I Hate You--Don't Leave Me - Jerold J. Kreisman [101]
Obsessive-Compulsive Personality Disorder
Future Diagnostic Definitions
Our current nomenclature defining BPD relies on fulfilling a threshold of descriptive symptoms listed in the APA’s DSM-IV-TR: An individual has BPD if he exhibits at least five of the nine criteria (see chapter 2). Thus, the person who reflects, say, five symptoms and is then able to eliminate just one is immediately relieved of the diagnosis.
This categorical paradigm, however, does not reflect the traditional perception of personality, which is that personality is not altered so abruptly. Thus, it is highly likely that future DSM definitions of BPD will integrate dimensional features. In this paradigm the degree of functioning or disability may be considered. More specifically, the doctor will be able to factor into an evaluation the degree of specific characteristics (such as impulsiveness, emotional lability, reward dependence, harm avoidance, etc.)—not just the presence of these symptoms—to diagnose (or not diagnose) BPD. The intent of such DSM changes is that these adaptations will more accurately measure changes and degrees of improvement, rather than merely determine the presence or absence of the disorder.
Appendix B
Evolution of the Borderline Syndrome
The concept of the borderline personality has evolved primarily through the theoretical formulations of psychoanalytic writers. Current DSM-IV-TR criteria—observable, objective, and statistically reliable principles for defining this disorder—are derived from the more abstract, speculative writings of psychoanalytic theorists over the past hundred years.
Freud
During Sigmund Freud’s era at the turn of the century, psychiatry was a branch of medicine closely aligned with neurology. Psychiatric syndromes were defined by directly observable behaviors, as opposed to unobservable, mental, or “unconscious” mechanisms, and most forms of mental illness were attributed to neurophysiological aberrations.
Though Freud himself was an experienced neurophysiologist, he explored the mind through different portals. He developed the concept of the unconscious and initiated a legacy of psychological—rather than physiological—exploration of human behavior. Yet he remained convinced that physiological mechanisms would eventually be uncovered to coincide with his psychological theories.
Over a century after Freud’s landmark work, we have come almost full circle: today, diagnostic classifications are once again defined by observable phenomena, and new frontiers of research into BPD and other types of mental illness are again exploring neurophysiological factors, while acknowledging the impact of psychological and environmental factors.
Freud’s explication of the unconscious mind is the underpinning of psychoanalysis. He believed that psychopathology resulted from the conflict between primitive, unconscious impulses and the conscious mind’s need to prevent these abhorrent, unacceptable thoughts from entering awareness. He first used hypnosis, and later “free association” and other classical psychoanalytical techniques, to explore his theories.
Ironically, Freud intended classical psychoanalysis to be primarily an investigative tool rather than a form of treatment. His colorful case histories—“The Rat Man,” “The Wolf Man,” “Little Hans,” “Anna O,” etc.—were published to support his evolving theories as much as to promote psychoanalysis as a treatment method. Many current psychiatrists believe that these patients, whom Freud felt exhibited hysteria and other types of neuroses, would today clearly be identified as borderline.
Post-Freud Psychoanalytic Writers
Psychoanalysts who followed Freud were the main contributors to the modern concept of the borderline syndrome.1 In 1925, Wilhelm Reich’s Impulsive Character described attempts to apply psychoanalysis to certain unusual characterological disorders that he encountered in his clinic. He found that the “impulsive character” was often immersed in two sharply contradictory feeling states at the same time, but was able