The DSM and the psychodynamic perspective model psychopathology in profoundly different ways. The intention of the DSM-III, adopted in 1980, was to purge psychopathology of all theoretical assumption, return to description as the foundation of the classification system, and build from there, in the hope that with time and research, description would give way to explanation—the goal of science. In doing so, however, the DSM-III implicitly made certain assumptions of its own, notably that all psy-chopathologies should, and could, be diagnosed as categories and that the boundaries between various categorical entities are correct, even though the disease processes responsible for pathology in any one category are for the most part unknown. Each syndrome is thus treated as a discrete entity, potentially unrelated to any other.
In contrast, the psychodynamic perspective asserts that threads of continuity unify many psychopathologies that are only superficially different. As we have seen, the hysterical character is usually regarded as a more mature form of the histrionic, which is more infantile and pathological. Here, differences of degree masquerade as differences of kind. From a psychodynamic perspective, the DSM mutilates this continuum by presenting only a histrionic personality, forcing everything into a single category. The same is true of the schizotypal personality. Despite the DSM's emphasis on the categorical and discrete, most analysts have historically viewed today's schizoids, avoidants, and schizotypals as existing at the nonpsychotic end of a continuum anchored at the psychotic extreme by schizophrenia (McWilliams, 1994).
Most mainstream clinicians would consider the metapsychological constructs of classical psychoanalysis to be far too remote from the particular person to be clinically useful. According to the classical view, schizophrenics react to a particularly harsh, cold, or withholding world by regressing back to a stage of development that existed before the ego was formed. Because the primary function of the ego is to coordinate the internal demands of the id, the prohibitions of the superego, and the constraints of external reality, almost everything we think of as distinctly human is thereby voided.
As the reality principle gives way to the fluidity of primary process thinking, behavior shifts abruptly as the id switches unpredictably from one drive state to another. Sense of time is absent or distorted. The boundary between internal and external worlds dissolves. Identity fragments. No superordinate motive synthesizes smaller goals into some superordinate action plan designed to fulfill some ultimate purpose. Loss of reality testing may be so complete that self and not-self are no longer strictly distinguishable. The individual may temporarily fuse with others or even with inanimate objects. Still more primitive levels of regression feature complete withdrawal into autistic or catatonic states, perhaps a protective retreat designed to shut others out, minimize all external stimulation, and thereby reinforce or preserve what little solidity the self might still possess. Neal has a degree of this, perhaps, but the description seems too severe.
By extension, the same logic would apply to the schizotypal. Rather than regress to some stage of development that preexists the ego, however, schizotypals would regress to some stable, but primitive, ego state characterized by temporary psychotic episodes. Again, normality provides an important reference point. Normal persons possess a coherent, integrated sense of self that provides a sense of continuity to experience and moderates the expression of impulses and feelings. Without this solid sense of self, we would be at the mercy of our drives and emotions, flung back and forth, like the borderline personality, from anger to tears, depending on the situation and the nature of our own personal associations. Like the borderline's, the internal world of the schizotypal is highly unintegrated, but for reasons that are primarily cognitive, not neurotic. In the borderline, waves of intense emotion wash over, swamp, and disrupt the formation of incipient self-structures that, given a friendly developmental environment, might otherwise form and contain these same emotions.
In the schizotypal, however, a basic neural capacity to consolidate a coherent sense of self, world, and others is somehow lacking. As a result, their internal representations are a jumbled mix of unassimilated and often contradictory memories, perceptions, impulses, and feelings. Any one of these can seize executive control and guide behavior temporarily before giving way to some other association. The desirable aspects of a particular stimulus object thus lead first to some positive emotion but just as easily call unintegrated negative aspects of the same stimulus object to consciousness, thus giving way to some negative emotion and vice versa. Consequently, schizotypals often seem affectively labile or neurotic, like the borderline. Borderlines, however, experience micropsychotic episodes mainly when overwhelmed by strong negative emotions, centering especially on anger and abandonment concerns. In contrast, schizotypals seem forever lost in the fog. They become mired in personal irrelevancies and tangential asides that seem vague, digressive, or even autistic.
Lack of integration at the basic level of internal self and other object-representations is a very important part of why the schizotypal is considered a structurally defective personality disorder. Moreover, it is important in creating a vulnerability to decompensation under even modest degrees of stress. Lacking a well-developed, coordinating ego, schizotypals discharge their emotions in haphazard ways, sometimes in a sequence of apparently unrelated actions. Often, they are easily overwhelmed by excess stimulation and must either seek retreat or suffer a psychoticlike disorganization. When social demands and expectations press hard against their uninvolved or withdrawn state, they may use their tendency to disorganize defensively by blanking out or seeming to drift off into another world. Undue encroachments may lead them to disconnect socially for prolonged periods, during which they may become confused and aimless, display inappropriate affect and paranoid thinking, and communicate in odd, circumstantial, and metaphorical ways.
Consider Neal again. Like most schizotypals, Neal is excessively anxious in social situations. Unable to separate tangential aspects of the consensual social world from those that are truly meaningful, his subjective world is a mixture of the relevant and irrelevant. Accidental aspects of reality are given as much heed as those that are planned or intended and become connected in ways that others find unfathomable. Obviously, Neal has trouble organizing his thoughts as it is. When forced into social encounters, he speaks slowly because, first, he finds it difficult to understand what others are requiring of him; second, he finds it difficult to coordinate his thoughts toward a single objective; and third, what concentration he does have becomes more brittle when he becomes more anxious. Unfortunately, during particularly stressful times, he sometimes becomes tangled up in his own mythologies. His social anxiety leads to ideas of reference, which lead him to rely on coping mechanisms that have a mystical flavor. For some schizotyp-als, the fear of total disintegration of self may lead to a frantic search for some safe harbor where the impending threat of existential annihilation can be weathered. Likewise, Neal's goal is simply to retreat. The inability to consolidate internal representations of self and others leads to alienation from others and, ultimately, to an alienation from self.
Many schizotypals possess superego residuals that are brought to bear unpredictably on their behavior and impulses, often leading to extraordinary guilt feelings. The word residuals is key, because the superego consists of the internalized prohibitions of caretakers, that is, the internalized objects of individuals central to early life experience, often called introjects. The normal superego expresses both the conscience and ego ideal, the prohibitions and prescriptions of life. In a crude sense, the conscience keeps you out of trouble, and the ego ideal gives you direction and value. The ego synthesizes the goals of the superego with ongoing behavior, so that actions are principled and goal-directed, rather than purely egocentric and gratification seeking.
In the schizotypal, however, images of introjects are as fragmented as the image of self. Bizarre mannerisms and idiosyncratic thoughts often reflect a retraction or reversal of forbidden acts or ideas, allowing repentance or nullification of perceived misdeeds, a defense mechanism known as undoing. Because schizotypals live in a subjective world populated by omens, a sixth sense, extrasensory information, and synchronicity, unforeseen connections among obscure metaphysical aspects of their world easily lead to unanticipated missteps that must be corrected through some equally magical means. Odd beliefs and ritualistic behaviors may be seen as superstitious means of undoing evil thoughts and actions that have "offended the spirits," essentially a process of atonement that attempts to put the individual right with the universe's own record keeping or correct some mistake by appeasing the powers that be. Because these actions serve to diminish the individual's inchoate moral anxiety, they further contribute to the construction of self-made, idiosyncratic realities composed of suspicion, illusion, and superstition rather than objective fact.
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