Differential-Diagnosis of Obsessive-Compulsive Symptoms in the Borderline Personality Disorder
Brunnhuber, Stefan, American Journal of Psychotherapy
Obsessive-compulsive symptoms are clinically unspecific and can be found in numerous disorders. Within the framework of psychothempeutically treatable illnesses, the classical obsessive-compulsive neurosis can be distinguished from early anancastia in the case of borderline personality disorder. The text refers to some aspects of the obsessive-compulsive disorder within these earlier disorders. At least five characteristics can he discussed: In the course of this, the varying functions of obsessive-compulsive symptoms for the inner-psychological organization become clear and specifically show that on a low structural level, symptoms do not appear to be primarily pathological but are a part of a "quasi-physiological" and ego-sustaining mechanism. What remains open to discussion in the end is, whether there may he an important substratum for the basis of a historiographical biology as called repeatedly for from psychosomatic theory repeatedly. In addition to this, the awareness of both forms is an important requirement for treatment.
From a clinical point of view, obsessive-compulsive symptoms are unspecific and appear in varying disorders (1). Thus obsessions and compulsions can be found described in encephalitis, in affective disorders, or also in schizophrenia, as well as in cerebral trauma and prepsychotic syndromes. Within the framework of the basal-ganglia hypothesis (2), a defect in serotonin reuptake is assumed in connection with neurological "soft signs." The following text is only concerned with theoretically and clinically distinguishable differences of two forms of obsessive-compulsive disorders within the psychotherapeutic practice: Here, obsessive-compulsive neurosis and an "early" form of obsessive-compulsive disorder, anancastia, can be theoretically and clinically distinguished. While the classical obsessive-compulsive neurosis is known to be at the disposal of neurotic mechanisms, like isolation of emotion, displacement, reaction formation, and rationalization, the obsessive-compulsive syndrome-the lower-level anancastia-is using other coping mechanism. The familiarity with these two forms is especially important because each calls for a completely different treatment strategy.
Isolated obsessive-compulsive illnesses (obsessive-compulsive disorder, OCD) without internal comorbidity with other psychiatric illnesses are common and occur with a life-time prevalence of 2.5%. Cases are equally distributed between males and females. According to Rasmussen and Eisen (3), the most common obsessions involve illusions of uncleanliness (45%) and pathological feelings of guilt (42%). The most clinically common compulsions are checking/controlling functions (63%) and cleaning/washing behaviors (37%). A genetic disposition to obsessive-compulsive illness is indicated by the incidence of obsessive- compulsive behavior among family members.
The distinction between an early anancastia and an obsessive-compulsive neurosis remains conceptually alien to the views of cognitive psychology due to the fact that biographical assessments of mental disorders are only accessible in terms of a learning history. Already in 1913, S. Freud (4) spoke of a "disposition to obsessive-compulsive neurosis" as a constitutional and biological factor that serves as a "fixation point." In 1936 (5) this concept lost its constitutional factor in favor of the phase-specific temporality of fixation within the development of ego. For the development and understanding of classical obsessive-compulsive neurosis, it is necessary that ego-development be more or less complete. Within the classical drive-psychology, two directions are known to be emphasized: a regression resulting from a situation of an unresolved Oedipus complex, and a progressive defense against verbal conflicts. The psychodynamic concepts regarding obsessive-compulsive neurosis, however, cannot be applied to the clinically common phenomenon of anancastic symptoms in "early" disorders" since the structural requirements are not yet available. …