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RSSAccording 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.
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I passionately appreciate your distinction between defensive strategies and disorders; that’s a highly refreshing, and desperately-needed distinction. Please count me IN the counter-revolution!! I’m a psychoanalytic therapist in Seattle, and if someone comes into my practice with a “diagnosis” given to them by their doctor or a previous therapist or psychiatrist, I immediately pry them loose of any investment, negative or positive, in that diagnosis. I explain that most people in pain fit a few diagnostic categories anyway, and the purpose of diagnosis is largely for billing insurance. I find people are mostly very relieved to be out of that trap. However, if someone is overly invested in his diagnosis, from my experience, it usually means “I don’t want to *work* at making my life better!”
The “New York Times” article featured so many people and interest groups complaining about the new criteria because it meant certain people wouldn’t get special privileges like money, housing, special education, etc., which just supports my idea that the greater the investment a person has in a diagnosis, the greater the entitlement.
One of my favorite psychoanalysts, Francis Tustin, who worked mostly with autistic children, wrote again and again of how important it is to be very firm (not harsh) when dealing with autistic children. She emphasized that “softie” parents really needed to be educated about how indulging the autistic child only worsened autistic entrenchment in that child.
Likewise a “softie”society that kind of coddles all of these diagnosed individuals can’t be good.
Regarding the whole diagnosis issue, there’s another useful article in today’s New York Times, about how these diagnostic labels don’t actually correspond to an actual disorder, in the way that the term “diabetes” does, for example. I think we may be turning a corner in our societal discussion of mental illness.
When autistics cover their ears to shield from loud noises or get overwhelmed in a store by bright lights, is there something other than the noise and overwhelming brightness that they are trying to “push away” from (defend against)?
Is not playing with toys how they are supposed to be played with a defense mechanism, and if so, what is that defending against?
Thanks.
First of all, I think that any experience which makes the autistic especially aware of the outside world — such as those loud noises and bright lights — is a threat, cracking through their defensive shell. Second, Frances Tustin has quite a lot to say about the idiosyncratic way autistics use toys. In a nutshell, it is often the “hardness” of the object that appeals to them, felt on an unconscious level to be a shield against the unbearable internal “softness”.
Thank you.
Slight tangent, but do you believe eliminating Narcissitic Personality Disorder from the DSM is a good move?
If it gets people to take a step back and consider whether these discrete diagnostic entities might not actually exist, then yes. The problem, as I keep saying, is that we’ve been told that one can “have” narcissistic personality disorder in the same way that one can “have” diabetes, but they’re not at all the same. The NPD label stops people from looking any deeper to consider the meaning of their symptoms and suffering.
I’m not sure how I feel about these potential exclusions or perhaps the tighter focused inclusions to the DSM. With regard to Aspergers’ Syndrome, I wonder how it is diagnosed in the first place if it is along a spectrum. It took 10 years for me to research and determine that’s what my husband has – the brilliant and intellectual man that he is. If it had not been for the accounts of many women who wrote about their experiences with husbands with AS, I would gone crazy.
I believe you could find reassurance in hearing different autistic behaviors described by such women, and the familiar pain suffered by them because of it, without having to apply a diagnostic label. It’s possible to identify and describe autistic defenses/maneuvers/strategies which can appear in different (artificially discrete) disorders without needing to believe they go along with some particular named syndrome.
“The NPD label stops people from looking any deeper to consider the meaning of their symptoms and suffering.”
Wow, yes! And I suppose this is true of any label…
That’s the problem with labels; they give us the mistaken idea that we actually understand something.
Hi there,
I wonder if you would generally consider bi-polar mood disorder to fall under the neurotic defense(s) category based on your experience? If so, would this be an overcontrolling response?
Finally if/when psychosis manifests with bi-polar mood disorder, what would you say about what has compounded or changed about the underlying neurotic defense?
Thank you Dr. Burgo
Hi Elizabeth, I think the dynamics of manic-depression — the shift from hopeless despair to magical answers — occur along a spectrum, so they could be either at the neurotic or psychotic end of things. The more hopeless and despairing the depression (the stronger the sense of internal damage), the more powerful the manic defense. But you often see these dynamics to a degree in “ordinary” depression, as well.
How interesting. I have not until now, understood why psychologists are opposed to making diagnosis. Explained this way it is understandable. I do think, though, that a label can be helpful at times and I am leery of the idea of throwing the entire model out.
I understand. It’s when it becomes too literal that it’s a problem. These diagnoses in no way correspond to diseases in the same way as, say, a diagnosis of diabetes.
I’m not getting your point with regard to autism spectrum disorders. Children I know who were diagnosed with high-functioning autistim or Aspergers are physically awkward, overly literal, and sometimes inappropriately honest or blunt, despite having superficially good manners. They have atypical MRIs and PET scans. How are these defense mechanisms?
Those aren’t defense mechanisms. The more I write about people who use autistic defenses, the more I realize that they’re fairly impossible to convey to someone who hasn’t worked analytically with them over many years. It takes a long time to enter into their world and understand the nature of their defenses … it took a long time for me, anyway. I understand why what I say makes no sense to most people and I don’t know how to do any better.
Your opinions regarding the current myopic focus on diagnostic labels in society (and in therapy) are ones I mostly agree with whole-heartedly. I firmly believe that labels should be used to explain behaviour and experiences rather than to excuse behaviour or limit experiences. In most cases, there is enough pain, anger and dysfunctional ways of being to work on, where the person’s label should inform therapy instead of being used to underline and conclude the process.
Where my agreement with your stance diverges, is in relation to Autism Spectrum Disorders, which I feel have too strong a neurobiological basis to be explained away entirely via your defence argument . I am doing a research PhD in Psychology, have a good decade of therapy under my belt (the bulk being psychodynamic), and I also have a diagnosis of Asperger’s. I’ll be the first to admit to employing a variety of defences in my time, including autistic ones like selective mutism, dissociation or being otherwise self-absorbed and separated.
There is something altogether qualitatively different though about my sensitivity to UV light, my problems with auditory discrimination, my motor clumsiness, or my inability at times to make sense of a person’s facial expression or keep a conversation going. These occur well within my conscious awareness, and, more importantly, serve no protective function that I can ascertain. Moreover, I have fought long and hard to overcome them, picking up my first book on nonverbal communication when I was ten and very confused about the gestures people used, which contrasted with my relative stiffness.
For the most part, yes, we need to reassess the value of diagnostic labels and how we (ab)use them in psychology, but, despite a highly vested interest in the notion that autistic dysfunction can be ameliorated via a good hard look at ones defences, I know intimately that my proprioceptive issues are rooted in a physicality that my selective mutism is not. The former will never be tackled by a deft interpretation, while the latter most surely can.