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III. Be. Use Of Ego Psychology In Diagnosis, Selection Of Treatment Modalities, and Technique III. Bea. Diagnosis Diagnostic and Statistical Manuals DSM III, IV and 5 (American Psychiatric Association, 1980, 1994 and 2013) and textbooks describing evaluations make reference to ego psychological concepts, although often without attribution (e.g., Sadock et al., 2009). The “mental status examination” usually includes assessment of ego functions and findings about ego strengths, such as regulation of wishes, affects, and the primary process, which constitute unconscious regulatory protection of autonomous ego functions from breakdown. Ego strengths are thought to have multiple origins: heredity; internalizations of soothing and limit- setting during development; adequate secure-organized attachments; successful childhood individuation and adolescent identity-formation; and adult “hardening” through experience. Although phenomenological diagnosis typically ignores “psychoanalytic” concepts, it unwittingly derives its descriptions from ego psychology. For example, schizophrenia can be considered a syndrome defined by a series of deficits – in integration (loose associations), in abstraction (concreteness), in reality testing (dereistic and paralogical thinking), and in prevalence of primary process (hallucinations and delusions). Robert Waelder ’s reformulation of Freud’s principle of overdetermination (1900, 1918) as the principle of multiple function (Waelder, 1936), re-stated in contemporary terms as the interchangeability of psychic elements (Rangell 1983, Papiasvili 1995) is also applicable to modern multifactorial clinical pathogenesis: Recent statistical evidence suggests a congenital or hereditary basis for the brain malfunctions responsible for some of the ego deficits seen in people suffering with a schizophrenic syndrome (Willick, 2001). However, in some forms of psychosis, contrarily, overwhelming persistent external forces (beatings, sexual abuse, war, crime-ridden neighborhoods) during early development can constitute a ‘traumatic’ etiology (Volkan, 2015), although a unitary theory of psychoses based on such formulations can be misleading (Willick, 1994). On the opposite end of the scale is ego function intactness . Some patients, though complaining of severe problems, show little or no damage to autonomous ego functions or ego strengths. They may suffer from anxiety, depression, conversion, obsessions, phobias, and a large variety of personality disturbances, which are explicable almost solely using conflict theory (Papiasvili, 1995; Brenner, 2006). In these disturbances, “analyzability” is favorable. This means that individual’s abstraction, integrative, reality, and self-preservation functions are more or less intact; they show sufficient impulse control, affect tolerance, and containment of primary process; they possess some capacity for empathy, trust, and emotional closeness (object-relations/attachment); and they manifest sufficient superego functioning (capacity for shame and/or guilt). Such individuals could be considered “neurotic,” because their ego functions are relatively intact and their complaints are primarily caused by maladaptive compromise formations, as ‘overdetermined’ attempts at solutions (Waelder, 1936a) of underlying inter-systemic conflicts among libidinal and aggressive wishes, superego, reality,
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