THE AMERICAN JOURNAL OF PSYCHOANALYSIS 3,7:309-315 (1977)
DIFFERENTIAL DIAGNOSTIC CONSIDERATIONS IN NEUROSIS AND CHARACTER DISORDER Frank Miller
The diagnosis and treatment of the characterologically disturbed patient is often complicated by the appearance of classical symptoms of neurosis. The appearance of neurotic symptoms, however, does not necessarily signify that there has been a movement, in the characterologically disturbed patient, toward neurosis. Anxiety, depression, and phobia, for example, may appear in the absence of neurosis and are readily discerned in the psychoses, the perversions, and the borderline states as well as in the character disorders. The following clinical material is taken from a case in which classical symptoms of neurosis were prominent. The elucidation of these symptoms however resulted in diagnostic and pgychotherapeutic considerations relating to the differential diagnosis and treatment of the characterologically disturbed patient. Mrs. K was a 40-year-old married mother of one. She was attractive despite her dyed hair, seductive manner, and excessive use of makeup. She arrived at the first interview with the chief complaint that on nearly every morning for the past two weeks she had experienced an overwhelming "sense of doom" which was associated with palpitations, shortness of breath and feeling faint. The episodes would last several minutes and then spontaneously subside. The episodes were 1Lerrifying, and the most recent episode was completely overwhelming. In the beginning of psychotherapy, Mrs. K compared her symptoms of distress with her mother's symptoms prior to her death several weeks before the first interview. The mother, who had been chronically ill, often described to her daughter her symptoms of faintness, palpitations, and shortness of breath. On the evening she died these symptoms were prominent. Though Mrs. K recognized that her mother's symptoms and her attacks shared a number of features, neither the frequency nor the severity of her attacks had been affected. Mrs. K stated that her lack of medical training and nursing expertise had shortened her mother's life. She argued that her recognition of these deficiencies had produced in her profound guilt and personal misgivings. Many months in psychotherapy passed before Mrs. K acknowledged that the night her mother died she and her mother had a violent argument concerning the mother's planned, eventual distribution of her property. As Mrs. K became increasingly comfortable discussing her mother's death, she Frank Miller is in the Department of Psychiatry, Cleveland Metropolitan General Hospital, Cleveland, Ohio. 309
310
FRANK MILLER
began to experience and express, though not consciously admit to, feelings of rage and anger toward her mother. She produced material indicating that she had not wanted her mother to live with her. In fact her mother's illness frightened her. She had been warned by a sister that the mother vomited frequently, kept odd hours, often lost control of her bladder, and moaned continually during the night. Feeling unequal to the task of nursing her mother, and loathing the nature of the illness, Mrs. K turned to her husband for help and support. Mrs. K had been unhappily married for 13 years. She described her husband as jealous, demanding, aloof, uncaring, and unloving. She believed that he was dishonest in business; that he drank too much and talked too much; that he had underworld connections; that he gambled excessively; and that he required the services of prostitutes. Thus, she was surprised and relieved when he agreed to help her care for her mother. Within a few weeks Mrs. K's husband was intimately involved with the care of her mother. He acquired nursing skills and he fed and bathed her routinely. On days when she was not bedridden he took her on his salesman's rounds. Although initially pleased by her husband's interest, Mrs. K became increasingly dissatisfied with his nursing role. She began to suffer from insomnia. Her weight fluctuated and her appetite was erratic. She desired to "punish" her husband, who seemed to ignore her now more than ever. She was very unhappy, lost interest in work, and lost interest in maintaining her appearance. To her surprise, and for the first time in their marriage, her husband was warm and affectionate. He nursed her as he had nursed her mother; but when her spirits brightened, he lost interest. When her symptoms returned so did his interest and attention. Once again she improved and once again he lost interest. When her symptoms appeared a third time, however, he did not respond. He had become increasingly frustrated with her. On one occasion he told her that she was out of her mind. With this, Mrs. K stopped going to work. She became fearful that she might lose control of her automobile and would "kill a pedestrian." She demanded that her husband buy a citizen's band radio and have it installed in his car and at her bedside so she could contact him if and when she experienced an anxiety attack. At times they would have bitter, abusive, and degrading arguments while using the citizen's band radio. She would demand that he come home at once while he would retort that he had to stay on the road in order to make a living. Her attacks became more frequent and disturbing. He became less sympathetic and finally disconnected the citizen's band radio. During this period she watched a television program in which hypoglycemia was described and discussed and she became convinced that her attacks were hypoglycemic episodes. She demanded that her husband buy special foods which she had determined were good for her. The crisis came when he informed her that he would be away for several days on business. He communicated this fact to her with some degree of pleasure. Before he could leave, however, she suffered a severe anxiety attack. An emergency psychiatric consultation was sought and an interview was arranged.
NEUROSIS AND CHARACTER DISORDER
311
At the interview, Mrs. K was perplexed and frightened by her symptoms of palpitation, shortness of breath, dizziness, and panic. She did not associate her symptoms with any ongoing environmental stress. On the contrary, she related her symptoms to her mother's death. She talked, at great length, about her lack of nursing skills and the guilt that this had generated, and she talked about her loss of a loved parent. During the first interview, Mrs. K denied ever having seen a psychiatrist or experiencing periods of significant psychological distress. However, during the ninth session of psychotherapy, Mrs. K referred to a psychiatric hospitalization which had occurred 14 years prior to the onset of her recent disorder. When asked if she remembered being questioned about a history of a past psychiatric hospitalization, she responded that the hospitalization had happened so long ago that it had not come to mind when originally questioned. She stated as well that since the question was never repeated it probably was not significant. Exploration of the issue revealed that Mrs. K had been hospitalized on the day she received from her first husband a final decree of divorce. Although she had sought the divorce, she had withdrawn her suit when her husband threatened to prove she was an adultress. She denied unfaithfulness, but stated that she was so mortified by the prospect of scandal that she had let her husband file for divorce. Shortly after receiving the document she experienced an episode of confusion and disorganization which lasted approximately four hours and was characterized by intense dysphoric affect and histrionic display. She received an injection of a phenothiazine at the time of admission, was hospitalized two days, and then discharged without follow-up. She immediately returned to work and was without sequela. Following the revelation of her past psychiatric hospitalization, Mrs. K began to acknowledge and describe numerous prolonged periods in her life during which she was intensely unhappy, dissatisfied, and anxious. The periods of discontent tended to overlap with one another and a picture emerged of a lifelong pattern of disappointment and dysphoria, of feeling cheated, short-changed, manipulated, and unloved. She stated that everyone had failed her. She mocked her husband and described her father as an alcoholic and a ne'er-do-well. She admitted to hating her mother-in-law and was not on speaking terms with neighbors or friiends. She had alienated co-workers with her complaints and demands. Her son, struggling with financial burdens, and a generally chaotic life style, was emotionally unavailable to her. In short, she was friendless and with little capacity for independent existence. Following an initial period of history-taking, reassurance, and the use of a tricyclic antidepressant, Mrs. K no longer experienced episodes of panic. However, she remained fearful and apprehensive that at any time she might be overwhelmed by her anxieties and rendered helpless. She remained convinced that the attacks were hypoglycemic even though appropriate laboratory examinations were within normal limits. At every opportunity she blamed her husband for the ills that had befallen them. During the sixth month of psychotherapy, Mrs. K"s attitude and demeanor changed. She revealed that she had been having an affair with a
312
FRANK MILLER
consultant at her place of employment. In explanation, she stated that her husband had driven her to it and that she was blameless. She did not conceptualize her act as infidelity, rather as a manifestation of her need to be loved. During this period, Mrs. K experienced no conscious guilt and her symptoms of depression, anxiety, and phobia disappeared. When the relationship ended several months after it began, her symptoms reappeared. In psychotherapy she returned to earlier themes such as her mother's death, her father's alcoholism and her husband's inadequacy. Anxiety, depression, and phobia are classical neurotic symptoms and their presence indicates that a conflict exists in which the ego participates. However, the presence of neurotic symptoms in conditions other than neurosis is generally acknowledged. The clinician frequently encounters patients, such as Mrs. K, who present with classical neurotic symptoms; but who do not suffer from a neurosis. The clinical ability to distinguish the neurotic from the character disorder when classical neurotic symptoms are present is invaluable; for not only the diagnosis, but the treatment, and often the outcome, may depend on th is distinction. There are two ways to proceed~first through a general analysis of the personality, and second through a specific analysis of the "neurotic" symptoms. The patient suffering from a neurosis often presents with a distinctive constellation of signs and symptoms. He tends to respond to his symptoms with displeasure and resignation. His reasons for requesting psychiatric consultation relate directly to his symptoms, which have either recently appeared or recently intensified. He tends to seek consultation spontaneously and, in general, has not been coerced by others. He views much of the behavior he associates with his symptoms as unacceptable and deviant. Prior to seeking consultation he has attempted to master his symptoms by specific methods which he is able to enumerate. In therapy he demonstrates a significant capacity to tolerate unpleasant affect. Often he is ashamed of not being able to control his emotions, which at times are painfully intense and unremitting. He is motivated for character change, tends to value insight, and, more importantly, makes use of it. The characterologically disturbed individual presents a different picture even when his symptoms superficially resemble those encountered in the neuroses. The presenting symptom of anxiety, for instance, may be described by the patient as overwhelming. However, little in his demeanor suggests the level of intense anxiety he describes. The anxiety that is experienced is poorly tolerated and the patient demands relief. When immediate relief is unavailable or delayed, he responds with anger and hostility. When psychiatric attention is sought it is often at the insistence of others who are concerned more with the patient's behavior than with his subjectively experienced discomfort. Once in psychotherapy, the patient is not motivated for characterologic change; for he does not believe that he is in any way responsible for his distress. He views psychotherapy as a mechanism with which he can manipulate an ungiving environment. He does not value insight and finds every attempt on the part of the psychotherapist to redirect responsibility or elucidate cause and effect intolerable. Although he may initially state that his problems are of
NEUROSIS AND CHARACTER DISORDER
313
recent origin, careful anamnesis reveals a lifelong history of disordered interpersonal relations, impulsiveness, and self-defeating behavior. The case of Mrs. K points out that a borderline exists between the neuroses and the character disorders in which easy distinctions cannot be made. Although an examination of manifest behavior is an essential step in making the diagnosis, mistakes will be made if other areas of investigation are ignored. The characterologically disturbed patient demonstrates profound distortions in the synthesizing functions of the ego. Defective object relations and unstable identifications are evident, and oedipal issues are few in number and lack significance. Intolerance of affects and inadequate impulse control are discernable. Finally, superego lacunae are evident and prove to be disruptive to all aspects of daily living. A review of Mrs. K's history reveals these findings. Superego lacunae were demonstrated specifically by the ease with which she entered into an extramarital relationship, by her purchasing furniture and clothes on credit the day she filed for bankruptcy, and by her hiring of a private investigator, at great expense, even though she acknowledged in therapy that she would never pay him for his services. In general, superego lacunae were demonstrated by her lack of empathy and by her extreme self-involvement and infatuation. Although oedipal issues dominated the early course of psychotherapy, they never proved to be significant. Pregenital aims, on the other hand, were central, and, accordingly, conflict arose around issues of feeding, clothing, shelter, and protection. Mrs. K was driven by impulses derived from exhibitionistic, sadomasochistic, and narcissistic identifications. She wore, for example, clothing that was inappropriate for her age and that was unnecessarily seductive and revealing. She was flattered by grossly suggestive statements made by co-workers and customers to whom she had communicated her availability. However, when they attempted to act on their impulses, she would become outraged and self-righteous. On several occasions she invited men to meet her in her office after work only to chastize them contemptuously once they explicitly made known what was implicitly understood. Mrs. K viewed these ew~nts with near philosophical detachment. She stated that she was "very appealing for a woman of 40" and that men were "understandably" attracted to her. At home, she controlled her husband by carefully titrating sexual favors; and when he became impotent, she accused him of infidelity. Her intolerance of affect was prominent and was a significant factor in bringing her to psychotherapy. Provocative situations, even when trifling, would result in the rapid emergence of a painful, anxiety-laden dysphoria which was experienced as overwhelming. Thus, a picture emerged of a woman who was unhappily married, angry, resentful, and bitter; who recognized her dissatisfaction, but felt powerless to alter it. Mrs. K's inability to initiate meaningful change in her life demonstrates a significant aspect of the characterologically disturbed patient's predicament: namely, excessive rigidity, paucity of defenses, and tendency to regress to archaic defensive positions when stressed. These factors tend to promote the repetitive,
314
FRANK MILLER
nonadaptive behavior that is the hallmark of the characterologically disordered individual. The tendency toward repetition, in combination with rigid defenses and the feeling that few realistic alternatives of action are available, render the patient vulnerable to traumatic anxiety. The mechanism of anxiety formation differs significantly from that seen in the neuroses, in which superego dissatisfaction plays a prominent, if not compelling, role. Attention, accordingly, will be turned to an elaboration of this distinction. In the characterologically disordered individual, anxiety appears when external circumstances change in some appreciable way. The change may be geographic, social, or economic. Nevertheless, the change usually results in an inhibition of habitual modes of tension discharge, on the one hand, and pleasure-seeking activity on the other. The patient concludes that the now altered environment is to blame and does not realize that his own adaptive mechanisms are deficient. The patient's belief that he has been deceived and cheated stems from this conclusion. In the neuroses, anxiety appears when the superego challenges and attempts to inhibit ego operations. This hypothesis reaffirms the Freudian view that neurotic anxiety implies superego dissatisfaction and that superego dissatisfaction indicates the presence of an advanced psychic position in which oedipal objects, rather than pregenital, part objects, have been internalized. Associated with, and inseparable from, the internalization of oedipal objects is the internalization of the proscriptive functions of these objects; for identification and superego development procede simultaneously and are interdependent. In the characterologically disturbed patient the struggle with and against identification has disrupted the smooth and even maturation of the superego. Whereas in the neurosis the superego tends to be harsh and intrusive, in the character disorders it tends to be intrinsically unsound. The neurotic patient attempts to appease the superego through defensive operations such as repression, displacement, reaction formation, isolation, and undoing, which often result in inhibition of function. The characterologically disturbed patient, on the other hand, does not routinely engage in a struggle with his superego. Instead, he attempts, through various mechanisms, to externalize the superego and, by so doing, to neutralize it. Defense mechanisms such as repression, reaction formation, and undoing, therefore, are of little value andl consequently, are not found. By way of concluding, the role played by the actual conflict in the production of psychopathology will be mentioned. In the neuroses and character disorders the actual conflict is significant. In the neuroses it functions primarily as an initiator of conflict. Once the actual conflict is internalized, conflict itself tends to become autonomous, feeding on earlier disappointment, doubt, and fear. In the characterologically disturbed individual, the actual conflict is paramount. The patient resists vigorously the internalization of the conflict; and, once the conflict is resolved, generally via environmental manipulation, equilibrium is rapidly restored. In this essay an attempt was made to present clinical criteria useful in the
NEUROSIS AND CHARACTER DISORDER
315
differential diagnosis of neurosis and character disorder. Hypotheses were presented suggesting that between the neuroses and the character disorders there were major differences in the basic handling of affect; in the use and availability of defense mechanisms; in the role of the superego in pathogenesis; and in the role of the actual conflict. Clinical material was presented in support of these views. Address reprint requests to 3395 Scranton Road, Cleveland, OH 44109.
DIFFERENTIAL DIAGNOSTIC CONSIDERATIONS IN NEUROSIS AND CHARACTER DISORDER Frank Miller
The diagnosis and treatment of the characterologically disturbed patient is often complicated by the appearance of classical symptoms of neurosis. The appearance of neurotic symptoms, however, does not necessarily signify that there has been a movement, in the characterologically disturbed patient, toward neurosis. Anxiety, depression, and phobia, for example, may appear in the absence of neurosis and are readily discerned in the psychoses, the perversions, and the borderline states as well as in the character disorders. The following clinical material is taken from a case in which classical symptoms of neurosis were prominent. The elucidation of these symptoms however resulted in diagnostic and pgychotherapeutic considerations relating to the differential diagnosis and treatment of the characterologically disturbed patient. Mrs. K was a 40-year-old married mother of one. She was attractive despite her dyed hair, seductive manner, and excessive use of makeup. She arrived at the first interview with the chief complaint that on nearly every morning for the past two weeks she had experienced an overwhelming "sense of doom" which was associated with palpitations, shortness of breath and feeling faint. The episodes would last several minutes and then spontaneously subside. The episodes were 1Lerrifying, and the most recent episode was completely overwhelming. In the beginning of psychotherapy, Mrs. K compared her symptoms of distress with her mother's symptoms prior to her death several weeks before the first interview. The mother, who had been chronically ill, often described to her daughter her symptoms of faintness, palpitations, and shortness of breath. On the evening she died these symptoms were prominent. Though Mrs. K recognized that her mother's symptoms and her attacks shared a number of features, neither the frequency nor the severity of her attacks had been affected. Mrs. K stated that her lack of medical training and nursing expertise had shortened her mother's life. She argued that her recognition of these deficiencies had produced in her profound guilt and personal misgivings. Many months in psychotherapy passed before Mrs. K acknowledged that the night her mother died she and her mother had a violent argument concerning the mother's planned, eventual distribution of her property. As Mrs. K became increasingly comfortable discussing her mother's death, she Frank Miller is in the Department of Psychiatry, Cleveland Metropolitan General Hospital, Cleveland, Ohio. 309
310
FRANK MILLER
began to experience and express, though not consciously admit to, feelings of rage and anger toward her mother. She produced material indicating that she had not wanted her mother to live with her. In fact her mother's illness frightened her. She had been warned by a sister that the mother vomited frequently, kept odd hours, often lost control of her bladder, and moaned continually during the night. Feeling unequal to the task of nursing her mother, and loathing the nature of the illness, Mrs. K turned to her husband for help and support. Mrs. K had been unhappily married for 13 years. She described her husband as jealous, demanding, aloof, uncaring, and unloving. She believed that he was dishonest in business; that he drank too much and talked too much; that he had underworld connections; that he gambled excessively; and that he required the services of prostitutes. Thus, she was surprised and relieved when he agreed to help her care for her mother. Within a few weeks Mrs. K's husband was intimately involved with the care of her mother. He acquired nursing skills and he fed and bathed her routinely. On days when she was not bedridden he took her on his salesman's rounds. Although initially pleased by her husband's interest, Mrs. K became increasingly dissatisfied with his nursing role. She began to suffer from insomnia. Her weight fluctuated and her appetite was erratic. She desired to "punish" her husband, who seemed to ignore her now more than ever. She was very unhappy, lost interest in work, and lost interest in maintaining her appearance. To her surprise, and for the first time in their marriage, her husband was warm and affectionate. He nursed her as he had nursed her mother; but when her spirits brightened, he lost interest. When her symptoms returned so did his interest and attention. Once again she improved and once again he lost interest. When her symptoms appeared a third time, however, he did not respond. He had become increasingly frustrated with her. On one occasion he told her that she was out of her mind. With this, Mrs. K stopped going to work. She became fearful that she might lose control of her automobile and would "kill a pedestrian." She demanded that her husband buy a citizen's band radio and have it installed in his car and at her bedside so she could contact him if and when she experienced an anxiety attack. At times they would have bitter, abusive, and degrading arguments while using the citizen's band radio. She would demand that he come home at once while he would retort that he had to stay on the road in order to make a living. Her attacks became more frequent and disturbing. He became less sympathetic and finally disconnected the citizen's band radio. During this period she watched a television program in which hypoglycemia was described and discussed and she became convinced that her attacks were hypoglycemic episodes. She demanded that her husband buy special foods which she had determined were good for her. The crisis came when he informed her that he would be away for several days on business. He communicated this fact to her with some degree of pleasure. Before he could leave, however, she suffered a severe anxiety attack. An emergency psychiatric consultation was sought and an interview was arranged.
NEUROSIS AND CHARACTER DISORDER
311
At the interview, Mrs. K was perplexed and frightened by her symptoms of palpitation, shortness of breath, dizziness, and panic. She did not associate her symptoms with any ongoing environmental stress. On the contrary, she related her symptoms to her mother's death. She talked, at great length, about her lack of nursing skills and the guilt that this had generated, and she talked about her loss of a loved parent. During the first interview, Mrs. K denied ever having seen a psychiatrist or experiencing periods of significant psychological distress. However, during the ninth session of psychotherapy, Mrs. K referred to a psychiatric hospitalization which had occurred 14 years prior to the onset of her recent disorder. When asked if she remembered being questioned about a history of a past psychiatric hospitalization, she responded that the hospitalization had happened so long ago that it had not come to mind when originally questioned. She stated as well that since the question was never repeated it probably was not significant. Exploration of the issue revealed that Mrs. K had been hospitalized on the day she received from her first husband a final decree of divorce. Although she had sought the divorce, she had withdrawn her suit when her husband threatened to prove she was an adultress. She denied unfaithfulness, but stated that she was so mortified by the prospect of scandal that she had let her husband file for divorce. Shortly after receiving the document she experienced an episode of confusion and disorganization which lasted approximately four hours and was characterized by intense dysphoric affect and histrionic display. She received an injection of a phenothiazine at the time of admission, was hospitalized two days, and then discharged without follow-up. She immediately returned to work and was without sequela. Following the revelation of her past psychiatric hospitalization, Mrs. K began to acknowledge and describe numerous prolonged periods in her life during which she was intensely unhappy, dissatisfied, and anxious. The periods of discontent tended to overlap with one another and a picture emerged of a lifelong pattern of disappointment and dysphoria, of feeling cheated, short-changed, manipulated, and unloved. She stated that everyone had failed her. She mocked her husband and described her father as an alcoholic and a ne'er-do-well. She admitted to hating her mother-in-law and was not on speaking terms with neighbors or friiends. She had alienated co-workers with her complaints and demands. Her son, struggling with financial burdens, and a generally chaotic life style, was emotionally unavailable to her. In short, she was friendless and with little capacity for independent existence. Following an initial period of history-taking, reassurance, and the use of a tricyclic antidepressant, Mrs. K no longer experienced episodes of panic. However, she remained fearful and apprehensive that at any time she might be overwhelmed by her anxieties and rendered helpless. She remained convinced that the attacks were hypoglycemic even though appropriate laboratory examinations were within normal limits. At every opportunity she blamed her husband for the ills that had befallen them. During the sixth month of psychotherapy, Mrs. K"s attitude and demeanor changed. She revealed that she had been having an affair with a
312
FRANK MILLER
consultant at her place of employment. In explanation, she stated that her husband had driven her to it and that she was blameless. She did not conceptualize her act as infidelity, rather as a manifestation of her need to be loved. During this period, Mrs. K experienced no conscious guilt and her symptoms of depression, anxiety, and phobia disappeared. When the relationship ended several months after it began, her symptoms reappeared. In psychotherapy she returned to earlier themes such as her mother's death, her father's alcoholism and her husband's inadequacy. Anxiety, depression, and phobia are classical neurotic symptoms and their presence indicates that a conflict exists in which the ego participates. However, the presence of neurotic symptoms in conditions other than neurosis is generally acknowledged. The clinician frequently encounters patients, such as Mrs. K, who present with classical neurotic symptoms; but who do not suffer from a neurosis. The clinical ability to distinguish the neurotic from the character disorder when classical neurotic symptoms are present is invaluable; for not only the diagnosis, but the treatment, and often the outcome, may depend on th is distinction. There are two ways to proceed~first through a general analysis of the personality, and second through a specific analysis of the "neurotic" symptoms. The patient suffering from a neurosis often presents with a distinctive constellation of signs and symptoms. He tends to respond to his symptoms with displeasure and resignation. His reasons for requesting psychiatric consultation relate directly to his symptoms, which have either recently appeared or recently intensified. He tends to seek consultation spontaneously and, in general, has not been coerced by others. He views much of the behavior he associates with his symptoms as unacceptable and deviant. Prior to seeking consultation he has attempted to master his symptoms by specific methods which he is able to enumerate. In therapy he demonstrates a significant capacity to tolerate unpleasant affect. Often he is ashamed of not being able to control his emotions, which at times are painfully intense and unremitting. He is motivated for character change, tends to value insight, and, more importantly, makes use of it. The characterologically disturbed individual presents a different picture even when his symptoms superficially resemble those encountered in the neuroses. The presenting symptom of anxiety, for instance, may be described by the patient as overwhelming. However, little in his demeanor suggests the level of intense anxiety he describes. The anxiety that is experienced is poorly tolerated and the patient demands relief. When immediate relief is unavailable or delayed, he responds with anger and hostility. When psychiatric attention is sought it is often at the insistence of others who are concerned more with the patient's behavior than with his subjectively experienced discomfort. Once in psychotherapy, the patient is not motivated for characterologic change; for he does not believe that he is in any way responsible for his distress. He views psychotherapy as a mechanism with which he can manipulate an ungiving environment. He does not value insight and finds every attempt on the part of the psychotherapist to redirect responsibility or elucidate cause and effect intolerable. Although he may initially state that his problems are of
NEUROSIS AND CHARACTER DISORDER
313
recent origin, careful anamnesis reveals a lifelong history of disordered interpersonal relations, impulsiveness, and self-defeating behavior. The case of Mrs. K points out that a borderline exists between the neuroses and the character disorders in which easy distinctions cannot be made. Although an examination of manifest behavior is an essential step in making the diagnosis, mistakes will be made if other areas of investigation are ignored. The characterologically disturbed patient demonstrates profound distortions in the synthesizing functions of the ego. Defective object relations and unstable identifications are evident, and oedipal issues are few in number and lack significance. Intolerance of affects and inadequate impulse control are discernable. Finally, superego lacunae are evident and prove to be disruptive to all aspects of daily living. A review of Mrs. K's history reveals these findings. Superego lacunae were demonstrated specifically by the ease with which she entered into an extramarital relationship, by her purchasing furniture and clothes on credit the day she filed for bankruptcy, and by her hiring of a private investigator, at great expense, even though she acknowledged in therapy that she would never pay him for his services. In general, superego lacunae were demonstrated by her lack of empathy and by her extreme self-involvement and infatuation. Although oedipal issues dominated the early course of psychotherapy, they never proved to be significant. Pregenital aims, on the other hand, were central, and, accordingly, conflict arose around issues of feeding, clothing, shelter, and protection. Mrs. K was driven by impulses derived from exhibitionistic, sadomasochistic, and narcissistic identifications. She wore, for example, clothing that was inappropriate for her age and that was unnecessarily seductive and revealing. She was flattered by grossly suggestive statements made by co-workers and customers to whom she had communicated her availability. However, when they attempted to act on their impulses, she would become outraged and self-righteous. On several occasions she invited men to meet her in her office after work only to chastize them contemptuously once they explicitly made known what was implicitly understood. Mrs. K viewed these ew~nts with near philosophical detachment. She stated that she was "very appealing for a woman of 40" and that men were "understandably" attracted to her. At home, she controlled her husband by carefully titrating sexual favors; and when he became impotent, she accused him of infidelity. Her intolerance of affect was prominent and was a significant factor in bringing her to psychotherapy. Provocative situations, even when trifling, would result in the rapid emergence of a painful, anxiety-laden dysphoria which was experienced as overwhelming. Thus, a picture emerged of a woman who was unhappily married, angry, resentful, and bitter; who recognized her dissatisfaction, but felt powerless to alter it. Mrs. K's inability to initiate meaningful change in her life demonstrates a significant aspect of the characterologically disturbed patient's predicament: namely, excessive rigidity, paucity of defenses, and tendency to regress to archaic defensive positions when stressed. These factors tend to promote the repetitive,
314
FRANK MILLER
nonadaptive behavior that is the hallmark of the characterologically disordered individual. The tendency toward repetition, in combination with rigid defenses and the feeling that few realistic alternatives of action are available, render the patient vulnerable to traumatic anxiety. The mechanism of anxiety formation differs significantly from that seen in the neuroses, in which superego dissatisfaction plays a prominent, if not compelling, role. Attention, accordingly, will be turned to an elaboration of this distinction. In the characterologically disordered individual, anxiety appears when external circumstances change in some appreciable way. The change may be geographic, social, or economic. Nevertheless, the change usually results in an inhibition of habitual modes of tension discharge, on the one hand, and pleasure-seeking activity on the other. The patient concludes that the now altered environment is to blame and does not realize that his own adaptive mechanisms are deficient. The patient's belief that he has been deceived and cheated stems from this conclusion. In the neuroses, anxiety appears when the superego challenges and attempts to inhibit ego operations. This hypothesis reaffirms the Freudian view that neurotic anxiety implies superego dissatisfaction and that superego dissatisfaction indicates the presence of an advanced psychic position in which oedipal objects, rather than pregenital, part objects, have been internalized. Associated with, and inseparable from, the internalization of oedipal objects is the internalization of the proscriptive functions of these objects; for identification and superego development procede simultaneously and are interdependent. In the characterologically disturbed patient the struggle with and against identification has disrupted the smooth and even maturation of the superego. Whereas in the neurosis the superego tends to be harsh and intrusive, in the character disorders it tends to be intrinsically unsound. The neurotic patient attempts to appease the superego through defensive operations such as repression, displacement, reaction formation, isolation, and undoing, which often result in inhibition of function. The characterologically disturbed patient, on the other hand, does not routinely engage in a struggle with his superego. Instead, he attempts, through various mechanisms, to externalize the superego and, by so doing, to neutralize it. Defense mechanisms such as repression, reaction formation, and undoing, therefore, are of little value andl consequently, are not found. By way of concluding, the role played by the actual conflict in the production of psychopathology will be mentioned. In the neuroses and character disorders the actual conflict is significant. In the neuroses it functions primarily as an initiator of conflict. Once the actual conflict is internalized, conflict itself tends to become autonomous, feeding on earlier disappointment, doubt, and fear. In the characterologically disturbed individual, the actual conflict is paramount. The patient resists vigorously the internalization of the conflict; and, once the conflict is resolved, generally via environmental manipulation, equilibrium is rapidly restored. In this essay an attempt was made to present clinical criteria useful in the
NEUROSIS AND CHARACTER DISORDER
315
differential diagnosis of neurosis and character disorder. Hypotheses were presented suggesting that between the neuroses and the character disorders there were major differences in the basic handling of affect; in the use and availability of defense mechanisms; in the role of the superego in pathogenesis; and in the role of the actual conflict. Clinical material was presented in support of these views. Address reprint requests to 3395 Scranton Road, Cleveland, OH 44109.
