In academic literature, we can relatively easily differentiate obsessive-compulsive psychodynamics from other psychopathologies.But what about clinical practice? In clinical practice, we as psychotherapists may encounter diagnostic uncertainty—when an obsessive structure is sometimes hard to distinguish from schizoid psychology, especially at the lower-functioning end of the developmental continuum, and from narcissistic personalities with obsessive defenses. Sometimes it can be hard to differentiate obsessive and compulsive dynamics from organic brain syndromes.
What are the consequences of this confusion?
When considering obsessive-compulsive and narcissistic personality disorders, two possible therapeutic trajectories emerge:
If a therapist misidentifies an essentially narcissistic person is misunderstood as obsessive or compulsive, when the therapist accordingly looks for unconscious anger, omnipotent fantasies, and guilt rather than subjective emptiness and fragile self-esteem. The damage is probably less serious when a mistake is made the other way, since all of us, whatever our character, can profit from therapies that focus on issues of self.
If an old-fashioned, moralistic obsessive or compulsive person being treated by someone who construes him or her as narcissistic would be eventually distressed, demoralized, and even insulted by being seen as needy rather than conflicted.
Obsessive and compulsive people with introjective dynamics have a strong center of gravity psychologically; they are judgmental and self-critical. A therapist who communicates empathic acceptance of their subjective experience without evoking the deeper affects and beliefs that shape that experience is depriving such patients of any empathy worth its name. Sometimes interventions that a therapist conceives as mirroring are received by obsessive and compulsive clients as corrupting, in that the patient views the therapist as implicitly condoning aspects of the self that the patient sees as indefensible.
Under these circumstances patients begin to doubt the moral credentials of the therapist. Analysis of the rationalistic and moralistic defenses of obsessive and compulsive clients should precede efforts to convey acceptance of the troublesome feelings these defenses have been erected to conceal.
How about the differentiation of obsessive-compulsive personality disorder from schizoid personality disorder?
In the symbiotic–psychotic range, some people who look schizoid may be in fact regressed obsessional patients. Although a schizoid person withdraws from the outer world, he or she tends to be conscious of intense inner feelings and vivid fantasies. In contrast, a withdrawn obsessional person uses isolation so completely that he or she may be subjectively “blank” or wooden in appearance.
Knowledge of the premorbid functioning of someone for whom this differential applies will provide clues about whether to communicate to the patient that it is safe to express his or her intense inner experience, or to convey that it must be terrible to feel so cold and dead inside.
Another source of confusion with obsessive-compulsive personality disorder often arises among inexperienced interviewers—whether or not they have had medical training—misconstrue behavior related to brain damage as obsessive–compulsive. The perseverative thinking and repetitive actions typical of organic brain syndromes can mimic “functional” obsessiveness and compulsivity, but dynamically informed questioning will reveal that isolation of affect and undoing are not involved. A good history, with inquiries about possible fetal alcohol syndrome or maternal addiction during pregnancy, complications at birth, illnesses with high fever (meningitis, encephalitis), head injury, and so forth may suggest an organic diagnosis, which may be confirmed by neurological examination.
Not all brain damage involves loss of intelligence. The practitioner should not assume that because a person is bright and competent, he or she could not suffer from organically based difficulties. This is a critical differential, since therapy to uncover unconscious dynamics in order to reduce a client’s obsessive–compulsive inflexibility may be radically different from treatment that emphasizes, to the organically damaged person and to his or her family, the value of maintaining order and predictability for the sake of the client’s emotional security and comfort.
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy