As the Diagnostic and Statistical Manual was undergoing its third revision and expansion (DSM-IV is 319 pages longer than DSM-IIIR) in a fourteen-year period, certain authors in England and Australia were arguing for a return to the concept of neurosis in psychiatry. In their view, the “splitting” of syndromes in DSM has little value for the clinician and implies a false separation between various disorders. In support of this view they cited recent studies indicating a high rate of co-morbidity and a lack of stability of diagnoses over time. In 1985 Peter Tyrer argued in The Lancet that “it is more appropriate to regard many of these conditions as manifestations of one disorder, which may be termed the ‘general neurotic syndrome.‘” He and his colleagues also criticized symptom-focused treatments developed from DSM categories. In 1990 Andrews et al. wrote in the British Journal of Psychiatry that “good treatment should involve not just the resolution of symptoms but also improvement in the vulnerability factors that appear to be so central to these disorders, vulnerability factors that may well define the general neurotic syndrome.”
Despite these criticisms, many psychiatrists and several studies support the view that the separation of syndromes in the DSM Axis I disorders has proven valuable in making certain treatment decisions, particularly with regard to choice of medication. As a general rule, analysts are probably paying too little attention to the DSM system, whereas general psychiatrists are paying too much. Both “lumping” and “splitting” play valuable scientific roles. The clinician serves patients best when able to identify discrete symptoms of various syndromes, while understanding the limitations of these diagnoses and the importance of dynamic factors leading to vulnerability and illness. Unfortunately, clinicians will sometimes disparage the value of either the dynamic or the descriptive perspective, often out of lack of knowledge of what these systems have to offer.
Among those who accept the importance of both dynamic concepts and diagnostic classification, many feel that the recent revisions of DSM have relied excessively on observable behavior, unnecessarily excluding meaning, inference, and theory. Efforts have been made to encourage integration of the intrapsychic world into the official psychiatric diagnostic system.
In 1990 The American formed an ad hoc committee to serve as a liaison group to committees involved in developing DSM-IV. The goal was to allow analysts more systematic input into the revision process than they had had with previous revisions. Arnold Cooper, chair of the committee, had been active for many years in efforts to sway DSM in a more psychodynamic direction. In a 1981 paper written with Allen Frances, he had suggested that “there are many diagnoses in DSM-III that could be further enriched by descriptive psychodynamic observations.” Richard Friedman, Otto Kernberg, Jon Meyer, Ann Price, and Miltiades Zaphiropoulos were members of the committee. In 1991, I was appointed secretary.
The committee identified several discrete areas in which dynamic perspectives could improve diagnoses. Throughout the process, the committee lobbied for the addition of an axis of defense mechanisms and for the inclusion of self-defeating personality disorder in the main text. Despite the fact that the revisers planned to change as little as possible from DSM-IIIR, the committee felt that its efforts were worthwhile.
Of major significance to psychoanalysts, DSM-IV includes a 'Defensive Functioning Scale“ in an appendix of ”Proposed Axes for Further Study.“ The appendix contains a definition of the term defense mechanism, groupings of defenses into different levels (from most to least adaptive), and a glossary of specific mechanisms. Also included is a form for recording an individual's primary defense levels and most prominent defenses.
Certain defenses and defense levels may appear idiosyncratic to the psychoanalytic reader. For instance, analysts may question whether passive aggression and help-rejecting complaining can be viewed as defense mechanisms. Also unfamiliar to most analysts will be the grouping of defenses into such categories as a disavowal level (denial, projection, rationalization), a major image-distorting level (autistic fantasy, projective identification, splitting of self- or object images), and an action level (acting out, apathetic withdrawal, help-rejecting complaining, passive aggression).
These atypical descriptions derive from the Defense Mechanism Rating Scale (DMRS), currently the most sophisticated system available for research on defense mechanisms. This scale, developed by J. Christopher Perry and Steven Cooper, contains definitions of defense mechanisms along with operationalized criteria for assessing the presence or absence of each defense. Perry directed the DSM-IV field trials for a defense mechanism axis and lobbied for its inclusion in the final version. The groupings of defenses are derived from this research, which showed that defenses co-occur and correlate, in terms of maturity, with other measures of functioning.
Once one gets past the initial idiosyncrasies of the Perry system, the defenses and rating scales prove quite interesting; essentially, they correspond
to the way most analysts think about defense mechanisms. As DSM-V is developed, increased research by analysts on defense mechanisms can demonstrate the importance of including the defense mechanism axis in the main text.
Another positive change, from the committee's perspective, is the expansion of clinical descriptions of personality disorders in Axis II of DSM-IV. These are found in the “Diagnostic Features” section preceding the diagnostic criteria. In these descriptions may be glimpsed the shadows of psychodynamic mechanisms, though they are not explicitly noted. Take, for example, the description of a conflict experienced by individuals with avoidant personality disorder: “Despite their longing to be active participants in social life, they fear placing their welfare in the hands of others.” Such descriptions provide a “clinical feel” and show how psychodynamic knowledge can enhance the understanding of personality organization and functioning.
The way in which Axis II personality disorders are organized remains controversial. Some theorists have suggested that DSM's “categorical” model, in which personality disorders are seen as distinct clinical syndromes, should be replaced by a dimensional system in which, as DSM-IV itself puts it, “Personality Disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another.” In 1985 Widiger and Frances supported a change to such a model, commenting that “a categorical system is admittedly simpler and easier to employ, but this simplicity may be inappropriate to the inherent complexity in classifying multiple and overlapping maladaptive personality traits.”
Other than offering a brief commentary on the dimensional perspective, however, DSM-IV carries over, basically unchanged, the categorical approach of DSM-IIIR.
Recent studies by Oldham et al. and Perry support the view that significant difficulties are encountered in assessing and validating personality disorders as defined in DSM-IIIR's Axis II. Notably absent is any means to assess the severity of these disorders. How best to classify and diagnose them will clearly be a focus of discussion and research for years to come.
DSM-IV, like its predecessors, fails to take advantage of psychodynamic constructs in addressing problems with personality diagnosis. Knowledge of motives, conflicts, and defenses can clearly aid the clinician in distinguishing between personality disorders. For example, Arnold Cooper and I, noting that the same behavioral characteristic can be secondary to a variety of internal motivators, argue in an unpublished paper that the motivation of the particular behavior best determines the category of personality disorder being observed. This point is actually acknowledged, in a single instance at least, in DSM-IIIR: indecisiveness is categorized there as part of a compulsive personality, unless it arises from a need for excessive reassurance, in which case it is considered part of a dependent personality disorder. In addition, what appears to be more than one disorder can often be explained as a single conflict with varying defensive reactions. For instance, a patient showing both obsessional rebelliousness and paranoid mistrust may be seen either as having the characteristics of two different personality disorders (co-morbidity) or as evincing two different ways of managing a fear of losing autonomy. With regard to classifying personality disorders according to severity, Kernberg suggested, almost two decades ago, that the use of certain defense mechanisms, the presence of ego weaknesses, and the capacity for object representation can be used to differentiate between more and less severe personality organizations.
Criteria for the diagnosis of self-defeating personality disorder were included in an appendix of DSM-IIIR. The American's ad hoc committee then strongly encouraged the inclusion of this disorder in DSM-IV's main text. Arnold Cooper noted how clinicians sometimes have difficulty identifying masochism because self-defeating traits are not described up front in DSM-IIIR. At first new evidence gained in field trials appeared to give a boost to inclusion of the diagnosis. For example, studies found a high rate of prevalence for this disorder.
Ultimately, however, the Axis II work group made a decision to exclude the diagnosis entirely from DSM-IV. Concern over social dangers stemming from use of the diagnosis won out, as considerations of how to identify and help those suffering from self-defeating behavior receded into the background. While research suggested that the diagnosis was gender neutral, many groups and individuals lobbied intensively against inclusion of the disorder, in any part of DSM-IV, on the basis of its being biased against women. It was argued that the diagnosis had a high potential for abuse, particularly within the legal system. However, no evidence of actual harm stemming from the diagnosis was presented. Then, late in discussions about the disorder, one instance of misuse Was brought to the attention of the Axis II work group by those opposing inclusion. Largely on the basis of this single report, the group concluded that the “significant potential for misuse” was a reason to exclude the disorder.
Scientific reasons for the exclusion were also presented, including overlap with other disorders and limited research on the diagnosis. Of course, one reason for the lack of research was the disorder's inclusion in the appendix rather than the main text of DSM-IIIR. With regard to overlap, this is a problem with many categories of personality disorder. The available research, though flawed, lent support to the diagnosis, and many felt it identified patients who would not be covered by other diagnoses. Ultimately, the issue was brought to a vote at the American Psychiatric Association's Assembly, which voted to exclude.
Interestingly, the struggle over self-defeating personality disorder mirrors the struggle that clinicians occasionally face in work with patients fitting the diagnosis. Initially it is often unclear to what degree they are actually victims of a hurtful social environment, and to what degree they only see themselves as such. Over time, however, the clinician gains the sense of a person who collects injustices, often gravitating toward hurtful situations. Social injustices must be redressed, but the means must also be found for helping individuals to understand why at times they are drawn to and remain in unjust situations.
Unfortunately, the exclusion of this diagnosis from DSM-IV will blind many clinicians to the presence of masochistic behavior, and patients will in consequence not receive proper treatment. DSM-V, it is to be hoped, will find a way to incorporate the disorder. In the interim, analysts must intensify efforts to educate clinicians-in-training about self-defeating behavior.
It is clear that certain efforts—a research program in the case of defense mechanisms, a lobbying campaign in the case of self-defeating personality disorder—were able to tip the scales as to whether these entities would be included in DSM-IV. This suggests that greater participation by analysts in the development of DSM-V can make a significant difference. Recognition of the impact that DSM has on psychiatric residents, as well as increased understanding of the potential value of the DSM classifications, should spur analysts to make these efforts. Ultimately, the goal of a diagnostic and statistical manual should be to interweave dynamic thinking within a system of descriptive classification.