According to a recent article in the New York Times, the revision to the APA’s Diagnostic and Statistical Manual currently underway will reconsider not only the personality disorders (rumor has it that Narcissistic Personality Disorder may be eliminated) but also the autistic disorders. In particular, it looks as if Asperger’s Syndrome will be eliminated as a separate diagnosis and subsumed within the more tightly focused Autism Spectrum Disorder. Read the entire article for an understanding of how the skyrocketing medical and social costs of treating autistic disorders are driving this revision, at least in part.
This change once again throws into question the validity of psychological diagnosis as a scientifically precise methodology. If Asperger’s Syndrome can be written out of the DSM by committee, one has to wonder if it was ever as distinct a disorder as many people have wanted to believe. Even though I object to the very idea of a diagnosis manual akin to the ICD-10, I’m moderately hopeful that the current revision to the DSM is a step in the right direction: the new name, at least, seems to acknowledge that there’s an entire spectrum of autistic disorders. Still, with its focus on symptoms and behaviors (rather than psychodynamic process), this new Autism Spectrum Disorder continues to reflect the kind of pseudo-scientific precision that characterizes the APA and all its efforts.
In working on my book about defense mechanisms, it has become increasingly clear to me that the problem with modern psychiatry is its renunciation of its psychodynamic roots. Whereas psychoanalytic thinking once dominated the American Psychiatric Association of 50 years ago, the continuing revision to the DSM that began in the 1970s has “re-medicalized” psychiatry — that is, made it more scientific, with identifiable diseases leading to sanctioned cures. Psychodynamic thinking has been written out of the clinical picture so that today, we talk about bipolar disorder, borderline personality disorder and post-traumatic stress disorder as if each was as consistent and identifiable a medical syndrome as diabetes, but with no understanding of their underlying psychic processes. (For more on the medicalization of psychiatry, see Robert Whitaker’s excellent book, The Anatomy of an Epidemic, which I reviewed in a series of three articles, beginning with one on the chemical imbalance theory of depression.)
An exchange of comments to my recent post on narcissistic rage in Citizen Kane helped me clarify my thoughts about this issue. As a therapist, I focus on defensive strategies for dealing with psychic pain; instead of trying to figure out the disorder from which a client suffers, which drug to prescribe or which cognitive-behavioral technique to recommend, I wonder about the nature of the client’s unconscious pain and the ways he or she is trying to evade it. I try to help my clients understand their defensive maneuvers, as a first step in learning how better to tolerate that pain. Freud stated that the goal of psychoanalysis was to transform neurotic pain into ordinary human suffering, and it still seems true. So much of what we human beings do with our defense mechanisms only makes the suffering worse; we need to learn how to tolerate and not defend against our suffering, in the process finding more constructive ways to address (but not necessarily eliminate) that pain.
In my experience, there are broadly speaking, five different categories of defenses: neurotic, schizoid, narcissistic, autistic and psychotic. Each one of these categories deserves its own individual discussion, and I’ll probably go into them separately in later posts. For now, I’d like to say something about autistic defenses and how they function. Although I disagree with the diagnosis, there is definitely something identifiably “autistic” in my experience, even though it may appear in all sorts of different disorders, including ones that would never qualify for a DSM label in that category. Minor autism symptoms often show up where narcissism is a powerful issue, for example, or with schizoid personalities.
About six months ago, I went to a party at the home of a new acquaintance. After I’d been there for about half an hour, another guest arrived with her 13-year-old son in tow. He was appropriately dressed and physically unexceptional. My host introduced me to the woman and her son; in about two minutes, I could tell I was in the presence of someone with autistic features. There was nothing about his behavior that blatantly stood out — no repetitive acts, no stereotyped language or rituals. He said little, made poor eye contact and most important, made me feel as if I weren’t there. When his mother found out I was a psychologist, she told me that her son had been diagnosed with Asperger’s. In my experience — and I admit I haven’t had a lot of experience working with truly autistic clients — the autistic defense seeks to shut out the world because it feels far too threatening to acknowledge it. In one way or another, the autistic finds contact with the outside world catastrophic, and through characteristic defensive maneuvers, seeks to shut out the awareness of that separate world. Repetitive behaviors, stereotyped language, rituals, etc. (all the familiar autism symptoms) represent defensive strategies either to exclude awareness of the world, or to reduce contact with the threatening outside to something familiar, repetitive and controllable.
We can apply this notion of defensive maneuvers to other psychological disorders. In many cases, what is often referred to as an “addiction” — say, to video gaming — might be better understood as an autistic-like defense. Certain forms of obsessive-compulsive behavior have their own autistic features. I’ve had zero clinical experience with hoarders, but I suspect the act of hoarding has its autistic aspects as well, where the hoarded objects are felt to be some kind of magical protection against the traumatic outside world. And a person suffering from the so-called Schizoid Personality Disorder surely relies upon autistic maneuvers as part of his or her defensive strategy.
We could look at other types of defensive strategies and apply an understanding of them to different disorders across the spectrum. For example, many people who suffer from a wide variety of emotional difficulties have certain narcissistic defenses in common, even if they don’t meet the criteria for the soon-to-be-obsolete Narcissistic Personality Disorder. My point here is to shift the emphasis away from diagnosis and onto defensive maneuvers; to focus on unconscious pain rather than counting symptoms and behaviors; to think psychodynamically instead of stopping once the label has been assigned and the drug
prescribed. I’m tired of people writing to me and announcing that they “have” Borderline Personality Disorder, or received a diagnosis of Asperger’s, as if the label says it all. No doubt there’s a good reason why they received that label; it might very well tell us something about the nature of their defensive maneuvers and point us in the right direction, but it’s only the very beginning of the journey.