A Freudian construct lost and reclaimed: The psychodynamics of personality pathology.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) developed by the American Psychiatric Association (1994) is a compelling effort at a best approximation to date of a scientifically based nomenclature, but even its authors have acknowledged that its diagnoses and criterion sets are highly debatable. Well-meaning clinicians, theorists, and researchers could find some basis for fault in virtually every sentence, due in part to the absence of adequate research to guide its construction. Some points of disagreement, however, are more fundamental than others. The authors discuss issues that cut across individual diagnostic categories and that should receive particular attention in DSM-V: (a) the process by which the diagnostic manual is developed, (b) the differentiation from normal psychological functioning, (c) the differentiation among diagnostic categories, (d) cross-sectional vs. longitudinal diagnoses, and (e) the role of laboratory instruments.

It is often not just life stress but also a person's idiosyncratic response to life stress that leads to psychopathology. Thus, despite problems in reliability, the validity of defenses makes them a valuable diagnostic axis for understanding psychopathology. By including a patient's defensive style as part of the diagnostic formulation, the clinician is better able to comprehend what seems initially most unreasonable about the patient and to appreciate what is adaptive as well as maladaptive about the patient's defensive distortions of inner and outer reality. Clinical appreciation of the immature defenses (e.g., hypochondriasis, fantasy, dissociation, acting out, projection, and passive aggression) is particularly useful in classifying and caring for individuals with personality disorders.