The differential diagnosis of obsessive-compulsive symptoms

The Differential Diagnosis of Obsessive-Compulsive Symptoms K. H. Blacker and M o r t o n Levitt D I S T R A U G H T Y O U N G W O M A N ' S M I N D was filled with u n w a n t e d s c e n e s of her b r o t h e r ' s suicide and images o f his"head partially blown off. A l a b o r a t o r y technician was unable to w o r k b e c a u s e of recurrent urges to cut her arms with b r o k e n g l a s s w a r e and to mangle h e r hands in m a c h i n e r y . A p r o f e s s o r ' s tidy mind was f r a g m e n t e d b y r e p e a t e d images of an injured laboratory h e l p e r and by his own fear of dying. A m o t h e r e x p e r i e n c e d s u d d e n a n d terrifying t h o u g h t s that h e r infant might die. E a c h sought help b e c a u s e of o b s e s s i v e s y m p t o m s ; y e t e a c h was v e r y different from the others as defined b y both the c o u r s e o f illness and the r e s p o n s e to t r e a t m e n t . H o w can we r e c o g n i z e the c o m m o n e l e m e n t s in their disorders and still be profitably a w a r e of idiosyncratic differences? It is this q u e s t i o n we wish to a d d r e s s in the p a p e r t h a t follows. O b s e s s i o n , "'an idea, e m o t i o n , or impulse that repetitively and insistently forces itself into consciousness even though & is unwelcome, ''~ and compulsion, "'a repetitive, s t e r e o t y p e d , and often trivial m o t o r action, the need for w h o s e performance insistently forces itself into consciousness even though the subject does not wish to perform the act "'2 are c o m m o n . O b s e s s i o n s a n d c o m p u l s i o n s are e x p e r i e n c e d by all o f us. In s o m e individuals a n d u n d e r certain c o n d i t i o n s , t h e y r e a c h a degree of intensity a n d f r e q u e n c y that disrupts mental life. T h e b o r d e r b e t w e e n thoughts and actions that b e c o m e defined as s y m p t o m s and those that r e m a i n within the realm o f adaptive f u n c t i o n i n g is defined by the degree o f i m p a i r m e n t caused by these intrusive ideas and urges. T h e m a j o r diagnostic p r o b l e m arises w h e n o b s e s s i v e - c o m p u l s i v e s y m p t o m s are the major manifestation o f emotional illness i n n o n p s y c h o t i c patients such as those d e s c r i b e d above. T o d a y such patients are d i a g n o s e d as suffering from o b s e s s i v e - c o m p u l s i v e p s y c h o n e u r o s e s . This diagnosis is i n a d e q u a t e b e c a u s e it fails to differentiate b e t w e e n wide varieties of p s y c h o p a t h o l o g y . F o r e x a m p l e , it Would n o t h a v e discriminated b e t w e e n the y o u n g w o m a n , t h e l a b o r a t o r y t e c h n i c i a n , the professor, or the m o t h e r . This diagnostic failure, in turn, leads to inappropriate patient m a n a g e m e n t and t r e a t m e n t . The a u t o m a t i c equating o f o b s e s s i v e - c o m p u l s i v e s y m p t o m s with a diagnosis o f o b s e s s i v e - c o m p u l s i v e p s y c h o n e u r o s i s s t e m s from errors that are i n h e r e n t in o u r p r e s e n t d a y diagnostic s c h e m a . In the Diagnostic and Statistical Manual

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From the School o f Atedicine, University o f California at Davis, Davis, Calif. K- H . B l a c k e r M . D . : Assbciate Dean f o r Hospital Educational Affairs and Clinical Professor o f P~'chiatry. School o f Medicine, University o f California at Davis: M o r t o n L e v i t t P h . D . : Acting Dean a n d Professor o f Psychiatry, School o f Medicine, University o f California at Davis. Address reprint requests to Dean Morton Levitt. School o f 3,tedicine, University o f California at Davis, Da~.is, Calif. 95616. © 1979 by Grune & Stratton, Inc. 0010-4402(t7912006-0006502.0010

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N u m b e r I ( D S M - I ) a o f the A m e r i c a n P s y c h i a t r i c A s s o c i a t i o n , p u b l i s h e d in 1952, p a t i e n t s with o b s e s s i v e - c o m p u l s i v e s y m p t o m s w e r e d i a g n o s e d as " ' O b s e s s i v e - C o m p u l s i v e R e a c t i o n " d e s c r i b e d u n d e r the s e c t i o n , "'Psyc h o n e u r o t i c D i s o r d e r s , " or as a " ' C o m p u l s i v e P e r s o n a l i t y " u n d e r the s e c t i o n , " P e r s o n a l i t y Trait D i s o r d e r s . ' " In D S M - I I ~ p r e s e n t l y o p e r a t i v e a n d p u b l i s h e d in 1968, p a t i e n t s w i t h o b s e s s i v e - c o m p u l s i v e s y m p t o m s are to be d i a g n o s e d as o b s e s s i v e c o m p u l s i v e n e u r o s i s u n d e r the h e a d i n g o f n e u r o s e s o r as " ' O b s e s s i v e - C o m p u l s i v e P e r s o n a l i t y " w i t h i n t h e c a t e g o r y " ' P e r s o n a l i t y Disord e r s . " In the p r o p o s e d D S M - I I I , 5 p a t i e n t s w i t h o b s e s s i v e - c o m p u l s i v e s y m p t o m s are to be d i a g n o s e d as " ' O b s e s s i v e C o m p u l s i v e D i s o r d e r s " u n d e r the s e c t i o n " ' A n x i e t y D i s o r d e r s " o r as " ' C o m p u l s i v e P e r s o n a l i t y D i s o r d e r s " found in t h e s e c t i o n " ' P e r s o n a l i t y D i s o r d e r s . " In D S M - I I I , a single p a t i e n t c a n b e g i v e n e i t h e r or b o t h d i a g n o s e s . A l t h o u g h t h e t e r m s " n e u r o s i s " a n d " ' p s y c h o n e u r o s i s " d o n o t a p p e a r in t h e n e w D S M - I I I classification, their historical significance lives on, since the t w o d i a g n o s e s for o b s e s s i v e - c o m p u l s i v e s y m p t o m s in D S M - I I I r e m a i n e s s e n t i a l l y as t h e y w e r e in D S M - I a n d D S M - I [ : the p r e s e n c e o f o b s e s s i o n s o r c o m p u l s i o n s as t h e m a j o r m a n i f e s t a t i o n o f a n e m o t i o n a l d i s o r d e r in a n a n x i o u s , n o n p s y c h o t i c individual. A t t h e c e n t e r o f o u r p r e s e n t difficulties is t h e c o n c e p t o f n e u r o s i s . W h a t d o e s n e u r o s i s m e a n ? W h a t is a n e u r o s i s ? T o d a y " ' n e u r o t i c " a n d " ' p s y c h o n e u r o t i c ' " are c o m m o n l y used w o r d s in the l a y p r e s s as well as in scientific j o u r n a l s . T h e i r m e a n i n g , o t h e r t h a n in the p o p u l a r d e r o g a t o r y s e n s e , h o w e v e r , is u n c l e a r e v e n a m o n g p r o f e s s i o n a l s . T h i s l a c k o f p r e c i s i o n is e v i d e n c e d b y t h e w i d e l y v a r y i n g definitions o f the t e r m offered at a r e c e n t s e m i n a r b y a g r o u p o f p r a c t i c i n g p s y c h i a t r i s t s . S o m e said n e u r o s i s is a relative w e a k n e s s o f the e g o s t e m m i n g from u n d e r l y ing e m o t i o n a l conflict that is m a n i f e s t e d in t h e f o r m o f a n x i e t y in a p a t i e n t w i t h n o i m p a i r m e n t in reality testing. O t h e r s d e f i n e d n e u r o s i s in t e r m s o f w h a t it is not, s a y i n g t h a t n e u r o s i s is not p s y c h o s i s , n o r a c h a r a c t e r d i s o r d e r , n o r an organic d i s o r d e r . T h i s g r o u p defined n e u r o s i s as a n e m o t i o n a l d i s o r d e r c h a r a c terized b y a n x i e t y or s y m p t o m f o r m a t i o n . A n o t h e r c o n t i n g e n t s t r e s s e d t h a t a n e u r o s i s is less s e v e r e t h a n a p s y c h o s i s , less s e v e r e a l s o t h a n a c h a r a c t e r d i s o r d e r , a n d o c c u r s in a n i n d i v i d u a l w i t h r e l a t i v e l y g o o d s t r e n g t h a n d unresolved psychological conflict. O t h e r s held that neurosis must be defined in a t r a n s f e r e n c e s e n s e , i.e., a p e r s o n v i e w i n g his or h e r p r e s e n t in t h e light o f the p a s t but with not as s e v e r e a d i s t o r t i o n as o c c u r s in p s y c h o s i s . F i n a l l y , a n o t h e r definition w a s offered s t r e s s i n g t h a t n e u r o s i s is a m i n o r p s y c h i a t r i c r e a c t i o n c o n c e r n e d with m a l a d a p t i v e b e h a v i o r s . M o s t p s y c h i a t r i s t s c o n s u l t e d u s e d w o r d s s u c h as ego, e m o t i o n a l conflict, a n x i e t y , s y m p t o m f o r m a t i o n , d i s t o r t i o n s , m a l a d a p t i v e b e h a v i o r , a n d psychological conflict. T h e single t e r m u s e d m o s t f r e q u e n t l y w a s a n x i e t y . T h e p r i m a r y a g r e e m e n t w a s in t h e p r a g m a t i c u s e f u l n e s s o f the t e r m to s e p a r a t e the less s e v e r e e m o t i o n a l d i s o r d e r s f r o m tile m o r e s e v e r e o n e s , i.e., n e u r o s i s as c o n t r a s t e d to p s y c h o s i s . S i n c e t h e r e is little a g r e e m e n t e v e n a m o n g p r a c t i c i n g p r o f e s s i o n a l s a b o u t the b r o a d e r m e a n i n g o f the t e r m n e u r o s i s , w e m u s t b e g i n at t h e b e g i n n i n g in o r d e r to e x p l o r e a n d clarify t h e b a s i c i s s u e s i n v o l v e d . T h e E n g l i s h w o r d n e u r o s i s o r i g i n a t e d from a G r e e k w o r d m e a n i n g s i n e w or

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n e r v e . '~ It w a s first u s e d in m e d i c i n e in the e i g h t e e n t h c e n t u r y b y W i l l i a m C u l l e n , a n o t e d S c o t t i s h p h y s i c i a n . C u l l e n p r o p o s e d e~n e n c o m p a s s i n g t h e o r y for all m e d i c a l d i s e a s e s a n d a s c h e m a for c l a s s i f y i n g m e d i c a l d i s e a s e s . "' . . h e [Cullen] saw all o f life as a f u n c t i o n o f n e r v o u s e n e r g y a n d all d i s e a s e (all m e d i c a l d i s e a s e s , not o n l y m e n t a l d i s e a s e ) as a n e r v o u s d i s o r d e r . "~ A c c o r d i n g to C u l l e n , all illness w a s c a u s e d by a m a l f u n c t i o n a n d m a l d i s t r i b u t i o n o f n e r v o u s e n e r g i e s . In his classification o f i l l n e s s e s , o b s e s s i o n s , c o m p u l s i o n s , a n d h y s t e r i a fell u n d e r the h e a d i n g o f " n e u r o s i s . "'8 As medical knowledge a d v a n c e d in the nineteenth century, the n e u r o p a t h o l o g i e s o f syphilis a n d o t h e r d e m e n t i a s w e r e identified a n d d e s c r i b e d . M e n t a l s y n d r o m e s a n d s y m p t o m s a s s o c i a t e d with t h e s e p a t h o l o g i c l e s i o n s w e r e identified a n d g r o u p e d t o g e t h e r as o r g a n i c m e n t a l i l l n e s s e s . A d i s t i n c t i o n was m a d e b e t w e e n m e n t a l s y m p t o m s a c c o m p a n y i n g o r g a n i c c h a n g e s a n d t h o s e that w e r e still c o n s t r u e d ( f o l l o w i n g C u l l e n ' s lead) to b e d y s f u n c t i o n s o f n e r v o u s e n e r g y , h e n c e n e u r o s e s o r f u n c t i o n a l illnesses. It is i m p o r t a n t to n o t e that this original m e a n i n g o f t h e t e r m " ' f u n c t i o n a l " refers to t h e d y s f u n c t i o n o f t h e flow of nervous energy. Later, during the twentieth century, functional changed m e a n i n g a n d r e f e r r e d , as it still d o e s t o d a y , t o s y m p t o m s p r o d u c e d b y p s y chological dysfunction. In t h e m i d - n i n e t e e n t h c e n t u r y , G e o r g e Miller B e a r d p r o p o s e d t h e c o n c e p t o f n e u r a s t h e n i a o r " ' n e r v o u s e x h a u s t i o n . " H e a s c r i b e d o v e r 100 s y m p t o m s t o t h e " ' e x h a u s t i o n o f n e r v o u s cells t h r o u g h d e p l e t i o n o f t h e i r s t o r e d n u t r i m e n t . t h e u n d e r l y i n g p r i n c i p l e w a s similar t o t h e a n a l o g y o f a b a t t e r y r u n n i n g d o w n " . 9 H y s t e r i c a l s y m p t o m s , o b s e s s i o n s , c o m p u l s i o n s , a n d p h o b i a s all fell into t h e w a s t e b a s k e t d i a g n o s i s o f n e u r a s t h e n i a , w h i c h s e r v e d as t h e c a t c h a l l for a l m o s t e v e r y i m a g i n a b l e s y m p t o m a n d p a t i e n t . F r e n c h c l i n i c i a n s , h o w e v e r , l a t e r in the n i n e t e e n t h c e n t u r y , c l u s t e r e d h y s t e r i a l s y m p t o m s t o g e t h e r as a s y n d r o m e t h o u g h t to be c a u s e d by h e r e d i t a r y d e g e n e r a c y . O b s e s s i v e t h i n k i n g a n d p h o b i a s w e r e v a g u e l y a n d b r o a d l y r e f e r r e d to in E u r o p e at this t i m e as i r r e p r e s s i b l e ideas o r i r r e p r e s s i b l e fears, x° In 1895, F r e u d ~ p r o p o s e d to b r i n g s o m e o r d e r a n d clarity to this c h a o s . H e w r o t e a series o f p a p e r s d e s c r i b i n g s e v e r a l n e w s y n d r o m e s a n d p o s t u l a t i n g n e w e t i o l o g i e s . In o n e , h e d e s c r i b e d a s y n d r o m e " ' a n x i e t y n e u r o s i s b e c a u s e all its c o m p o n e n t s c o u l d b e g r o u p e d a r o u n d the c h i e f s y m p t o m o f a n x i e t y a n d bec a u s e e a c h o n e o f t h e m has a d e f i n i t e r e l a t i o n s h i p t o a n x i e t y . " I n a n o t h e r p a p e r , ~2 F r e u d g r o u p e d t o g e t h e r h y s t e r i a , o b s e s s i o n s , a n d c e r t a i n c a s e s o f acute hallucinatory confusion u n d e r the n a m e "'the n e u r o p s y c h o s e s of d e f e n s e " b e c a u s e t h o s e afflictions ( h y s t e r i a s , o b s e s s i o n s , a n d p h o b i a s ) t u r n e d out t o h a v e o n e a s p e c t in c o m m o n , "'that t h e i r s y m p t o m s a r o s e t h r o u g h t h e p s y c h i c a l ~mechanism o f ( u n c o n s c i o u s ) "defense," t h a t is, a n a t t e m p t to r e p r e s s a n i n c o m p a t i b l e i d e a w h i c h h a d c o m e into d i s t r e s s i n g a p p o s i t i o n w i t h t h e p a t i e n t ' s e g o . " In this p a p e r , F r e u d p o s t u l a t e d that t h e s y m p t o m s o f o b s e s s i o n a n d h y s t e r i a w e r e g e n e r a t e d by p s y c h o l o g i c a l f o r c e s , t h a t is, conflicts b e t w e e n a p a t i e n t ' s r e p r e s s e d m e m o r i e s a n d his o r h e r m o r a l v i e w o f h i m s e l f . F r e u d ' s t e c h n i q u e o f free a s s o c i a t i o n e n a b l e d h i m to i d e n t i f y e x p e r i e n c e s that p r o d u c e d p s y c h o l o g i c a l conflict a n d g e n e r a t e d s y m p t o m s . E x p e r i e n c e with his first p a t i e n t s led to t h e d i s c o v e r i e s o f r e p r e s s e d m e m o r i e s a n d a s s o c i a t e d

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affects p r o d u c i n g powerful cathartic and a b r e a c t i v e e x p e r i e n c e s that resulted in removal o f s y m p t o m s . O v e r time, F r e u d ' s original term, d e f e n s e neurop s y c h o s i s , c h a n g e d to p s y c h i c a l neurosis. P s y c h i c a l neurosis, in turn, c h a n g e d to p s y c h o n e u r o s i s , and p s y c h o n e u r o s i s in c o m m o n usage b e c a m e s h o r t e n e d to neurosis. T w o o f F r e u d ' s seminal ideas h a v e been c o n f u s e d with one a n o t h e r and h a v e led directly to o u r p r e s e n t diagnostic problem. F i r s t , he described several t y p e s o f clinical s y m p t o m s o b s e s s i v e , h y s t e r i c a l , phobic, and a n x i e t y . T h e s e groupings c a m e to be called n e u r o s e s , and this c o n j u n c t i o n has been c o n t i n u e d to be referred to in this m a n n e r b y several g e n e r a t i o n s o f p s y c h i a t r i s t s . S e c o n d , Freud p o s t u l a t e d that an i n d i v i d u a l ' s s y m p t o m s were p r o d u c e d by internal p s y c h o l o g i c a l conflict. The t h e o r y o f p s y c h i c conflict c a m e to be called neurotic conflict. T h u s , t h e s e two m a j o r c o n t r i b u t i o n s , (1) the descriptions o f several groups o f s y m p t o m s , and (2) the p o s t u l a t e d etiology o f the s y m p t o m s , b e c a m e almost i n s e p a r a b l y c o m m i n g l e d . T h i s c o n f u s i o n is r a m p a n t in t h e d i a g n o s e s in DSM-I and DSM-II. U n d e r s t a n d a b l y , p s y c h o a n a l y t i c literature reflects the same commingling. We s e a r c h e d F e n i c h e l ' s ~a er~cyclopedic s u m m a r y and s y n t h e s i s o f psyc h o a n a l y t i c information for a definition o f neurosis. F e n i c h e l ' s Initial Essay on the Definition o f N e u r o s i s c o n t a i n e d d e s c r i p t i o n s o f p s y c h i c conflict. His section, Psychoneurosis, the Neurotic Conflict, again s t r e s s e d neurotic conflict in s y m p t o m formation. S o m e of his s u b s e c t i o n s w e r e h e a d e d , What is Neurotic Conflict?, A r e Neurotic Conflicts b e t w e e n Opposing Instincts Possible?, and The External World in Neurotic" Conflict s. F e n i c h e l provided formulations describing and explicating neurotic conflicts but offered no meaningful definition o f neurosis. F e n i c h e l did m a k e one particularly puzzling s t a t e m e n t : "'The neurotic conflict is not y e t a neurosis. H o w e v e r , the e f f e c t i v e n e s s o f the conflict manifests i t s e l f in certain p s y c h o l o g i c a l p h e n o m e n a which n e v e r t h e l e s s a r e also f r e q u e n t l y called neurotic. ~" A n d there it lay. We h a v e also s e a r c h e d the Glossary o f P s y c h o a n a l y t i c Terms a n d C o n c e p t s published b y the A m e r i c a n P s y c h o a n a l y t i c A s s o c i a t i o n . ~a T h e r e w e found e s s e n t i a l l y a c a p s u l i z e d s u m m a r y o f o u r o w n historical s u r v e y . N e u r o s i s is described as used l o o s e l y but almost universally s y n o n y m o u s with psyc h o n e u r o s i s . In the Glossao', t h e r e f e r e n c e s to n e u r o s i s , actual neurosis, a n x i e t y , p s y c h o n e u r o s i s , i n t r a p s y c h i c conflict, s y m p t o m formation, transfere n c e n e u r o s i s , a n d traumatic neurosis all relate to t h e n o t i o n that neurosis i s i n e x t r i c a b l y linked to the c r e a t i o n o f s y m p t o m s by p s y c h i c conflict. Although neurosis is used b y practicing p s y c h o a n a l y s t s as a diagnosis in t h e i r clinical work, it is n e v e r defined as a diagnosis in the A s s o c i a t i o n ' s Glossary. To s u m m a r i z e , neurosis has two m e a n i n g s for m a n y clinicians: first, a c l i n i c a l s y n d r o m e , and s e c o n d , the etiologic agent o f s y m p t o m formation. T h i s intermingling is so c o m m o n p l a c e that it goes u n r e c o g n i z e d in the minds o f m a n y psychiatrists and psychoanalysts. After the early papers referred to a b o v e , F r e u d did not contribute f u r t h e r to the d e v e l o p m e n t o f diagnostic categories. H e c o n c e n t r a t e d on e x p a n d i n g his k n o w l e d g e o f p s y c h i c conflict a n d its role in the mental life and b e h a v i o r o f his patients. P s y c h i c o r neurotic conflict r e m a i n e d his central thesis, a n d as his

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experience and understanding grew, he elaborated several succeeding theoretical f r a m e w o r k s o r s y s t e m s . A b r i e f r e p r i s e is o f f e r e d b e l o w . ~.~z.J's'jn-~r In his earliest p a p e r s in 1894, F r e u d s a w conflict as arising f r o m c l a s h e s b e t w e e n r e p r e s s e d t r a u m a t i c m e m o r i e s , m e m o r i e s o f real e v e n t s , a n d a pat i e n t ' s d e s i r e d v i e w o f him- o r herself. In 1900, n e w observations c a u s e d h i m to r e v i s e this t h e o r y , a n d h e t h e n v i s u a l i z e d t h e p s y c h i c conflict as r e s u l t i n g f r o m r e p r e s s e d w i s h e s and f a n t a s i e s ( r a t h e r t h a n m e m o r i e s o f real e v e n t s o r s e d u c tions) a n d a p a t i e n t ' s v i e w o f him- o r herself. In 1905, F r e u d p r o p o s e d that conflicts w e r e g e n e r a t e d b e t w e e n t h e sexual d r i v e a n d its r e l a t i o n s h i p t o a n o t h e r i n f e r r e d d r i v e - - s e l f - p r e s e r v a t i o n . T h e conflict a n d r e s u l t i n g a n x i e t y w e r e s e e n as arising f r o m struggles b e t w e e n sexual a n d e g o i n s t i n c t s . In 1924, F r e u d a p p l i e d his n e w s t r u c t u r a l m o d e l o f id, e g o , a n d s u p e r e g o t o clinical m a t e r i a l a n d s t a t e d , " N e u r o s i s is t h e r e s u l t o f conflict b e t w e e n the e g o a n d t h e id. "'~s H e w r o t e : N e u r o s e s originate from the e g o ' s refusing t o a c c e p t a p o w e r f u l instinctual impulse in the id o r to help it find a m o t o r outlet, o r f r o m the e g o ' s forbidding that impulse the object for which it is aiming. In such a c a s e . t h e ego d e f e n d s itself against the instinctual impulse b y the m e c h a n i s m o f r e p r e s s i o n . T h e r e p r e s s e d material struggles against this fate. It c r e a t e s for itself, a l o n g p a t h s o v e r w h i c h the ego has no p o w e r , a substitute o f r e p r e s s i o n (which f o r c e s itself u p o n the ego b y w a y o f a c o m p r o m i s e ) - - t h i s s y m p t o m . T h e ego finds its unity t h r e a t e n e d and impaired b y this intruder, and it c o n t i n u e s to struggle against the s y m p t o m , j u s t as it f e n d e d o f f the original instinctual impulse. All this p r o d u c e s the picture o f a neurosis, t9

T h e r e v i e w h e l p s us u n d e r s t a n d t h e p r e s e n t d i a g n o s t i c c o n f u s i o n . It d o e s not, a l t e r the p r e s e n t d i l e m m a h o w e v e r , n a m e l y , t h e inability to d e s c r i b e p a t i e n t s with o b s e s s i v e - c o m p u l s i v e s y m p t o m s in a f a s h i o n t h a t c o r r e s p o n d s to t h e s e r i o u s n e s s o f t h e i r illness. In this p a p e r , w e p r o p o s e to o u t l i n e a n e w s y s t e m o f classification f o r n o n p s y c h o t i c p a t i e n t s w h i c h w e feel offers significant a d v a n t a g e s o v e r t h e p r e s e n t o n e . O u r i d e a s a r e b o t h p r e l i m i n a r y a n d f r a g m e n t a r y a n d s h o u l d not b e r e g a r d e d as c o m p l e t e , but t h e y d o r e p r e s e n t o u r effort t o c o l l a t e a n u m b e r o f clinical o b s e r v a t i o n s o f o u r o w n a n d o t h e r s s c a t t e r e d t h r o u g h o u t t h e psyc h o a n a l y t i c a n d p s y c h i a t r i c literature. W e h o p e o u r p r o p o s a l will s t i m u l a t e o t h e r i n v e s t i g a t o r s to put f o r t h h y p o t h e s e s o f t h e i r o w n . T h e u n d e r p i n n i n g s o f o u r p r o p o s e d s y s t e m are the p s y c h o a n a l y t i c c o n c e p t s of character formation and personality d e v e l o p m e n t . These concepts had their origins in 1908 w h e n F r e u d z° d e s c r i b e d i n d i v i d u a l s w h o w e r e h a n d i c a p p e d in t h e i r lives b y e m o t i o n a l d i s t r e s s c a u s e d b y e n d u r i n g a n d m a l a d a p t i v e o r g a n i z a t i o n s of t h e i r p e r s o n a l i t i e s . F r e u d ' s initial o b s e r v a t i o n s a n d t h e o r e t i c f o r m u l a t i o n s w e r e cast in t e r m s o f a p a t i e n t ' s i n s t i n c t u a l life. A b r a h a m ' s z~ classic p a p e r on t h e oral c h a r a c t e r is a n e x a m p l e o f this e a r l y a p p r o a c h a n d e x e m p l i f i e s t h e f o c u s o n t h e instinctual life. W i l h e l m Reich'-'" f u r t h e r d e v e l o p e d the i m p o r t a n c e o f c h a r a c t e r f o r m a t i o n in t h e e a r l y thirties. S o m e w h a t l a t e r , A n n a F r e u d "-z c o n t r i b u t e d significantly to t h e u n d e r s t a n d i n g o f e g o d e f e n s e m e c h a n i s m s w h i l e H a r t m a n n ' s "-'~ efforts in t h e mid-1950s f u r t h e r e d t h e u n d e r s t a n d i n g o f the e g o ' s a d a p t i v e c a p a c i t i e s a n d o f biological g i v e n s in t h e f o r m a t i o n o f p e r s o n a l i t y s t r u c t u r e . E r i k E r i k s o n ' s °-~ c o n t r i b u t i o n s s t r e s s e d t h e i m p o r t a n c e o f social a n d cultural f a c t o r s . R e c e n t l y , D a v i d S h a p i r o 26 m o r e c l e a r l y d e l i n e a t e d t h e pro-

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c e s s e s by w h i c h the p e r s o n a l i t y m o d u l a t e s a n d i n t e g r a t e s d r i v e s a n d affects. A m o r e e x t e n s i v e r e v i e w o f t h e s e d e v e l o p m e n t s can b e f o u n d in ]Blacker a n d T u p i n ' s z? p a p e r o n hysterical p e r s o n a l i t y o r g a n i z a t i o n . W e wish to o f f e r t h e i d e a t h e r e is a c o n t i n u u m o f h e a l t h a m o n g n o n p s y c h o t i c p a t i e n t s r a n g i n g f r o m m o s t h e a l t h y o r m o s t a d a p t a b l e t o least h e a l t h y o r least a d a p t a b l e . T h e s e p e r s o n a l i t y s t r u c t u r e s are a s s u m e d to b e d e r i v e d f r o m t h e b i o l o g i c a n d e x p e r i e n t i a l c o m p o n e n t s o f an i n d i v i d u a l ' s life, t h a t is, t h e y are t h e r e s u l t o r the a d m i x t u r e s o f f a m i l y i n t a c t n e s s , p a r e n t a l p h y s i c a l a n d e m o t i o n a l h e a l t h , b i o l o g i c g i v e n s , r i c h n e s s o f e d u c a t i o n , a n d social milieu. F o r h e u r i s t i c p u r p o s e s , w e h a v e b r o k e n this c o n t i n u u m into four c o m p o n e n t s as illustrated in Fig. !. T h e c o m p o n e n t s r a n g e f r o m m o s t h e a l t h y o n t h e far left to t h e least h e a l t h y o n t h e far right. T h e o r e t i c a l l y , t h e r e w o u l d b e m u l t i p l e p o i n t s a l o n g this c o n t i n u u m , but t h e r e s e e m s t o u s t o b e c l e a r e v i d e n c e f o r d e s c r i b i n g f o u r m a j o r p e r s o n a l i t y s t r u c t u r e s t h a t are c l e a r l y d i s t i n g u i s h a b l e f r o m o n e a n o t h e r , that r e l a t e to p r o g n o s i s , a n d t h a t r e q u i r e d i f f e r e n t t r e a t m e n t a p p r o a c h e s . W e p r o p o s e to r e d e f i n e c u r r e n t p s y c h i a t r i c t e r m s in m o r e p r e c i s e f a s h i o n t o d e s i g n a t e t h e s e c a t e g o r i e s . W e h a v e n a m e d t h e m o s t h e a l t h y p e r s o n a l i t y structure " ' n e u r o t i c , f l e x i b l e , " t h e n e x t h e a l t h i e s t " n e u r o t i c r i g i d , " t h e n e x t "'narc i s s i s t i c , " a n d t h e least h e a l t h y " ' b o r d e r l i n e . " In this p r o p o s e d s y s t e m , w e h a v e i n c o r p o r a t e d a n d m o d i f i e d o b s e r v a t i o n s b y K e r n b e r g , ~a K o h u t , ~a N a g era, a° D a v a n l o o , a~ S i f n e o s , 3~ M a l a n , ~ W a l l e r s t e i n a n d R o b b i n s , 34 a n d B l a n c k a n d B l a n c k . 3s E a c h o f t h e f o u r p e r s o n a l i t y s t r u c t u r e s c a n b e identified b y t h e types and organization of defense mechanisms, their developmental histories, t h e i r p r e s e n t i n g c o m p l a i n t s , a n d t h e i r style o f i n t e r a c t i n g with a t h e r a p i s t [ t r a n s f e r e n c e issues]. W e will d i s c u s s e a c h o f t h e s e p a r a m e t e r s b e l o w . T h i s m o d e l c h a n g e s t h e e m p h a s i s d u r i n g the d i a g n o s t i c p r o c e s s . O u r m o d e l d o e s not f o c u s on s y m p t o m s . It s t r e s s e s t h e c o n c u r r e n t identification o f a t y p e o f p e r s o n a l i t y s t r u c t u r e as well as t h e d e s c r i p t i o n o f s y m p t o m s . It s t r e s s e s t h e c o n t e x t as w e l l as t h e s y m p t o m ( s ) ; t h e c o m b i n a t i o n o f t h e t w o offers a clinician a m u c h m o r e p o w e r f u l c o n c e p t u a l tool. W e h a v e not w r e s t l e d w i t h t h e p r o b l e m o f n o r m a l i t y h e r e . O u r initial t h o u g h t s are t o c o n s i d e r as n o r m a l an i n d i v i d u a l w h o w o u l d b e p l a c e d o n t h e far left o f t h e c o n t i n u u m , i.e., an i n d i v i d u a l w i t h a n e u r o t i c , flexible t y p e o f p e r s o n a l i t y w h o is a s y m p t o m a t i c ; h o w e v e r , this i s s u e requires further exploration and work. DEFENSES

The defense mechanisms of repression, suppression, projection, denial, d o i n g a n d u n d o i n g , r e a c t i o n f o r m a t i o n , a n d isolation a r e f o u n d in p a t i e n t s w i t h n e u r o t i c p e r s o n a l i t y s t r ~ c t u r e s . T h e i n d i v i d u a l w i t h a flexible n e u r o t i c s t r u c t u r e is o p e n to n e w i n f o r m a t i o n a n d n e w e x p e r i e n c e s a n d is m o r e t o l e r a n t o f s t r o n g affects. T h e s e qualities m a n i f e s t t h e m s e l v e s as a w i l l i n g n e s s t o v i e w b e h a v i o r a n d e x p e r i e n c e s w i t h i n n e w f r a m e w o r k s , o r if y o u w i s h , a r e s p o n s i v e n e s s to i n t e r p r e t a t i o n . T h e d i f f e r e n c e b e t w e e n t ~ e n e u r o t i c flexible s t r u c t u r e a n d the n e u r o t i c fixed s t r u c t u r e lies i n t h e d e g r e e o f fle~ibifity o f t h e s e d e f e n s e s . ~A p a t i e n t w i t h a n e u r o t i c fixed s t r u c t u r e is m o r e rigid, l e s s o p e n to c h a n g e o r to g r o w t h . H e n c e , w h e n h e o r s h e b e c o m e s s y m p t o m a t i c , m o r e e x t e n s i v e psyc h o l o g i c a l w o r k is r e q u i r e d if t h e t r e a t m e n t p r o c e s s is t o b e s u c c e s s f u l . T h e

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differences are a d m i t t e d l y q u a n t i t a t i v e , b u t t h e y are i m p o r t a n t . O p e n n e s s is t h e h a l l m a r k o f good mental health. Its d i m i n u t i o n , e v e n in a relative s e n s e , s e r v e s as a n i m p o r t a n t p a t h o g e n i c indicator. P a t i e n t s w i t h narcissistic s t r u c t u r e s m a k e u s e o f the a b o v e d e f e n s e m e c h a nisms, but t h e m e c h a n i s m s are h i n d e r e d b y t h e lack o f a c o h e s i v e , intact self; the n a r c i s s i s t i c p e r s o n a l i t y s t r u c t u r e is v u l n e r a b l e to f r a g m e n t a t i o n , shattering, and s e v e r e a n d s u d d e n d r o p s in self-esteem. S u c h , s y m p t o m s , as a r c h a i c f o r m s o f g r a n d i o s i t y , cold and i m p e r v i o u s b e h a v i o r , h y p o c h o n d r i a s i s , p e r v e r s e fantasies, and d i m i n i s h e d w o r k i n g c a p a c i t y , are the h a l l m a r k o f the c o n d i t i o n . T h e p a t i e n t with a b o r d e r l i n e s t r u c t u r e utilizes all o f the a b o v e d e f e n s e m e c h a n i s m s but also m a k e s use o f m o r e primitive p s y c h o t i c - l i k e m e c h a n i s m s . H e r e , there is often i n t e n s e r e l i a n c e on p r o j e c t i o n - - u s u a l l y e x p r e s s e d as cold p a r a n o i d rage, splitting, p r o j e c t i v e identification, i n t e r m i t t e n t delusional t h o u g h t p r o c e s s e s , m a s s i v e denial, and r e l i a n c e on a c t i n g o u t in dealing with conflicts. T h e r e are also f r e q u e n t d i s t o r t i o n s a n d primitive r e v e r s a l s .

DEVELOPMENT N e u r o t i c p e r s o n a l i t y s t r u c t u r e s are f o r m e d within the m a t r i c e s o f r e l a t i v e l y stable and loving families. T h e s e i n d i v i d u a l s h a v e had the e x p e r i e n c e o f at least one e m p a t h i c give-and-take r e l a t i o n s h i p w i t h a significant p e r s o n . 3z T h e fixed n e u r o t i c s t r u c t u r e is more likely to be f o r m e d in less stable families or in h i g h l y rigid and a u t h o r i t a r i a n o r o p p r e s s i v e family e n v i r o n m e n t s . T h e h i s t o r y o f the patient with a narcissistic s t r u c t u r e m a y a p p e a r a t first g l a n c e to h a v e b e e n a r e l a t i v e l y stable o n e , b u t on c l o s e r i n s p e c t i o n , we find a p a r e n t , u s u a l l y the m o t h e r , w h o has failed to p r o v i d e e m p a t h y and w a r m t h f o r the g r o w i n g infant. T h i s g r o u p often h a s b e e n well c a r e d for in t e r m s o f p h y s i c a l a n d e d u c a t i o n a l n e e d s , but there h a s b e e n a m a s s i v e failure in p r o v i d i n g n e e d e d e m p a t h y and u n d e r s t a n d i n g . D e p r e s s i o n a n d o t h e r p s y c h i a t r i c illnesses o f a s e v e r e nature are l i k e l y f o u n d in the m o t h e r s o f t h e s e patients. T h e d e v e l o p m e n t a l h i s t o r i e s o f p a t i e n t s w i t h b o r d e r l i n e p e r s o n a l i t y structures are often filled with c h a o s and m a s s i v e t r a u m a . B a s i c p h y s i c a l a n d e d u c a t i o n a l n e e d s o f t h e s e individuals m a y n o t be m e t . O n e is apt to find multiple f o s t e r - h o m e p l a c e m e n t s , s e v e r e a l c o h o l i s m , a n d p h y s i c a l neglect on the p a r t o f the p a r e n t s . T h e r e is also a g r o u p o f p a t i e n t s w i t h i n this c a t e g o r y w h o s e family histories s e e m r e l a t i v e l y u n r e m a r k a b l e but w h o s e d e v e l o p m e n t a l p i c t u r e s s e e m highly significant, b e c a u s e from v e r y e a r l y i n f a n c y t h e s e indiv i d u a l s h a v e b e e n o b s e r v e d to be e x t r e m e l y d e m a n d i n g , e a s i l y d i s t u r b e d , a n d u n h a p p y c h i l d r e n . It is as t h o u g h biologically r o o t e d d e m a n d s h a v e overwhelmed their developing personality structures and their needs have exceeded w h a t is o r d i n a r i l y a v a i l a b l e from the a v e r a g e e x p e c t a b l e e n v i r o n m e n t .

CHIEF COMPLAINT OR METHOD OF PRESENTATION P a t i e n t s w i t h n e u r o t i c flexible-type p e r s o n a l i t y s t r u c t u r e s u s u a l l y p r e s e n t with a c u t e s y m p t o m s . A n e x a m p l e h e r e m i g h t b e the s u d d e n a p p e a r a n c e o f i n t r u s i v e o b s e s s i v e i m a g e s a n d t h o u g h t s . T h i s might follow a t r a u m a t i c e v e n t o r be p r e c i p i t a t e d b y a n a n n i v e r s a r y r e a c t i o n . P a t i e n t s w i t h n e u r o t i c fixed s t r u t -

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tures often p r e s e n t w i t h a n a c u t e e x a c e r b a t i o n o f a c h r o n i c s y m p t o m that h a s e x i s t e d b e f o r e as rigid d e f e n s e s are u n a b l e to a d a p t to n e w e v e n t s and c i r c u m s t a n c e s . O c c a s i o n a l l y , ~hese i n d i v i d u a l s c o m e i n t o t h e r a p y b e c a u s e t h e y h a v e r e c o g n i z e d that t h e i r rigidity h a s d e n i e d t h e m pleasa]re in life a n d c a u s e d pain both to t h e m s e l v e s a n d their families. P a t i e n t s w i t h n a r c i s s i s t i c p e r s o n a l i t y structures seek psychiatric treatment because of feelings of intense loneliness, h u m i l i a t i o n , a n d a n x i e t y . D e s p i t e some~times o u t s t a n d i n g ,levels o f f u n c t i o n i n g in p r o f e s s i o n s o r e x e c u t i v e p o s i t i o n s , t h e s e i n d i v i d u a l s are v u l n e r a b l e to sudden a n d i n t e n s e d r o p s in s e l f - e s t e e m w h e n t h e y l o s e e m o t i o n a l s u p p o r t o r feel slighted, o r w h e n t h e y fail to a c h i e v e w h a t t h e y feel is a p p r o p r i a t e r e c o g n i t i o r . In t h e p a t i e n t w i t h a b o r d e r l i n e p e r s o n a l i t y s t r u c t u r e , t h e s e v e r i t y o f t h e s y m p t o m s may cause impairment of functioning, and temporary hospitalization m a y b e n e e d e d . O f t e n t h e s e p a t i e n t s a r e first s e e n b y p s y c h i a t r i s t s w h e n h o s p i t a l i z a t i o n is r e q u i r e d .

TRANSFERENCE ISSUES P a t i e n t s w i t h n e u r o t i c flexible-type s t r u c t u r e s g e n e r a l l y relate to a t h e r a p i s t w i t h relative t r u s t a n d a c c e p t a n c e . A w o r k i n g a l l i a n c e is r a p i d l y e s t a b l i s h e d . P a t i e n t s w i t h n e u r o t i c f i x e d - p e r s o n a l i t y s t r u c t u r e s are m o r e w a r y o f e n t e r i n g into an i n t i m a t e r e l a t i o n s h i p w i t h a t h e r a p i s t . T h e y i s o l a t e t h e m s e l v e s b e c a u s e o f t h e i r f e a r o f i n t i m a c y a n d d e p e n d e n t n e e d s . I n t e r p r e t a t i o n o f t h e s e fears a n d c a l m a c c e p t a n c e a n d i n q u i r y into t h e i r p r o b l e m s u s u a l l y h e l p to d e v e l o p ,a w o r k i n g a l l i a n c e w i t h i n a r e a s o n a b l e time period. Pal.ients w i t h n a r c i s s i s t i c p e r s o n a l i t y s t r u c t u r e s m a y o s c i l l a t e b e t w e e n a rapid a t t a c h m e n t a n d o v e r idealization of the therapist and a n g r y , bitter attacks upon him. Either the idealized s t a t e o r the n e g a t i v i s t i c a t t a c k s m a y p e r s i s t f o r m o n t h s b e f o r e its o p p o s i t e a p p e a r s . P a t i e n t s with b o r d e r l i n e p e r s o n a l i t y s t r u c t u r e s ofte~ d e m o n s t r a t e f e a r f u l n e s s a n d d e s p a i r in t h e i r p e r c e p t i o n o f t h e t h e r a p i s t . F r e q u e n t l y t h e r e are g r o s s p r o j e c t i o n s a n d d i s t o r t i o n s . S o m e b o r d e r l i n e p a t i e n t s f e a r d i s a p p e a r i n g " ' i n t o " o r b e i n g s w a l l o w e d u p b y t h e t h e r a p i s t ; t h e y often c a n n o t differentiate between their own bodies and actions and those of the therapist: There are bitter sadistic rages directed towards the therapist, who seems t o r e p r e s e n t the p a t i e n t ' s d i s o w n e d b a d qualities. T r a n s i e n t p s y c h o t i c d i s t o r t i o n s m a y be o b s e r v e d in r e l a t i o n s h i p to the t h e r a p i s t . W e a r e a w a r e that t h e a b o v e d e s c r i p t i o n s are i n c o m p l e t e . H o w s h o u l d w e consider psychosomatic s y m p t o m s ? Where should we place action-prone individuals o r s o c i o p a t h s in t h e a b o v e s c h e m a ? W e are u n c e r t a i n a b o u t the a n s w e r s t o t h e s e q u e s t i o n s s i n c e t h e y c l e a r l y require f u r t h e r i n v e s t i g a t i o n . A b r i e f r e v i e w o f o u r s c h e m a u s i n g a series o f s i m p l e d i a g r a m s m a y h e l p clarify o u r p r o p o s a l . In F i g . 1, a single h o r i z o n t a l line d e n o t e s the c o n t i n u u m o f nonpsychotic disorders. The four proposed personalit~ structures are located as p o i n t s a l o n g this line. T h e first s t e p in m a k i n g a d i a g n o s i s is a d e s c r i p t i o n a n d listings o f a p a t i e n t ' s s y m p t o m s . T h e s e c o n d is t h e i d e n t i f i c a t i o n o f t h e u n d e i ' l y i n g p e r s o n a l i t y s t r u c ture, t h a t is, t h e m a t r i x w i t h i n w h i c h the s y m p t o m s o c c u r . T h e third a n d final step is t h e i n t e g r a t i o n o f t h e s e t w o fields o f i n f o r m a t i o n . F i g u r e 2, c o n s i s t i n g o f a light s o u r c e , a s e r i e s o f l e n s e s , a s c r e e n , a n d a n o b s e r v e r , i l l u s t r a t e s t h i s

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NEUROTIC FLEXIBLE

NEUROTICFIXED

NARCISSISTIC

BORDERLINE

Fig. 1. The continuum of nonpsychotic disorders. Four proposed personality sUuctures are located as points along this line.

t h r e e - s t e p a p p r o a c h . T h e s y m p t o m s a r e p o r t r a y e d as o n e lens. T h e p e r s o n a l i t y s t r u c t u r e is d e p i c t e d as a s e c o n d lens. T h e s u p e r i m p o s i t i o n or c o m b i n a t i o n o f the t w o a p p e a r as a total G e s t a l t on the s c r e e n . T h e r e s u l t a n t i m a g e s a p p e a r on the s c r e e n as we o b s e r v e a n d i n t e r v i e w a p a t i e n t . F i g u r e 3, c o n s i s t i n g o f frontal v i e w s o f f o u r l e n s e s , illustrates the f o u r p e r s o n a l i t y s t r u c t u r e s . T h e lens i l l u m i n a t i n g the b o r d e r l i n e p e r s o n a l i t y structure a p p e a r s m u c h like a p i e c e o f S w i s s c h e e s e . T h e h o l e s a n d the v a r i a t i o n s in the s u r f a c e o f the l e n s e s are s y m b o l i c r e p r e s e n t a t i v e s o f the s e v e r e d i s t o r t i o n s a n d l a c u n a e in t h e s e patients" p e r s o n a l i t y s t r u c t u r e . T h e lens illustrating the narcissistic personality structure contains jagged cleavage planes symbolizing its fragility a n d p r o p e n s i t y to f r a g m e n t . T h e lens i l l u s t r a t i n g the n e u r o t i c fixed p e r s o n a l i t y s t r u c t u r e is s e g m e n t e d i n t o m a n y small b o x e s s y m b o l i c o f the isolation a n d rigidity o f s u c h s t r u c t u r e s . T h e l e n s p o r t r a y i n g t h e n e u r o t i c flexible p e r s o n a l i t y c o n t a i n s e a s y , flowing lines s y m b o l i z i n g t h e i n t e g r a t i o n o f this s t r u c t u r e . F i g u r e 4 c o n t a i n s lens i l l u s t r a t i n g d i f f e r e n t t y p e s o f s y m p t o m s . O b s e s s i v e s y m p t o m s , t h e m a j o r f o c u s in this "paper, are s y m b o l i z e d b y a d a r k lens. H y s t e r i c a l s y m p t o m s , c o n v e r s i o n r e a c t i o n s , h y p e r e m o t i o n a l i t y , e t c , , are s y m bolized b y a light lens. F i g u r e s 5 a n d 6 are illustrations o f the final g e s t a l t p r o d u c e d on the s c r e e n b y the o b s e s s i v e a n d h y s t e r i c a l s y m p t o m s s u p e r i m p o s e d on t h e f o u r p e r s o n a l i t y structures. O u r m o d e l is u n d o u b t e d l y simplistic. H o w e v e r , w e d o feel this m o d e l h a s distinct a d v a n t a g e s o v e r t h e p r e s e n t o n e f o r the r e a s o n s e l u c i d a t e d a b o v e . W e also feel that t h e m o d e l r e l a t e s d i r e c t l y to clinical e x p e r i e n c e a n d p h e n o m e n a . T h e different e l e m e n t s o f t h e m o d e l h a v e b e e n d e s c r i b e d f r e q u e n t l y in the p s y c h i a t r i c l i t e r a t u r e , a n d it c a n be a s s i m i l a t e d b y t o d a y ' s clinicians. T h e m o d e l ' s p o t e n t i a l for c o n c e p t u a l i z i n g p a t i e n t s a n d d i f f e r e n t i a t i n g a m o n g t h e m is illustrated in t h e c a s e h i s t o r i e s w h i c h follow. LIGHT SOURCE

PERSONALITY SYMPT~ STRUCTURE

SCREEN

Fig. 2. Three-step approach t o diagnosis.

D I A G N O S I S OF O B S E S S I V E - C O M P U L S I V E S Y M P T O M S

NEUROTIC FLEXIBLE

Fig. 3.

~EUROTIC FIXED

NARCISSISTIC

541

BORDERLINE

Frontal v i e w of lens tllustrsting t h e four personality structures. OBSESSIVE SYMPTOMS

HYSTERICAL SYMPTOMS

Fig. 4. Lens illustrating different types of symptoms.

Fig. 5.

Obsessive s y m p t o m s superimposed on the personality structures.

Fig. 6.

Hysterical s y m p t o m s superimposed on the personality structures.

CASE REPORTS Case ! Lisa was an attractive, 19-year-old w h o a t l e n d e d j u n i o r college in her h o m e town. Although she w a s doing well in s c h o o l and had an active a n d rich social life, she suffered from the intrusion o f images o f h e r b r o t h e r with his head b l o w n off. T h e s e images u n d e r s t a n d a b l y c a u s e d her great distress, and she cried often. T h e y o u n g man was a recent suicide. A p p r o x i m a t e l y 6 m o n t h s before her first therapeutic a p p o i n t m e n t . L i s a ' s perfeclionistic b r o t h e r , frustrated in his ability to sculpt a clay figure e x a c t l y as

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he wanted it, had walked into his r o o m . shut his d o o r . and blown a hole in his head with a shotgun. Lisa° w h o was in the next b e d r o o m , did not recall hearing the shot, but heard his b o d y fall. She had not entered the room n o r seen the b o d y . Lisa was born and raised in the small town in which she n o w lived. H e r father was a skilled blue-collar w o r k e r , while her m o t h e r was a nurse and w a s the more ambitious o f the parents. T h e family had been a stable and caring one. L i s a ' s birth and d e v e l o p m e n t were essentially normal. She had m a n y friends and was a superior student. She had looked forward to leaving home the next Fall to attend the state university. In the initial interview, she w a s appropriately reticent to talk to a stranger a b o u t such painful events, but soon g a v e an open, honest and poignant description o f her distress and pain. She described the g o r y , intrusive imagc~ and she readily reported d r e a m s which c o n t a i n e d similar themes. She utilized supportive c o m m e n t s and rapidly r e c o g n i z e d that the d r e a m s and repetitive images were her attempt to r i a s l e r the painful event. With this e n c o u r a g e m e n t , her p u z z l e m e n t , s h o c k , hurt, and anger finally tumbled out. It b e c a m e apparent from her descriptions that she had not permitted herself to grieve her b r o t h e r ' s death because o f her perceived need to support her mother~ W h e n this pattern was identified for her, she readily a c k n o w l e d g e d it and during the next several h o u r s was able to e x p e r i e n c e and describe her sense o f loss and anger towards her b r o t h e r and her a n g e r towards h e r m o t h e r as well f o r the latter's failure to help Lisa with her pain. T h e obsessive s y m p t o m s diminished greatly in intensity and f r e q u e n c y after the first h o u r , and had essentially disappeared w h e n the final session was c o n c l u d e d s~me 3 w e e k s later.

CO/Illllc/II T h e a b o v e c a s e can s e r v e as an e x a m p l e o f o b s e s s i v e s y m p t o m s in a patient with a n e u r o t i c flexible p e r s o n a l i t y structure. T h e s y m p t o m s w e r e s u c c e s s f u l l y treated by b r i e f focal p s y c h o a n a l y t i c p s y c h o t h e r a p y .

Case 2 Mrs. A., a 28-year-old, married, professional w o m a n , sought help b e c a u s e o f obsessional fears that her 6-month-old daughter might die. T h e s e unbidden and intrusive fears had s u d d e n l y appeared one evening while she was r o c k i n g her b a b y . W h e n she a p p e a r e d for the first interview d r e s s e d in a b o x y , drab, b r o w n suit, Mrs. A. d e s c r i b e d her obsessive fears and the crying in a quick, precise manner. Obviously intelligent and with a p e r c e p t i v e mind, she tended to d e m e a n herself in her descriptions and disguise her a t t r a c t i v e features b y her dress and her plain hair style. During the first several interviews, she b e c a m e c o n s c i o u s o f the fact that the fears a n d crying had b e g u n on the anniversary o f the death o f a y o u n g e r brother, a fact that had not been in her c o n s c i o u s mind before the s y m p t o m s erupted. W h e n she was 14 y e a r s old, her b r o t h e r . 7 y e a r s y o u n g e r , died a brutal accidental death while she and a friend played n e a r b y . She had a l w a y s feared his d e a t h had been c a u s e d by her negligence. Mrs. A. had n e v e r been accused o f this b y h e r parents, family o r neighbors, and indeed, h e r a c c u s a t i o n w a s in fact not true, but she had n o n e t h e l e s s h a r b o r e d this false indictment for 14 years. It gradually b e c a m e clear that her o b s e s s i v e fears were the punishment for her happiness with her o w n child, f o r w h y should she be allowed happiness and pleasure w h e n her b r o t h e r had been bnltally killed? Mrs. A . ' s early mothering had been adequate. H e r father was a stable and loving person. T h e family unit r e m a i n e d intact until after the b r o t h e r ' s accident. A most important d e v e l o p m e n t a l f a c t o r in her life had been her intense rivalry with her o l d e r sister. The patient's native e n e r g y and considerable talents had a l w a y s resulted in her being victorious despite her y o u n g e r age. T h e s e and o t h e r factors resulted in powerful guilt feelings with the d e v e l o p m e n t o f s e v e r e inhibitions. Sexual. social, and professional inhibitions had d e v e l o p e d as she e x p e r i e n c e d m o r e and m o r e o p p o r t u n i t y for success. T h e s e r e a s o n s , as well as the obsessive fears related to her child, finally p e r s u a d e d Mrs. A. to e n t e r p s y c h o a n a l y s i s .

DIAGNOSIS OF OBSESSIVE-COMPULSIVE SYMPTOMS

543

Comment

The 3-year analysis was successful. The presenting obsessive s y m p t o m s disappeared within several months, and the rigid defenses of isolation and re: pression o f pleasurable emotions as well as her need to defeat herself and obstruct her achievements~\were successfully ameliorated in the analytic work. Although initially inhibited in her relationship with the analyst, Mrs. A. rapidly gained trust, b e c a m e less f~arful, a n d within several months began to m a k e profitable use o f the analytic 'milieu. Most of the a n a l y s t ' s interpretations were directed t o w a r d s h e r defenses, and t h e p a t i e n t ' s basic trust resulted in the d e v e l o p m e n t of the full-blown 'transference neurosis which permitted the recreation and resolution o f the cruclai and conflictual issues in her development. Mrs. A. is best conceptualized in o u r diagnosti c s c h e m a as neurotic a n d rigid. The type o f treatment needed to effect the s y m p t o m s and personality Was analysis. As a result o f h e r treatrfient, h e r s y m p t o m s d i s a p p e a r e d , and her rigid personality structure was modifidd. \

-

s

Case 3 P r o f e s s o r C., a 32oyear-old m a r r i e d scidntist, sought help b e c a u s e of r e c u r r e n t o b s e s s i v e thoughts. H i s o b s e s s i o n s began following the fadure o f a r o u t i n e l a b o r a t o r y e x p e r i m e n t which had resulted m a shght injury to a l a b o r a t o r y assistant. T h e o b s e s s i v e |ntrusJons c0ns~sted o f ~mages o f the injury a n d a c o n c o m i t a n t dreadful f e a r that he h i m s e l f might die. Although P r o f e s s o r C. c o n t i n u e d to function p r o f e s s i o n a l l y in his us/aal d r i v e n a n d highly s u c c e s s f u l fashion, h e had w i t h d r a w n since the incident f r o m his wife a n d t w o children. In addition, he w a s significantly d e p r e s s e d and a c u t e l y a n x i o u s . P r o f e s s o r C . ' s f a t h e r w a s a n aloof, intellectual scientist w h o h a d Worked in the s a m e field as his son. H e had paid little attention to his child and had c o n c e n t r a t e d o n his o w n professional a c h i e v e m e n t s . T h e mother, had c a t e r e d to the f a t h e r ' s e v e r y w h i m . a n d b o t h had b e e n insensitive to their s o n ' s needs and feelings. T h e s a m e lack o f e m p a t h y w a s a p p a r e n t w h e n s h e v i s i t e d him as a n adult o r w h e n s h e p l a y e d with h e r g r a n d c h i l d r e n . P r o f e s s o r C. h a d b e e n a lonely, brilliant child w h o had c o n c e i v e d that his only c h a n c e for survival lay in perfection. Only in this w a y could he p r o t e c t h i m s e l f f r o m d e a t h , si~,ce the w a r m t h and e m p a t h y that is ordinarily p r e s e n t to p r o t e c t and n o u r i s h a g r o w i n g child w a s n o t p r e s e n t for him. T h e godlike f a t h e r left the fam;ly w h e n the patient w a s in his s e n i o r y e a r o f high school: the p a t i c n t ' s m o t h e r b e c a m e depress~cd, a n d the patient h i m s e l f e x p e r i e n c e d fears o f death. During t r e a t m e n t , it b e c a m e c l e a r that P r o f e s s o r C . ' s m i n o r scientific failure a n d the slight injury to the w o r k e r had s h a t t e r e d his feelings o f o m n i p o t e n c e . H e f e a r e d that he v-as n o w powerlessT d e f e n s e l e s s , a n d could die at a n y time2 H i s life had b e e n b a s e d o n a c o n s c i o u s recognition o f his need to b e perfect, and his s k y r o c k e t i n g c a r e e r and brilliant s u c c e s s had p r o v i d e d c o n t i n u i n g f u e l for his o m n i p o t e n t orbit. H o w e v e r , the slight s e t b a c k h a d diminished his s e l f - e s t e e m a n d his personality structure had fragmented. C.'s defenses were of obsessive-compulsive type--doing and u n d o i n g , isolation, intellectualization, e t c . - - - a n d w e r e h o o k e d t o g e t h e r in the fragile s y s t e m des c r b e d a b o v e without an integration into a c o h e s i v e self. In the beginning s e s s i o n s , the patient s p o k e o f his wish that the analyst b e perfect. I f the analyst w e r e o m n i p o t e n t , he c o u l d a t t a c h h i m s e l f to the perfect a n a l y s t to gain strength a n d be s a v e d . With this e m o t i o n a l c o n n e c t i o n , the p a t i e n t gained strength a n d the o b s e s s i v e thmaghts diminished. O t h e r p r o b l e m s a r o s e , h o w e v e r . I f the a n a l y s t w e r e all p o w e r f u l a n d o m n i p r e s e n t , t h e patient w a s h i m s e l f nothing, a n d this feeling w a s intolerable to him. H e could push the a n a l y s t a~-ay, but t h e n he w o u l d r e e x p e r i e n c e f e a r s o f d e a t h . T h e s e oscillations o c c u r r e d within m i n u t e s o f o n e a n o t h e r in the t h e r a p e u t i c hours. E n o u g h Stability on the a t t a c h m e n t side o f t h e t r a n s f e r e n c e d e v e l o p e d t o a l | e v i a t e the o b s e s s i o n a l s y m p t o m s a n d p r o v i d e the f o u n d a t i o n f o r f u r t h e r analysis. A n e w s e n s e o f s e c u r i t y a l l o w e d the patient t o criticize the a n a l y s t . H e w o u l d s a y . " ' S o m e t i m e s y o u s a y stupid t h i n g s . " " ' H o w c a n y o u .

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sit there and let m e criticize y o u s o ? " Still later, he w a s a m a z e d that the patient and the analyst might agree or disagree, d i s c u s s a q u e s t i o n or o b s e r v a t i o n together. H e said that this had n e v e r h a p p e n e d to h i m before.

ColIlllleIlt

T h e t r e a t m e n t is p r o g r e s s i n g w e l l w i t h ,this n a r c i s s i s t i c p a t i e n t . A l t h o u g h his d e f e n s e s are o f the o b s e s s i v e - c o m p u l s i v e t y p e , the d e f e n s e s a r e h o o k e d tog e t h e r in the fragile s y s t e m d e s c r i b e d a b o v e a n d are not i n t e g r a t e d i n t o a c o h e s i v e self. A p p r o p r i a t e t r e a t m e n t m u s t be d i r e c t e d t o w a r d s the deficit. P r o f e s s o r C. c a n n o t b e treated in the s a m e f a s h i o n as L i s a or M r s . A.

Case 4 B e t t y w a s first seen on an e m e r g e n c y b a s i s in a l a b o r a t o r y at a m e d i c a l c e n t e r , S h e w a s a technician, and seemed perplexed, stupified, and s o m e w h a t confused as she described how she had b e e n u n a b l e to w o r k that a f t e r n o o n b e c a u s e o f r e c u r r e n t o b s e s s i v e t h o u g h t s that s h e w o u l d h a r m h e r s e l f on the l a b o r a t o r y m a c h i n e r y o r cut h e r s e l f with the g l a s s w a r e . B e t t y r e p o r t e d t h a t she h a d b e e n u n h a p p y all h e r life a n d h a d c o m e t o t h e w e s t c o a s t s e v e r a l m o n t h s p r e v i o u s l y in a n a t t e m p t t o e s c a p e f r o m h e r f a m i l y , w h o m s h e still c a l l e d e v e r y d a y , H e r w e s t w a r d m i g r a t i o n h a d failed to s o l v e h e r p r o b l e m s . B e t t y w a s 23 y e a r s old a n d u n m a r r i e d . S h e w a s t h e m i d d l e o f 3 c h i l d r e n f r o m a n u p p e r - c l a s s family. S h e had a l w a y s felt e s t r a n g e d f r o m h e r p a r e n t s , sibilings, a n d p e e r s . S h e c o u l d not r e c a l l a t i m e w h e n s h e w a s not s u b j e c t to pain a n d d e p r e s s i o n . S h e c o u l d n o t d i f f e r e n t i a t e h e r o w n w i s h e s a n d f e a r s f r o m t h o s e a b o u t h e r , and h e r p r o j e c t i o n s w e r e i n t e n s e a n d p r i m i t i v e . S h e had t r a n s i e n t e p i s o d e s in w h i c h s h e e x p e r i e n c e d m e r g i n g w i t h o t h e r s a n d d i s a p p e a r i n g . T h e r e w a s no h i s t o r y o f h a l l u c i n a t i o n s o r d e l u s i o n s . S h e w a s c o n f u s e d f o l l o w i n g h e r first s e x u a l e x p e r i e n c e . S h e h a d felt it w o u l d b e a m o r e painful e x p e r i e n c e t h a n it a c t u a l l y h a d b e e n . A f t e r the y o u n g m a n h a d left, she t o o k a c a n o p e n e r a n d g o u g e d h e r f o r e a r m , w h i c h s e e m e d to s o m e h o w m a k e h e r feel b e t t e r . In a t h e r a p e u t i c h o u r in w h i c h s h e w a s a n g r y , she b e c a m e terrified a n d c r i e d . S h e w a s fearful that s o m e o n e w a s g o i n g t o be killed, b u t c o u l d n ' t tell if the s o m e o n e w a s h e r s e l f o r the t h e r a p i s t . Periodically, she b e c a m e unable to function.

Cottlltlent

S e v e r a l t i m e s d u r i n g t h e .next 4 y e a r s it w a s n e c e s s a r y to h o s p i t a l i z e B e t t y for 1 - 2 - w e e k p e r i o d s b e c a u s e o f i n c r e a s e d o b s e s s i v e fears a n d d e p r e s s i o n . Trials o n s e v e r a l t y p e s o f p s y c h o a c t i v e m e d i c a t i o n s w e r e n o t helpful. It finally s e e m e d that it w a s all o n e c o u l d d o t o m a i n t a i n h e r in t h i s c h r o n i c b o r d e r l i n e c h a o t i c state. W~hen h e r e m p l o y e r finally d i s m i s s e d h e r b e c a u s e o f h e r c o n t i n u e d m a r g i n a l p e r f o r m a n c e , s h e r e t u r n e d to the east c o a s t t o live o n c e a g a i n with t h e family a n d r e e n t e r e d t h e r a p y t h e r e . S h e k e p t in t o u c h w i t h h e r previous t h e r a p i s t for s e v e r a l y e a r s , a n d as b e s t as c o u l d b e d e t e r m i n e d f r o m t h e s e c o n t a c t s , :her b o r d e r l i n e f u n c t i o n i n g c o n t i n u e d in t h e s a m e w a y .

DISCUSSION It h a s o c c a s i o n a l l y b e e n said that F r e u d s h o o k p s y c h i a t r y o u t , o f its p o s t K r a e p e l i n d o l d r u m s . T h i s c o m m e n t c o n t a i n s t w o i m p l i c i t reflectionS: t h e first, that K r a e p e l i n w a s a f i x e d star in the p s y c h i a t r i c c o n s t e l l a t i o n at F r e u d ' s a d v e n t o n t h e s c e n e , a n d t h e s e c o n d , that t h e p s y c h o a n a l y s t h a d rm;'interest in n o s o l o g i c a l entities. T h i s a r g u m e n t , h o w e v e r p e r s u a s i v e l y p r e s e n t e d , m u s t b e f a u l t e d o n at least o n e a n d p o s s i b l y b o t h c o u n t s . F r e u d a n d K r a e p e l i n w e r e

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e s s e n t i a l l y c o n t e m p o r a r i e s , a n d F r e u d w a s i n t e r e s t e d in, but c a u t i o u s a b o u t , classifications b e c a u s e t h e y t e n d e d to p r o v i d e e x t e r n a l h a n d l e s - - t o r e m o v e t h e d i s e a s e f r o m t h e p e r s o n , as it w e r e . T h e p s y c h o a n a l y s t w a s m u c h m o r e int e r e s t e d in d y n a m i c i s s u e s t h a n in labels a n d r e m a i n e d r o o t e d t o t h e c o n c e p t o f a d a p t a t i o n a n d i n t e g r a t i o n in t h e p s y c h i c e s t a b l i s h m e n t . F r e u d o c c a s i o n a l l y s e e m e d t o try t o p o u r n e w w i n e into old b o t t l e s b y c o m b i n i n g t r a d i t i o n a l p s y c h i a t r i c d i a g n o s e s w i t h e v o l v i n g p s y c h o a n a l y t i c c o n c e p t s , a n d this c o n t r i b u t e d to s o m e o f t h e p r o b l e m s w e h a v e d i s c u s s e d . W r i t i n g r e c e n u y in a s o m e w h a t d i f f e r e n t c o n t e x t , M i c h a e l B a s c h o f f e r e d t h e following assay of Freud's view of neuroses: "'... neuroses were seen essentially as f u n c t i o n a l conflicts t h a t c a u s e d an a r r e s t o r r e v e r s a l o f t h e n o r m a l d e v e l o p m e n t a l p r o c e s s (1975b).'" B a s c h g o e s o n t o p o i n t o u t t h a t F r e u d , h a v i n g f o r m u l a t e d laws for t h e d e v e l o p m e n t o f t h o u g h t ( s o m e t i m e s c a l l e d d e s c r i p t i v e explanatory theories) then converted these laws into causal explanatory t h e o r i e s by p o s t u l a t i n g a b s t r a c t e n t i t i e s that w e r e r e s p o n s i b l e f o r g e n e r a t i n g t h e described conditions. The connection between our own premises and Basch's seem inescapable. A series o f s t u d i e s at the H a r v a r d S c h o o l o f H e a l t h c o n c l u d e d t h a t p h y s i c i a n s w h o a r e able to m a i n t a i n s e v e r a l h y p o t h e s e s in t h e i r m i n d s at t h e s a m e t i m e t e n d to p e r f o r m b e t t e r o n s i m u l a t e d clinical t a s k s t h a n p h y s i c i a n s w h o t o o r a p i d l y n a r r o w e d t h e i r list o f d i a g n o s t i c possibilities. H o w c a n s u c h d i s p a r a t e e l e m e n t s as F r e u d ' s u n d e r s t a n d a b l e e a r l y m i s t a k e s , B a s c h ' s a f f i r m a t i o n o f o u r p r e v i o u s l y s t a t e d p o s i t i o n , a n d s t u d i e s d o n e at t h e H a r v a r d S c h o o l o f H e a l t h b e c o m b i n e d in a m e a n i n g f u l s y n t h e s i s ? L e t us try. T h e d i a g n o s t i c d i l e m m a in n o n p s y c h o t i c p a t i e n t s is c o m p l i c a t e d b y t h e fact that e x p e r i e n c e s u s t a i n s t h e i m p r e s s i o n that t h e c l e a r e s t d i a g n o s i s a r r i v e s o u t o f t h e t h e r a p e u t i c p r o c e s s itself, i . e . , t h e r e is a c e r t a i n p e r s u a s i v e q u a l i t y t o t h e n o t i o n t h a t w e k n o w finally w h a t w e are t r e a t i n g w h e n w e h a v e finished t h e treatment. O u r p a p e r offers t h e a r g u m e n t that this is a l u x u r y w e c a n s c a r c e l y a f f o r d in an e r a c h a r a c t e r i z e d by a n e x p l o s i o n o f scientific k n o w l e d g e . T h e s o o n e r w e k n o w w h a t d i s o r d e r w e are treating, the b e t t e r w e a r e able to f o r m u l a t e the r e m e d y . In o u r effort to i l l u m i n a t e t h e p r o b l e m , w e h a v e c h o s e n t o c o n c e n t r a t e o n i s s u e s that d e v e l o p w h e n o b s e s s i v e - c o m p u l s i v e s y m p t o m s a r e the m a j o r m a n i f e s t a t i o n o f a n e m o t i o n a l illness in n o n p s y c h o t i c patients. S u c h p a t i e n t s a r e u s u a l l y d i a g n o s e d as s u f f e r i n g f r o m o b s e s s i v e - c o m p u l s i v e p s y c h o n e u r o s e s . This d i a g n o s i s is i n a d e q u a t e b e c a u s e it fails to d i f f e r e n t i a t e b e t w e e n t h e w i d e v a r i e t y o f p s y c h o p a t h o l o g y f o u n d in t h e s e p a t i e n t s . T h i s failure in d i a g n o s i s l e a d s in t u r n to i n a p p r o p r i a t e p a t i e n t m a n a g e m e n t a n d t r e a t m e n t . The automatic equating of obsessive-compulsive symptoms with a diagnosis o f o b s e s s i v e - c o m p u l s i v e p s y c h o n e u r o s i s s t e m s f r o m e r r o r s that a r e i n h e r e n t in o u r p r e s e n t d a y d i a g n o s t i c s c h e m a . T w o o f F r e u d ' s m a j o r contri'l~utions---the i d e n t i f i c a t i o n o f clinical s y n d r o m e s a n d the e t i o l o g y o f s y m p t o m ~ : ~ - h a v e b e e n confused with each other and have contributed directly t o the diagnostic dilemma. T h i s p a p e r h a s o u t l i n e d a n e w s y s t e m o f classification for n o n p s y c h o t i c p a t i e n t s . T h e u n d e r p i n n i n g s o f o u r p r o p o s a l are t h e p s y c h o a n a l y t i c c o n c e p t s o f

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c h a r a c t e r formation and personality d e v e l o p m e n t . W e h a v e suggested that there is a c o n t i n u u m o f health among n o n p s y c h o t i c patients ranging from the most h e a l t h y or most a d a p t a b l e to the least h e a l t h y or least adaptable. F o r p u r p o s e s o f illustration, we have offered diagnostic and clinical e x a m p l e s of four p s y c h i a t r i c categories, i.e., neurotic flexible, neurotic .rigid, narcissistic, and borderline, and h a v e e x a m i n e d these s t r u c t u r e s in terms o f defense mechanisms, d e v e l o p m e n t a l histories, presenting c o m p l a i n t s , and t r a n s f e r e n c e issues, with the intent to d i s c o v e r how these s t r u c t u r e s impact upon p s y c h i a t r i c care.

O u r model does not focus on s y m p t o m s ; rather, it s t r e s s e s the c o n t e x t as well. It is our feeling that this c o m b i n a t i o n i m p r o v e s o u r diagnostic a c u m e n . O u r t h o u g h t s are offered as preliminary o n e s , and we are hopeful that the discussion will recognize the tentative nature o f o u r efforts. REFERENCES I. Hinsie E, Campbell J: Psychiatric Dictionary (ed 4). N e w York. Oxford University Press, 1970. p 518 2. Hinsie L E . Campbell RJ: Psychiatric Dictionary (ed 4). New York, Oxford University Press, 1970, p 418 3. Diagnostic and Statistical Manual o f Mental Disorders (DSM-I). Washington, D.C., American Psychiatri c Association, 1952 4. Diagnostic and Statistical Manual o f Mental Disorders (DSM-III. Washington, D.C., American Psychiatric Association, 1968 5. Spitzer L (ed): Diagnostic and Statistical Manual o f Mental Disorders (Draft). Am Psychiat Assoc, Wash. DC, Jan. 31, 1978 6. Random H o u s e Dictionary o f the English Language. New York, Random House, 1967, p 960 7. Veith t: Four Thousand Years o f Hysteria, in Horowitz J (ed): Hysterical Personality. New York, Jason Aronson, 1977, p 32 8. Veith I: F o u r Thousand Years o f Hysteria, in Horowitz MJ (ed): Hysterical Personality. New York, Jason Aronson, 1977, p 33 9. Chrzanowski, G: Neurasthenia and Hypochondriasis, in Orieti S (ed): American Handbook of Psychiatry. New York, Basic Books, 1959, p 262 10. Kraepelin, E: Lectures on clinical psychiatry, h facsimili of the 1904 edition. New York, H o r n e t Publishing, 1968, p 264 I 1. Freud, S: On the ground for detaching a partic~t~ar syndrome from neurasthenia under the description "'anxiety n e u r o s i s . " Strochey, J (ed): in T h e Standard Edition of,the Complete Psychological Works o f Sigmund Freud (vol. 3). L o n d o n , Hogarth Press. 1962, p g l

12. S t r o c h e y J (ed) by Freud S: The neuropsychoses o f defense. T h e Standard Edition o f the Complete Psychological Works o f Sigmund Freud (vol 3). London, Hogarth, 1962. p 162 13. Fenichei O: The Psychoan,'dytic T h e o r y o f Neurosis. New York, W W Norton. 1945 14. Burness E: Glossary o f Psychoanalytic T e r m s and Concept s . N e w York, American Psychoanalytic Association, 1968 15. Freud S: Further remarks on the neuropsychoses o f defense, in T h e Standard Edition o f the Complete Psychological Works o f Slyround Freud (vol 3). London, Hogarth, 1962, pp 162-185 16. Freud S: Sexuality in the aetiotogy o f the neuroses, in T h e Standard Edition o f the Complete Psychological Works o f Sigmund Freud (vol 3). L o n d o n , Hogarth, 1962, pp 263-

285 17. Freud Si Fragment o f an analysis o f a case o f hysteria, in T h e Standard Edition o f the Complete Psychological Works o f Sigmund Freud (vol 3). L o n d o n . Hogarth, 1962, pp 7 - t22 18. Freud S: Neurosis and psychosis. "The Standard Edition o f the Complete Psychological Works o f Sigmund Freud (vol 19). L o n d o n , Hogarth, 1962, pp 149-153 19. Freud S= Neurosis and psychosis, in The Standard Edition o f the Complete Psychological Works o f Sigmund Freud (vol 19). L o n d o n , Hogarth, 1962, p 150 20. Freud S: Character and anal eroticism, in The Standard Edition o f the Complete Psychological Works o f Sigmund Freud (vol 9). L o n d o n , Hogarth, 1908, pp 167-175 21. Abraham K: The influence o f oral eroticism in character formation, in Bryan D,

DIAGNOSIS OF OBSESSIVE-COMPULSIVE SYMPTOMS Strachey A (translators): Selected Papers of Karl Abraham. London, Hogarth, 1948, pp 393-406 22. Reich W: Character Analysis (ed 3). New York. Noonday, 1949 23. Freud A: The Ego and the Mechanisms of Defense, New York, International Universities Press. 1946 24. Hartmann H: Ego Psychology and the Problem of Adaptation. New York, lmernati0nal Universities Press, 1958 25. Edkson EH: Childhood and Society. New York, WW Norton, 1963 26. Shapiro D: Neurotic Styles. New York, Basic Books, 1965 27. Blacker KH, Tupin JP: Hysteria and hysterical structures, Horowitz MJ (ed): New York, Jason Aronson, 1977, pp 97-141 28. Kernberg, O: Borderline Conditions and Pathological Narcissism. New York, Jason Aronson, 1975 29. Kohut H: The Analysis of the Self. New York, International Universities Press. 1971

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30. Nagera, H: Obsessional Neuroses: Developmental Psychopathology. New York, Jason Aronson, 1976 31. Davanloo H: Evaluation, criteria for selection of patients, in Davanloo H (ed): Basic Principles and Techniques in Short-Term Dynamic Psychotherapy. New York, SP Medical and Scientific Books, 1978, pp 9-34 32. Sifneos PE: Short-term Psychotherapy and Emotional Crisis, Cambridge, Harvard University Press, 1972 33. Malan, DH: The Frontier of Brief Psychotherapy. New York, Plenum 1976. chapter 9, pp 247-258 34. Wallerstein RS. Robbins LL: Concepts. Bull Menninger Clinic 20:239-262, 1956 35. Blanck G, Blanck R: Ego Psychology: Theory and Practice. New York, Columbia University Press, 1974 36. Basch, M: Presentation at the Michael Reese School of Health Sciences Chicago Conference on the Psychology of the Self, October 13. 1978