A multidimensional
View of the Obsessive Character
Richard 6. Cornfield and Richard L. Malen
C
URRENTLY, our diagnostic classifications are based primarily in descriptive and phenomenologic criteria.’ A problem arises in our reliance on this method of classification; it does not differentiate varying levels of pathology in nonpsychotic patients showing similar personality style. A case in point is the difficulty in understanding the extent of dysfunction when the label “obsessivecompulsive” is applied. This diagnosis may include individuals of vastly differing capacities for psychosocial adaptation. Precision requires an attempt at further organization and di~erentiation. The need for a more effective diagnostic system in psychiatry is a major impetus behind the present work on DSM-III. Lately, Strauss’has argued the benefits of a comprehensive, multivariable approach to diagnosis compared to the current “typologic” approaches, which focus on symptoms and require additional complementary, broad categories of little descriptive value. He claims that a multivariable system employing such components as symptoms, previous duration and course, personal relationships, and work function “could result in a broader and sharper understanding of the crucial aspects of psychiatric disorder and treatment.” Bachrach” has stated the need for diagnostic precision based on such factors as “dispositional” and “conditional” aspects of behavior. Among other suggestions for a broad-based approach have been the recommendations of EssenMoller4 and the World Health Organization.~ INVESTIGATIONS
ON THE HYSTERICAL
CHARACTER
Curiously, in the last twenty years, the hysterical character has received more careful scrutiny than the obsessive. The multidimensional assessment that has been derived may be equally valuable in clarifying: the extent of obsessive character disorder, the variable prognoses based on degrees of pathology, and different approaches to treatment based on such understanding. Perhaps the perennial interest in hysteria has emotional roots emerging from the earliest modern-day, in-depth studies of mental and emotional disorders. A number of authors have suggested that within this character type, a wellfunctioning group can be distinguished from a dependent, emotionally immature group. as discussed in a review by Lazare.” Among them, Freud,; Wittels,’ and Marmor” have argued that the hysterical character appeared deeply rooted in primitive, oral levels of development; however, this view failed to account for individuals with hysterical phenotype who showed healthy overall functioning outside From the Departments of Psychiatry. Mount Sinai School 01 Medicine, the Bronx Veterans Administration Hospital. and St. Vincent’s Hospiial and Medical Center. Richard B. Cornfield, M.D.: .4ssociate in Psychiarr!, Mount SinaiSchool of Medicine. and Chief’of Psychiatry. Bronx Veterans Administration Hospital; Richard L. Malen, M.D.: Clinical instructor in P.ychiatry, Mount Sinai School of Medicine, and Assirtant in P.ychiatrv, St. Vincent’s Hospital and Medical Center. Address reprint requests to Richard B. Cornfield, M.D., Chi# of P~~~h~atr~, Bronx Veterans .~dmin~.~tration Hospital. Room A-223, 130 West ~in~,~~r~d~eRoad, Brony. N. Y. 10468. c: 197X hv Grune & Stratton. Inc. ~SS~~~~~l~~44~.~.0010 440X/l~~lf9Of~000HSOI,a(~J(r Comprehensive Psychiarry, Vol. 19. No. 1 lJanuary/February).
1978
.73
74
CORNFIELD
AND
MALEN
the area of conflict. Contemporary authors such as Easser and Lesser’” saw the hysterical personality along a continuum of character pathology; they defined the “hysteric” as a specific clinical entity with conflicts at a more mature developmental stage, whose lifelong functioning was generally much healthier in the areas of relationships, stability of personality and defenses, and capacity for adaptation. “Hysteroid,” on the other hand, was the label they applied to a person who, while also appearing labile, seductive, overexcitable, imprecise, and childish, evidenced strong primitive orality trends. They claimed that in the “hysteroid,” adaptive, vocational, and academic patterns were extremely erratic and highly dysfunctional; that relationships showed an engulfing, devouring quality with pseudoerotic sexual excesses and acting-out as a frequent defensive maneuver. Kernberg” also acknowledged the spectrum of such disorders through a structural, genetic, symptomatic, and dynamic comparison, differentiating the healthy hysteric, as described by Easser and Lesser, from the “infantile personality” with an abundance of primitive traits and character mechanisms; this “infantile personality” shows a “borderline” range of functioning. Significant articles by Zetzel,‘” Chodoff and LyonsI and others have discussed the spectrum of this character style, along with the social, cultural, and interpersonal reinforcements of this particular type of behavior. THE OBSESSIVE
SPECTRUM:
CASE REPORTS
The obsessive-compulsive character has been seen comparatively unidimensionally. It is our belief that obsessive-compulsive psychopathology can also present itself at many loci along a relative healthsickness continuum ranging from the normal or near-normal to the schizophrenic, and that effective classification must go beyond descriptive terminology to include a spectrum of capacities within this character diagnosis. Obsessive-compulsive disorders must be differentiated in terms of overall psychosocial adaptation, including the development or arrest of multiple functions. We suggest that clarifying the diverse group ranging from the prepsychotic regressed individuals to the more differentiated obsessives would be helpful in organizing clinical observations of the obsessive character. The following cases represent such a spectrum of function and impairment.
Dr. R. L. was a 35-year-old, married, successful cardiologist from a middle-class family who sought treatment for moderate depression of 4 months’ duration; prominent also in his presenting picture were frequent migraine headaches and anxiety. The patient had spent much time brooding about his marriage and his job: he was resentful and frustrated although he had applied himself methodically and diligently but without spontaneity or inspiration to both. He complained of lack of enjoyment in his life and felt, in general, that he had missed the right approach in his pursuit of contentment. He was eager to discover a better method or strategy to find happiness, and he promised the therapist the same kind of diligence in striving for personal insight as he had shown in his work. The patient was serious and ruminative; his speech was precise and his words were carefully chosen. His dress and grooming were stylish and controlled. Outside the area of discomfort, his life showed stability and accomplishment. He had deep, stable relationships with friends and siblings, with whom he corresponded regularly. He was capable of a variety of emotional responses, including realistic feelings of guilt, mourning, and periods of pleasure through relaxation. His history revealed no evidence of gross familial disruption, no perverse sexuality, bizarre fantasies, or preoccupations, addictions, or polyneurotic symptomatology. His capacity for anxiety tolerance and delay of gratification was strong. There were no suggestions of a formal thought disorder. As psychotherapy proceeded, the patient revealed a well-constructed shield of intellectualization, affective isolation, and crisp rationality in areas of personal conflict, namely the areas surrounding his own dependency longings. He was, however, capable of reflectively pursuing his fears of dependency and his resultant intellectualized, competitive attitude, and he worked toward insight through carefully examining his disturbed relationship with his parents in the area of warmth and emotionality. He was
OBSESSIVE
75
CHARACTER
also capable of examining his distorted, ambivalent attitude toward the therapist within the framework of the professional interaction, feeling an ally in his therapist. His capacity to maintain critical attitudes toward his own behavior permitted the development of an expressive form of intensive psychotherapy. He was regarded as an obsessive-compulsive personality functioning within a high level of character integration.
Miss K. B., a 58-year-old, single bookkeeper, was referred for treatment because of progressively deepening depression of 2 months’ duration, during which time she had withdrawn interest in her relatives and in ail activities outside of her job. After the inst~liation of new data processing equipment in her office, she had begun exhibiting out-of-character behavior, including outbursts of pro~nity toward her sisters. She worried excessively about the handling of financial matters in the office and was bitter and negative about her fife in general. Her withdrawal and pessimism lifted considerably within a supportive, outpatient treatment modality that included antidepressant medication. In discussing her earlier adjustment patterns, she revealed a lifelong history of timidity and excessive concern over offending others, She had had a poverty of warm, mutually-gratifying relationships with men, although she related pleasantly yet dependently with women and immediate family. Chronic feelings of inadequacy in comparison to her younger sister, who had received preferential treatment by her parents, contributed to the development of patterns of reaction formation that barely masked an intense stubborness and guilt-laden hostility. As her feelings of depression lifted, hostile impulses were repressed and the patient appeared more relaxed and quietly strengthened. However, her self-consciousness, worrisome frugality. and need for regimentation remained unchanged, and a childish, fragile needfulness toward the therapist precluded the development of an insight-oriented mode of therapy. She was quite comfortable in reestablishing her previous coping style, however limited and constricted, within the support of a benevolent family network. She was regarded as an obsessive-compulsive personality functioning at an intermediate level ofcharacter integration.
Gas e 3 Mr. R.W., a 28-year-old. single, part-time sociology teacher, was seen in the outpatient clinic. His chief complaint was lack of progress on his doctoral dissertation which had been pending for 2 years, due to distraction, difficulty in concentrating, and anxiety about formulating his topics. He was teaching in a community college in a large metropolitan area and drove a taxicab at other times to supplement his income. He had lived at home until 3 years previously, when he left home abruptly, cutting himself off from his parents after a tumultuous quarrel with his father. Depressive moods were frequent, characterized by brooding, self-deprecatory accusations, withdrawal, and thoughts of throwing himself onto the subway tracks. Obsessive manifestations. including ruminative intellectualized thinking without affective ~om~nents. often increased during such periods. At times of frustration. a sadistic outburst would erupt to relieve tension. in one such moment he deliberately strangled his pet cat. an action that was bizarre and frightening to him. However, he expressed no remorse for it, saying only that he was afraid of its social consequences should other people find out. His social relationships were fleeting and characterized by ambivalence, angry outbursts. emotional shallowness, and preoccupation with himself, seldom recognizing other people’s needs. When interviewed he was tendentious. engaging the interviewer in a struggle for control. There was a quality ot suspiciousness that marked this and other relationships; he kept a careful distance between himself and other persons. This patient showed a marginal functional adjustment and an obsessive character style that served as a bulwark against the potential breakthrough of massive rage. In moments of regressron, he exhibited a tendency toward sadistic actions without any organized psychotic processes such as delusions. At other times he functioned in a superficially adaptive way. He was considered an obsessivecompulsive personality functioning within a low (~rderline) level of character integration. DISCUSSION
The unifying pattern in these disparate individuals is a common cognitive and connotes. inflexibility, ritual, ambivaemotional style that the term “obsessive” lence, and characteristic mechanisms of isolation, undoing, reaction formation.
CORNFIELO
76
AND
MALEN
etc., have been attributed to this style. *4.15 That the obsessive style of behavior can be characterized by its formal properties is significant for a descriptive psychologic model. Shapiro’” has discussed with clarity this mode of functioning, avoiding psychodynamic etiologic issues: a continuous rigid state of deliberate activity or tension . and an intense, sharp focus (of attention, such that) they seem always to be concentrating. . . and unable to allow their attention simply to wander or passively permit it to be captured. Thus, they rarely seem to get hunches, and they are rarely struck or surprised by anything. Their state of tense deliberateness . . . automatically restricts affect experience, also whim, playfulness, and spontaneous action in general . ..And no amount of hard work, driven activity, or willpower will help in the slightest degree to make a decision. To a person driven by a sense of pressure and guided by moral directives . . . the act of decision, which by its nature pivots around wants and normally brings with it a senseof freedom and free choice, can only be extremely discomforting.
It is the broad, intermediate range of functioning between generally healthy integrated obsessives and borderline marginal ones that presents diagnostic difficulty. If one surveys this range of obsessives as our case examples illustrate, the “pure type” represent the high end of a spectrum of ego capacities. Obsessive persons greatly impaired and restricted in their emotional lives, often showing strong schizoid or paranoid trends, are in the lower level of character pathology. Diagnostically, they are usually included under the rubric of “obsessional neurosis,” “ schizoid personality, ” “paranoid personaIity,” or “latent Similar to the “hysteroid,” the term “obsessionoid” would not be inappropriate for these persons. On an adaptive scale, they occupy a place where obsessive traits are seen in conjunction with primitive mechanisms and defenses. The association of obsessive defenses with borderline ego functioning was observed by Knight” in his pioneering article on borderline states. In a contemporary contribution, GoldbergI described case and treatment histories of patients with mixed paranoid and obsessive defenses existing in long-term equilibrium. With the evolution of the concept of borderline syndromes, Kernberg” described a sadistic character type functioning at the primitive level. In keeping with his view of the borderline state, mechanisms of splitting, primitive idealization of objects, and serious aggressive manifestations would be evident. Kernberg emphasized the level of integration of the superego as an indicator of the extent of character pathology. The better-functioning persons maintain healthy mechanisms of conscience and guilt, which do not intrude excessively or are not lacking. Similarly, he noted the capacity for tolerance of anxiety or depression without ego disorganization as a differentiation of the extent of pathology. In prepsychotic individuals, as Stengel’” observed, obsessive preoccupation is exaggerated during the course of decompensation. BychowskP has shown that the emergence of obsessive rituals during a psychotic process represents an attempt at adaptation and restoration. However, these psychotic obsessives can be treated with the usual means, regardless of the form of their cognitive trend. Psychotic patients are disabled by their primary symptoms more than by the particular obsessive style of their functioning. DIAGNOSTIC
CONSIDERATIONS
Two questions seem crucial in diagnostic or classificatory labeling of distorted character functioning: (1) What is the style of mode of behavior in observable, sta-
OBSESSIVE
77
CHARACTER
ble, regularly occurring traits characteristic of that individual? (2) How severe are the impairments in functioning? The first question addresses formal aspects of observable functioning and presently constitutes the basis of our diagnostic schema. However, a truly inclusive assessment of psychopathology must answer the second question as well, and therein ties the advantage of a multidimensional approach. To exemplify such an approach in evaluating dysfunction in the obsessive character type, attention could be directed toward the following four variables.
This category includes the degree of freedom from primitive or self-destructive impulses or tendencies; the capacity to deal effectively with a variety of emotions; the maturity of personality factors and adoptive mechanisms available to tolerate stress, such as the capacity to delay grat~~cation, to cope with anxiety, and to adjust to loss. Depending upon one’s theoretical persuasion, there will be different ways of approaching this assessment of the balance and harmony of personality.
Does the individual have the abibty to enter into and sustain relationships with people’? Are his relations complicated by the presence of excessive hostiIity, immature wishes, and conflicts? Or is he capable of forming a reciprocal, mutuallygratifying bond with another individuaI? Social- Vocational
Productivit?’
This addresses the patient’s ability to be productive in a social and vocational context; what is the individual’s history of satisfactions and achievements, scholastically and vocationally? What is his capacity for creative endeavors‘! Can he sustain his achievements or is he threatened by success?
This category includes an assessment of the extent of developmental traumata as well as gratifications that were age-appropriate. Here would be included, for example, severe trauma such as loss of a parent at an early age, disabling physical iitness, etc. or signintant areas of mastery Ieading to the deveiopment of setfesteem. CONCLUSIONS
These four categories are a suggested initial approach to the multidimensional evaluation of obsessive as well as other character pathology. The assessment of dysfunction in individuals with personality disorders can be somewhat more subtle than the evaluation of psychotic states, due to a relative lack of symptomatolo~y and precipitating stress factors, and to the absence of an overtly abnormal mental process. The task of clinicaf evafuation is a broad one and must, of necessity, include all important data related to an ind~vidual’s psychosocial functioning. The multivariate approach to diagnosis, emphasizing significant evaluative criteria, can allow for meaning in the classificatory system. And such a broad-based assessment of the level of personality organization can also bring clarit! to the complicated tasks of prognosis and effective treatment planning.
78
CORNFIELD
AND MALEN
REFERENCES I. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (ed 2). Washington, D.C. American Psychiatric Association, 1968 2. Strauss JS: A comprehensive approach to psychiatric diagnosis. Am J Psychiatry 132:1193~1197, 1975 3. Bachrach H: Diagnosis as strategic understanding. Bull Menninger Clin 38:390-405, 1974 4. Essen-Moller E: On classification of mental disorders. Acta Psychiatr Scan 37:119-126, 1961 5. World Health Organization: Report of the seventh WHO seminar on Standardization of Psychiatric Diagnosis, Classification and Statistics of Personality Disorders and Drug Dependence. Geneva, WHO, 1971 6. Lazare A. The hysterical character in psychoanalytic theory. Arch Gen Psychiatry 25:131-137, 1971 7. Freud S: Libidinal types, in Collected Papers, vol 5. London, Hogarth Press, 1950, pp 247725 1 8. Wittels F: The hysterical Rev Rev 36:186-190, 1930
character.
Med
9. Marmor J: Orality in the hysterical personality. J Am Psychoanal Assoc 1:656-67 I, 1953 10. Easser
BR,
Lesser
SR:
Hysterical
per-
sonality: A reevaluation. Psychoanal Q 34:390-405, 1965 1 I. Kernberg 0: Borderline Conditions and Pathological Narcissism. New York, Jason Aronson, 1975 12. Zetzel E: The so-called good hysteric. Int J Psychoanal 49:256-260, 1968 13. ChodolT P, Lyons H: Hysteria, the hysterical personality and hysterical conversion. Am J Psychiatry I14:734-740, 1958 14. Salzman L: The Obsessive Personality. New York, Science House, 1968 15. Nemiah J: Obsessive-compulsive reaction, in Freedman AM, Kaplan HI (eds): Comprehensive Textbook of Psychiatry. Baltimore, Williams & Wilkins, 1967 16. Shapiro D: Neurotic Styles. New York, Basic Books, 1965 17. Knight RP: Borderline states. Bull Menninger Clin 17:l- 12, 1953 18. Goldberg GJ: Obsessional paranoid syndromes. Psychiatr Q 39:43-56, 1965 19. Stengel E: A Study on some clinical aspects of the relationship between obsessional neuroses and psychotic reaction types. J Ment Sci 91:84-103, 1945 20. Bychowski G: Obsessive-compulsive facade in schizophrenia. Int J Psychoanal 47:189--197, 1966
View of the Obsessive Character
Richard 6. Cornfield and Richard L. Malen
C
URRENTLY, our diagnostic classifications are based primarily in descriptive and phenomenologic criteria.’ A problem arises in our reliance on this method of classification; it does not differentiate varying levels of pathology in nonpsychotic patients showing similar personality style. A case in point is the difficulty in understanding the extent of dysfunction when the label “obsessivecompulsive” is applied. This diagnosis may include individuals of vastly differing capacities for psychosocial adaptation. Precision requires an attempt at further organization and di~erentiation. The need for a more effective diagnostic system in psychiatry is a major impetus behind the present work on DSM-III. Lately, Strauss’has argued the benefits of a comprehensive, multivariable approach to diagnosis compared to the current “typologic” approaches, which focus on symptoms and require additional complementary, broad categories of little descriptive value. He claims that a multivariable system employing such components as symptoms, previous duration and course, personal relationships, and work function “could result in a broader and sharper understanding of the crucial aspects of psychiatric disorder and treatment.” Bachrach” has stated the need for diagnostic precision based on such factors as “dispositional” and “conditional” aspects of behavior. Among other suggestions for a broad-based approach have been the recommendations of EssenMoller4 and the World Health Organization.~ INVESTIGATIONS
ON THE HYSTERICAL
CHARACTER
Curiously, in the last twenty years, the hysterical character has received more careful scrutiny than the obsessive. The multidimensional assessment that has been derived may be equally valuable in clarifying: the extent of obsessive character disorder, the variable prognoses based on degrees of pathology, and different approaches to treatment based on such understanding. Perhaps the perennial interest in hysteria has emotional roots emerging from the earliest modern-day, in-depth studies of mental and emotional disorders. A number of authors have suggested that within this character type, a wellfunctioning group can be distinguished from a dependent, emotionally immature group. as discussed in a review by Lazare.” Among them, Freud,; Wittels,’ and Marmor” have argued that the hysterical character appeared deeply rooted in primitive, oral levels of development; however, this view failed to account for individuals with hysterical phenotype who showed healthy overall functioning outside From the Departments of Psychiatry. Mount Sinai School 01 Medicine, the Bronx Veterans Administration Hospital. and St. Vincent’s Hospiial and Medical Center. Richard B. Cornfield, M.D.: .4ssociate in Psychiarr!, Mount SinaiSchool of Medicine. and Chief’of Psychiatry. Bronx Veterans Administration Hospital; Richard L. Malen, M.D.: Clinical instructor in P.ychiatry, Mount Sinai School of Medicine, and Assirtant in P.ychiatrv, St. Vincent’s Hospital and Medical Center. Address reprint requests to Richard B. Cornfield, M.D., Chi# of P~~~h~atr~, Bronx Veterans .~dmin~.~tration Hospital. Room A-223, 130 West ~in~,~~r~d~eRoad, Brony. N. Y. 10468. c: 197X hv Grune & Stratton. Inc. ~SS~~~~~l~~44~.~.0010 440X/l~~lf9Of~000HSOI,a(~J(r Comprehensive Psychiarry, Vol. 19. No. 1 lJanuary/February).
1978
.73
74
CORNFIELD
AND
MALEN
the area of conflict. Contemporary authors such as Easser and Lesser’” saw the hysterical personality along a continuum of character pathology; they defined the “hysteric” as a specific clinical entity with conflicts at a more mature developmental stage, whose lifelong functioning was generally much healthier in the areas of relationships, stability of personality and defenses, and capacity for adaptation. “Hysteroid,” on the other hand, was the label they applied to a person who, while also appearing labile, seductive, overexcitable, imprecise, and childish, evidenced strong primitive orality trends. They claimed that in the “hysteroid,” adaptive, vocational, and academic patterns were extremely erratic and highly dysfunctional; that relationships showed an engulfing, devouring quality with pseudoerotic sexual excesses and acting-out as a frequent defensive maneuver. Kernberg” also acknowledged the spectrum of such disorders through a structural, genetic, symptomatic, and dynamic comparison, differentiating the healthy hysteric, as described by Easser and Lesser, from the “infantile personality” with an abundance of primitive traits and character mechanisms; this “infantile personality” shows a “borderline” range of functioning. Significant articles by Zetzel,‘” Chodoff and LyonsI and others have discussed the spectrum of this character style, along with the social, cultural, and interpersonal reinforcements of this particular type of behavior. THE OBSESSIVE
SPECTRUM:
CASE REPORTS
The obsessive-compulsive character has been seen comparatively unidimensionally. It is our belief that obsessive-compulsive psychopathology can also present itself at many loci along a relative healthsickness continuum ranging from the normal or near-normal to the schizophrenic, and that effective classification must go beyond descriptive terminology to include a spectrum of capacities within this character diagnosis. Obsessive-compulsive disorders must be differentiated in terms of overall psychosocial adaptation, including the development or arrest of multiple functions. We suggest that clarifying the diverse group ranging from the prepsychotic regressed individuals to the more differentiated obsessives would be helpful in organizing clinical observations of the obsessive character. The following cases represent such a spectrum of function and impairment.
Dr. R. L. was a 35-year-old, married, successful cardiologist from a middle-class family who sought treatment for moderate depression of 4 months’ duration; prominent also in his presenting picture were frequent migraine headaches and anxiety. The patient had spent much time brooding about his marriage and his job: he was resentful and frustrated although he had applied himself methodically and diligently but without spontaneity or inspiration to both. He complained of lack of enjoyment in his life and felt, in general, that he had missed the right approach in his pursuit of contentment. He was eager to discover a better method or strategy to find happiness, and he promised the therapist the same kind of diligence in striving for personal insight as he had shown in his work. The patient was serious and ruminative; his speech was precise and his words were carefully chosen. His dress and grooming were stylish and controlled. Outside the area of discomfort, his life showed stability and accomplishment. He had deep, stable relationships with friends and siblings, with whom he corresponded regularly. He was capable of a variety of emotional responses, including realistic feelings of guilt, mourning, and periods of pleasure through relaxation. His history revealed no evidence of gross familial disruption, no perverse sexuality, bizarre fantasies, or preoccupations, addictions, or polyneurotic symptomatology. His capacity for anxiety tolerance and delay of gratification was strong. There were no suggestions of a formal thought disorder. As psychotherapy proceeded, the patient revealed a well-constructed shield of intellectualization, affective isolation, and crisp rationality in areas of personal conflict, namely the areas surrounding his own dependency longings. He was, however, capable of reflectively pursuing his fears of dependency and his resultant intellectualized, competitive attitude, and he worked toward insight through carefully examining his disturbed relationship with his parents in the area of warmth and emotionality. He was
OBSESSIVE
75
CHARACTER
also capable of examining his distorted, ambivalent attitude toward the therapist within the framework of the professional interaction, feeling an ally in his therapist. His capacity to maintain critical attitudes toward his own behavior permitted the development of an expressive form of intensive psychotherapy. He was regarded as an obsessive-compulsive personality functioning within a high level of character integration.
Miss K. B., a 58-year-old, single bookkeeper, was referred for treatment because of progressively deepening depression of 2 months’ duration, during which time she had withdrawn interest in her relatives and in ail activities outside of her job. After the inst~liation of new data processing equipment in her office, she had begun exhibiting out-of-character behavior, including outbursts of pro~nity toward her sisters. She worried excessively about the handling of financial matters in the office and was bitter and negative about her fife in general. Her withdrawal and pessimism lifted considerably within a supportive, outpatient treatment modality that included antidepressant medication. In discussing her earlier adjustment patterns, she revealed a lifelong history of timidity and excessive concern over offending others, She had had a poverty of warm, mutually-gratifying relationships with men, although she related pleasantly yet dependently with women and immediate family. Chronic feelings of inadequacy in comparison to her younger sister, who had received preferential treatment by her parents, contributed to the development of patterns of reaction formation that barely masked an intense stubborness and guilt-laden hostility. As her feelings of depression lifted, hostile impulses were repressed and the patient appeared more relaxed and quietly strengthened. However, her self-consciousness, worrisome frugality. and need for regimentation remained unchanged, and a childish, fragile needfulness toward the therapist precluded the development of an insight-oriented mode of therapy. She was quite comfortable in reestablishing her previous coping style, however limited and constricted, within the support of a benevolent family network. She was regarded as an obsessive-compulsive personality functioning at an intermediate level ofcharacter integration.
Gas e 3 Mr. R.W., a 28-year-old. single, part-time sociology teacher, was seen in the outpatient clinic. His chief complaint was lack of progress on his doctoral dissertation which had been pending for 2 years, due to distraction, difficulty in concentrating, and anxiety about formulating his topics. He was teaching in a community college in a large metropolitan area and drove a taxicab at other times to supplement his income. He had lived at home until 3 years previously, when he left home abruptly, cutting himself off from his parents after a tumultuous quarrel with his father. Depressive moods were frequent, characterized by brooding, self-deprecatory accusations, withdrawal, and thoughts of throwing himself onto the subway tracks. Obsessive manifestations. including ruminative intellectualized thinking without affective ~om~nents. often increased during such periods. At times of frustration. a sadistic outburst would erupt to relieve tension. in one such moment he deliberately strangled his pet cat. an action that was bizarre and frightening to him. However, he expressed no remorse for it, saying only that he was afraid of its social consequences should other people find out. His social relationships were fleeting and characterized by ambivalence, angry outbursts. emotional shallowness, and preoccupation with himself, seldom recognizing other people’s needs. When interviewed he was tendentious. engaging the interviewer in a struggle for control. There was a quality ot suspiciousness that marked this and other relationships; he kept a careful distance between himself and other persons. This patient showed a marginal functional adjustment and an obsessive character style that served as a bulwark against the potential breakthrough of massive rage. In moments of regressron, he exhibited a tendency toward sadistic actions without any organized psychotic processes such as delusions. At other times he functioned in a superficially adaptive way. He was considered an obsessivecompulsive personality functioning within a low (~rderline) level of character integration. DISCUSSION
The unifying pattern in these disparate individuals is a common cognitive and connotes. inflexibility, ritual, ambivaemotional style that the term “obsessive” lence, and characteristic mechanisms of isolation, undoing, reaction formation.
CORNFIELO
76
AND
MALEN
etc., have been attributed to this style. *4.15 That the obsessive style of behavior can be characterized by its formal properties is significant for a descriptive psychologic model. Shapiro’” has discussed with clarity this mode of functioning, avoiding psychodynamic etiologic issues: a continuous rigid state of deliberate activity or tension . and an intense, sharp focus (of attention, such that) they seem always to be concentrating. . . and unable to allow their attention simply to wander or passively permit it to be captured. Thus, they rarely seem to get hunches, and they are rarely struck or surprised by anything. Their state of tense deliberateness . . . automatically restricts affect experience, also whim, playfulness, and spontaneous action in general . ..And no amount of hard work, driven activity, or willpower will help in the slightest degree to make a decision. To a person driven by a sense of pressure and guided by moral directives . . . the act of decision, which by its nature pivots around wants and normally brings with it a senseof freedom and free choice, can only be extremely discomforting.
It is the broad, intermediate range of functioning between generally healthy integrated obsessives and borderline marginal ones that presents diagnostic difficulty. If one surveys this range of obsessives as our case examples illustrate, the “pure type” represent the high end of a spectrum of ego capacities. Obsessive persons greatly impaired and restricted in their emotional lives, often showing strong schizoid or paranoid trends, are in the lower level of character pathology. Diagnostically, they are usually included under the rubric of “obsessional neurosis,” “ schizoid personality, ” “paranoid personaIity,” or “latent Similar to the “hysteroid,” the term “obsessionoid” would not be inappropriate for these persons. On an adaptive scale, they occupy a place where obsessive traits are seen in conjunction with primitive mechanisms and defenses. The association of obsessive defenses with borderline ego functioning was observed by Knight” in his pioneering article on borderline states. In a contemporary contribution, GoldbergI described case and treatment histories of patients with mixed paranoid and obsessive defenses existing in long-term equilibrium. With the evolution of the concept of borderline syndromes, Kernberg” described a sadistic character type functioning at the primitive level. In keeping with his view of the borderline state, mechanisms of splitting, primitive idealization of objects, and serious aggressive manifestations would be evident. Kernberg emphasized the level of integration of the superego as an indicator of the extent of character pathology. The better-functioning persons maintain healthy mechanisms of conscience and guilt, which do not intrude excessively or are not lacking. Similarly, he noted the capacity for tolerance of anxiety or depression without ego disorganization as a differentiation of the extent of pathology. In prepsychotic individuals, as Stengel’” observed, obsessive preoccupation is exaggerated during the course of decompensation. BychowskP has shown that the emergence of obsessive rituals during a psychotic process represents an attempt at adaptation and restoration. However, these psychotic obsessives can be treated with the usual means, regardless of the form of their cognitive trend. Psychotic patients are disabled by their primary symptoms more than by the particular obsessive style of their functioning. DIAGNOSTIC
CONSIDERATIONS
Two questions seem crucial in diagnostic or classificatory labeling of distorted character functioning: (1) What is the style of mode of behavior in observable, sta-
OBSESSIVE
77
CHARACTER
ble, regularly occurring traits characteristic of that individual? (2) How severe are the impairments in functioning? The first question addresses formal aspects of observable functioning and presently constitutes the basis of our diagnostic schema. However, a truly inclusive assessment of psychopathology must answer the second question as well, and therein ties the advantage of a multidimensional approach. To exemplify such an approach in evaluating dysfunction in the obsessive character type, attention could be directed toward the following four variables.
This category includes the degree of freedom from primitive or self-destructive impulses or tendencies; the capacity to deal effectively with a variety of emotions; the maturity of personality factors and adoptive mechanisms available to tolerate stress, such as the capacity to delay grat~~cation, to cope with anxiety, and to adjust to loss. Depending upon one’s theoretical persuasion, there will be different ways of approaching this assessment of the balance and harmony of personality.
Does the individual have the abibty to enter into and sustain relationships with people’? Are his relations complicated by the presence of excessive hostiIity, immature wishes, and conflicts? Or is he capable of forming a reciprocal, mutuallygratifying bond with another individuaI? Social- Vocational
Productivit?’
This addresses the patient’s ability to be productive in a social and vocational context; what is the individual’s history of satisfactions and achievements, scholastically and vocationally? What is his capacity for creative endeavors‘! Can he sustain his achievements or is he threatened by success?
This category includes an assessment of the extent of developmental traumata as well as gratifications that were age-appropriate. Here would be included, for example, severe trauma such as loss of a parent at an early age, disabling physical iitness, etc. or signintant areas of mastery Ieading to the deveiopment of setfesteem. CONCLUSIONS
These four categories are a suggested initial approach to the multidimensional evaluation of obsessive as well as other character pathology. The assessment of dysfunction in individuals with personality disorders can be somewhat more subtle than the evaluation of psychotic states, due to a relative lack of symptomatolo~y and precipitating stress factors, and to the absence of an overtly abnormal mental process. The task of clinicaf evafuation is a broad one and must, of necessity, include all important data related to an ind~vidual’s psychosocial functioning. The multivariate approach to diagnosis, emphasizing significant evaluative criteria, can allow for meaning in the classificatory system. And such a broad-based assessment of the level of personality organization can also bring clarit! to the complicated tasks of prognosis and effective treatment planning.
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