connect to something in the patients experience, but the degree is another matter. Something is occurring in the external world, but internal problems wildly exaggerate it. Of course, many horror movies and thrillers turn on whether the patient was right or not. In Gaslight it turned out that Ingrid Bergmans husband (Charles Boyer) was trying to drive her mad by repeatedly claiming that what she heard was not real, that she was forgetting things, losing things, etc. Thanks to Joseph Cotten it eventually emerged that it was the husband who was mad and a murderer.
Unlike a delusion, a hallucination is not merely a distortion. Something is experienced which other people in the same place do not experience at all. It is not there as far as others are concerned. Typically the patient will hear voices or see things or experience smells or sensations. They often experience something being put or pumped into them, and there is a historicity to this extending from evil spirits to steam to x-rays, to radio waves to television waves to atomic radiation to internet messages. Of course, people still experience evil spirits and perhaps all of the other things listed above, but fashions in hallucinations decidedly change with the history of technology. Voices are the most common. Indeed, there is a patients movement called Hearing Voices, whose members say that they dont want to pretend that they dont hear voices in order to please doctors and others who are alarmed by this symptom. They want, in effect, to persuade people to see this phenomenon as a lot more common than is usually thought. They discovered that lots of people hear voices and never mention the fact to a doctor or mental health worker (Romme and Escher, 1993). Mentally ill people are often persecuted by their voices, and in the (rare) cases of homicidally ill people they sometimes report that they are under the influence of voices which told them to commit the act. But the voices need not be malign. I met an American Indian who had voices telling him to teach his people to read. I also met a man who had seen a vision of God and Jesus who told him to sell his successful company and spend the considerable proceeds promoting psychotherapy, which is exactly what he has done.
Delusions and hallucinations are not experienced only by people who suffer from traditional functional psychoses. Anorexics actually see themselves in the mirror as fat. Alcoholics with delirium tremens actually see bugs crawling on the walls or all over them, as was graphically rendered in The Lost Weekend, in which Ray Milland played an advanced alcoholic. I was once exhausted at the end of a long lecture tour. As I waited in the flat of my host before going to the university to give my last talk, my eye fell on some notes he had made for his introduction of me. I became absolutely certain that he was going to denounce me publicly. In fact, the notes were his jottings about some affectionate personal reminiscences about our friendship and some things we had in common.
I want to turn now to a brief exposition of the major functional psychoses and of a number of other diagnoses in classical psychiatry texts. My first experience of these was as an aide in a traditional American state mental hospital. I was taught these diagnoses, sat in on diagnostic interviews and became proficient enough to get them right almost every time and was awarded a certificate of competence. We learn to see to experience patients in terms of the diagnostic categories.
Schizophrenia is the largest single diagnostic category in psychiatry. It involves profound disturbance of the form and content of thought, perception, affect, sense of self, volition, relationship to the external world, and psychomotor behaviour. None of these is always seen or is exclusive to schizophrenia. In fact, like most psychiatric diagnoses, there is a longish list of symptoms, and the diagnosis is made when a certain number is present. The list for schizophrenia is two pages long and begins with delusions and hallucinations. When I was a student there were four sub-types: Paranoid, Catatonic, Hebephrenic and Simple. Now there are five: Paranoid, Catatonic, Disorganised, Undifferentiated and Residual. The undifferentiated type has delusions and hallucinations but does not meet the criteria for the paranoid, catatonic or disorganised, and the undifferentiated type is without delusions or hallucinations but meets some of the criteria of symptoms which are listed as prodromal, or residual, of which there are nine, e.g., peculiar behaviour, inappropriate affect, odd or magical beliefs, impairment of personal hygiene or grooming, unusual perceptual experiences, marked lack of initiative. (You can read all about these diagnostic criteria in DSM-IV, 1994.)
This list is disturbingly inclusive, but my experience is that it attempts to capture in words something which is pretty clear when one is in the presence of it: craziness or madness of a kind which is usually unmistakable. If the symptoms last for six months or longer, schizophrenia is diagnosed. No one knows what causes it. There is a growing belief that there are both hereditary and experiential factors involved. However, just because there may well be a genetic component is no reason for believing that schizophrenics experiences are not meaningful or amenable to psychodynamic interpretations which may prove helpful. Most schizophrenics never get entirely better but many have quiescent periods and increasingly less severe relapses. Harold Searles worked with a number of schizophrenics, in one case for thirty-six years (Langs and Searles, 1980; see his comments on working psychoanalytically with her and his analysis of the transcript of a session, ch. 4 and Appendix to ch. 4.). His view is that some can improve with psychoanalytic treatment. I have worked with one for a number of years. He holds down a job, is kinder to his wife, both physically and mentally, and more able to perceive her legitimate needs and to allow in her criticisms. He is increasingly able to be a caring father to his children. He is less distressed most of the time. However, he still believes absolutely in a complex multi-generational delusional system and appeals to it to explain the most mundane matters when more ordinary explanations would do at least as well. He still has bad periods, calls on various forms of community support, sometimes cries uncontrollably and says certain pathetic things over and over. But he is better. I know another person who was diagnosed schizophrenic as a teenager who works well in an academic setting but has periodic bouts of hallucination and is fairly socially reclusive, though very active and creative in communications which are not face-to-face.
The second of the clearly-demarcated functional psychoses was called True Paranoia when I was training but is now designated Delusional (Paranoid) Disorder. One manifestation is person who believes himself to be Napoleon, Christ or someone grand like that. It can involve a persistent, non-bizarre delusion. It can also involve the certainty that ones spouse is being unfaithful or an erotomania, grandiosity or a particular persecution or a particular physical defect or disease. Nothing will shift the patient from his or her belief. Some people get over the belief; others have relapses; others have it for life. It occurs more often in women than men. I once had a patient who was utterly persuaded that his lower legs were two inches too long and another who believe that his bad fortune was entirely due to his having a big nose. Each of these patients was preoccupied with his somatic problem and suffered from a focal psychosis.
The two other best-established diagnostic categories of psychosis are the Manic-Depressive or Bipolar Disorder and Psychotic Depression, sometimes called Unipolar Disorder. Manic-depressives usually have extreme, cyclical mood changes from mania to depression with periods of quiescence in between. The manic phase can be profoundly creative, full of energy, maddening and sorely trying to others. The depressive can be suicidal, hopeless, indistinguishable from a major depression itself (whether a single episode or recurrent) except for the periodicity, the phasic quality of the disorder. Bipolar disorder is divided into Manic, Depressive and Mixed types. People with Bipolar Disorder may mellow but usually have it for life. It occurs more in women than men, and there is a familial pattern.
My psychiatric and psychoanalytic experience brackets these disorders Schizophrenia, True Paranoia, Manic Depressive Disorder and Psychotic Depression as the major psychiatric classifications. As I have said, I experience them as wired in and relatively intractable. I hasten to repeat that the experiences of people with these disorders make a kind of sense to any careful and sympathetic listener and make absolute and proper sense to the patients.
If we move on and work our way through the classifications of disorders in the Diagnostic and Statistical Manual, we also move into forms of mental distress which are more amenable to psychoanalytic and psychotherapeutic intervention. They are not as inaccessible as those outlined above; nor are they as intractable:
Panic. People who have panic attacks may believe that they are about to die. They experience this so strongly that the emergency services are sometimes summoned. A person with panic attacks stands at the edge of a precipice, below which is annihilation. The dread they feel is the threat of oblivion. On the other hand, they know where that boundary is and that they are standing on the right side of it. Even the most distressing symptom has its compensations.
Phobia. Phobias can be extreme. Most people have mild ones, e.g., mice, spiders. I had a patient who was for a time phobic about escalators. When she became clearer about her sexual anxieties it faded to a manageable level.
Obsessive-Compulsive Disorder (OCD). This has recently become well-known as a result of Jack Nicholsons Oscar-winning portrayal of a person with OCD in As Good as It Gets. He had to wash with a new bar of soap and then another one. He had to wear gloves outside, to eat with his own plastic utensils, to avoid cracks in the pavement, not to be touched. I had a patient who had to check the gas and water taps many, many times before she could leave the house.
Agoraphobia. The fear of open spaces can lead a person to avoid leaving home or of going into open fields. The anxiety is one of being overwhelmed by boundarylessness falling through empty space.
Claustrophobia. Fear of confined spaces can be just as distressing as the opposite fear. Crowds can have the same effect, as can the presence of a single person.
Vertigo. This disorder is similar but pertains to heights, with resulting fear of falling and dizziness.
Hypochondria. The hypochondriac is persuaded that he or she has contracted a disease, sometimes one after another, and is recurrently in need of medical reassurance.
Sadism. Named after the French libertine, the Marquis de Sade, this disorder is a perversion in which intense pleasure is gained from inflicting pain and suffering onto others.
Masochism. Masoch had the complementary psychosexual need to have pain and suffering inflicted on him or her. Sado-masochistic relations need not involve physical torment; they can be just as effective when conducted in the psychological realm.
Fetishism. The fetishist can only gain sexual gratification from a particular object, often something worn near to the genital area or symbolising it or other sexual zones underwear, shoes, lipstick, hair, rubberwear, leatherwear. The real thing is too dangerous; the chosen fetish object is a compromise getting close but not too close.
Sexual Dysfunctions. There are many of these, e.g., no desire, no or short-lived erection, failure of vaginal lubrication, inhibited orgasm, premature ejaculation, pain on intercourse to the point of tightening of vaginal muscles so that entry cannot occur.
Conversion. This is a general concept. A psychological conflict is projected into the body so that something abnormal occurs. It may be a strange sensation, no sensation, paralysis, blindness, inability to smell. The psychological causation is clear from the fact that no organic cause can be found and psychological investigation reveals that the meaning of the symptom is symbolic, e.g., not being able to bear seeing or feeling something or the inhibition of movement for fear of what one might do. Many conversion symptoms lead to secondary gains, e.g., the crippled person has to be waited on.
As I said at the beginning of this exposition of psychological disorders other than the main functional psychoses, these disorders are more amenable to psychotherapy of various kinds than the functonal psychoses. There are, for example, sex therapists specialising in sexual disorders, others concentrating on phobias and OCD, still others who approach such symptoms as a part of more general psychological problems. I have had one or more patient with each of the above and have been able to help by means of psychoanalytic psychotherapy, thought not in all cases.
As we move toward the back of the Diagnostic and Statistical Manual my experience is that we move nearer and nearer to the vicissitudes of everyday life. I will outline two diagnoses which strike me as characterising lot of people I know and myself at one time or another. When I read out these criteria in seminars my students vacillate between discomfort and nervous laughter.
Passive-Aggressive Personality Disorder
A. A pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following
(1) passively resists fulfilling routine asocial and occupational tasks
(2) complains of being misunderstood and unappreciated by others
(3) is sullen and argumentative
(4) unreasonably criticises and scorns authority
(5) expresses envy and resentment towards those apparently more fortunate
(6) voices exaggerated and persistent complaints of personal misfortune
(7) alternates between hostile compliance and contrition
Does not Occur exclusively during Major Depressive Episodes and is not later accounted for by Dysthymic Disorder (DSM-IV, 1994, p.735).
I qualify under all but the last of the numbered criteria quite a lot of the time.
My favourite diagnosis from the Diagnostic and Statistical Manual is Self-Defeating Personality Disorder, the criteria for which are as follows:
A. A pervasive pattern of self-defeating behavior, beginning by early adulthood and present in a variety of contexts. The person may often avoid or undermine pleasurable experiences, be drawn to situations or relationships in which he or she will suffer, and prevent others from helping him or her, as indicated by at least five of the following:
(1) chooses people and situations that lead to disappointment, failure, or mistreatment even when better options are clearly available
(2) rejects or renders ineffective the attempts of others to help him or her
(3) following positive personal events (e.g., new achievement), responds with depression, guilt, or a behavior that produces pain (e.g., an accident)
(4) incites angry or rejecting responses from others and then feels hurt, defeated, or humiliated (e.g., makes fun of spouse in public, provoking an angry retort, then feels devastated)
(5) rejects opportunities for pleasure, or is reluctant to acknowledge enjoying himself or herself (despite having adequate social skills and the capacity for pleasure)
(6) fails to accomplish tasks crucial to his or her personal objectives despite demonstrated ability to do so, e.g., helps fellow students write papers, but is unable to write his or her own
(7) is uninterested in or rejects people who consistently treat him or her well, e.g., is unattracted to caring sexual partners
(8) engages in excessive self-sacrifice that is unsolicited by the intended recipients of the sacrifice
B. The behaviors in A do not occur exclusively in response to, or in anticipation of, being physically, sexually, or psychologically abused.
C. The behaviors in A do not occur only when the person is depressed (DSM-III-R, 1987, pp. 373-74)..
Well, that describes me and practically everyone I know, at least for important periods of life. It is with some relief that I report that I could not find this category in the subsequent edition, DSM-IV. Actually it was in a sort of probationary space in DSM-III-R; it was listed under Proposed Diagnostic Categories Needing Further Study.
My serious point in rather satirically presenting the diagnostic criteria for these last two conditions is that as we move through the manual we find ourselves moving closer and closer to the everyday lives of normally troubled people who have bad patches, some more than others. I recall once writing a long apologia for my position in a strong disagreement occurring in a psychotherapy training organization where I was pursuing a postgraduate qualification. I put in a sentence that I had been involved in a number of struggles of this sort at various stages in my life. A kind colleague insisted that I remove the sentence, insisting that they would pathologise me on the basis of it. Yet I did have such a track record, and I am seriously proud of it. I wonder what DSM might say about it. I was right in the instance mentioned here, as well, as subsequent events proved. Of course, my willingness to stand and fight had some pathological aspects. We sometimes do good things for very mixed motives. Life and mind are mixtures of good and bad attributes, proneness to mild and powerful reactions, and mine includes a hair trigger about injustice and for not kow-towing to bullies.
The general point I am making is that irrational processes are ubiquitous and play a greater part in our everyday mental processes than a sharp dichotomy between the normal and the pathological would lead one to believe. I am not suggesting that psychotic processes control the everyday lives of people not suffering from one of the major functional psychoses. I am suggesting, however, that processes which occur in those psychoses also occur in our everyday mental processes to some degree that it is a matter of degree, of how much of the personality is in ther grip of such processses and how much of the time. Similarly, as we move down the list of diagnoses we find more and more symptoms which are likely to constitute abnormal phases of differing duration in our normal lives. I have at times been claustrophobic, vertiginous, agoraphobic, hypocondriacal, fetishistic, sadistic, masochistic and so on. In fact, I am afraid of heights and suspect that I have a potentially fatal disease practically all of the time. I am not, however, taken over or incapacitated by any of these forms of distress to the point where I merit a psychiatric diagnosis.
I want to offer here a passage from Joan Riviere which the role of primitive thinking in all our minds:
I wish especially to point out therefore that from the very beginning of life, on Freud's own hypothesis, the psyche responds to the reality of its experiences by interpreting them or rather, misinterpreting them in a subjective manner that increases its pleasure and preserves it from pain. This act of a subjective interpretation of experience, which it carries out by means of the processes of introjection and projection, is called by Freud hallucination; and it forms the foundation of what we mean by phantasy-life. The phantasy-life of the individual is thus the form in which the real internal and external sensations and perceptions are interpreted and represented to himself in his mind under the influence of the pleasure-pain principle. (It seems to me that one only has to consider for a moment that in spite of all the advances man has made in adaptation of a kind to external reality, this primitive and elementary function of his psyche to misinterpret his perceptions for his own satisfaction still retains the upper hand in the minds of the great majority even of civilized adults (Riviere, 1952, p. 41).
This general function for phantasy is repeated in Susan Isaacs' definition. The "mental expression" of instinct is unconscious phantasy... There is no impulse, no instinctual urge or response which is not experienced as unconscious phantasy' (Isaacs, 1952, p. 83).
Riviere and Isaacs are stressing that distortion of experience to the point of hallucination in the very having of experience, as well as an ongoing process of unconscious phantasy, are synonymous with having a mental life. To the extent that psychopathological writings eschew dynamic formulations and confine themselves to descriptive ones, they will tend to leave out the interplay of emotions and the important role of irrational forces in our ordinary mental processes, as well as the presence of quite crazy processes in all our minds some of the time. Once again, I am not suggesting that we are all psychotic, only that psychotic processes form a part of our mundane cogitations and unconscious thought processes. Moreover, these phantasies include an ongoing role for unconscious psychotic anxieties throughout life, based on the fear of annihilation (Isaacs, 1952, pp. 82-83, 109, 112).
I also want to reprise a critical reflection by German Berrios, author of the most systematic study in this field (Berrios, 1996). It is his opinion that the persistence of psychopathology in British psychiatry can be attributed to the empiricist false consciousness seeking theory-neutral statements. The effort to describe and classify frees one from understanding, process, dynamics and aetiology. If, on the contrary, we seek to understand these matters, we must turn to the narratives of peoples lives, their stories, the vicissitudes of their familial and other significant relationships, the formative experiences and enduring patterns in their inner worlds. We must seek to understand, emphathise, explain and enlighten. The empiricist false consciousness to which Berrios refers seeks to confine psychiatric description to facts, not values, to behaviour, not internal worlds, to classification, not interpersonal dynamics, to pigeon-holing at the likely expense of an empathic understanding of our fellow human beings.
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