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Introspection   |    
The Ruined Good Boy
Ronald Pies, M.D.
Am J Psychiatry 2011;168:1145-1146. doi:10.1176/appi.ajp.2011.11050791
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Introspection accepted for publication June 2011.

Address correspondence to Dr. Pies (ronpies@massmed.org).

Accepted June , 2011.

Copyright © American Psychiatric Association

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We all see cases of depression that seem to arise, like some dark Venus, from a mysterious sea of genes and biology, without a clear precipitant. But this time there seemed to be a specific, inciting event. My patient, an accountant for over 30 years, had agreed to prepare a family member's federal income tax return. Unfortunately, the IRS discovered an underpayment of about $70, which the relative dismissed as “no big deal.” But for my patient, the moral order of the universe had been overturned. How, he wondered, could he have been so careless—and so stupid? He, who had prepared thousands of tax returns without a penny's error, and whose entire life was based on duty, honor, responsibility, and perfection! How could such vile incompetence issue from so pure a stream?

I was a third-year resident, and the patient's symptoms first struck me as garden-variety major depression, with the usual DSM mix of somatic and psychic complaints. But the corrosive vehemence of his guilt seemed almost of delusional proportions. My supervisor and I considered the possibility of an affective psychosis, as we called it back then, but the patient was able to “reality test” some of his exaggerated ideas of guilt and shame. He could acknowledge, for example, that most people would regard his error as “honest,” if not downright trivial. After we explored more of his childhood and adolescence, it became clear that my patient's depressive episode had sprung from the fertile soil of a condition sometimes described as “your conscience on steroids.”

Some features of obsessive-compulsive personality disorder are clearly adaptive, up to a point. Could any of us have gotten through medical school and residency without some penchant for order, precision, control, and self-discipline? But in the case of my patient and others like him, these traits have taken over the personality like an occupying army. The prick of healthy conscience has morphed into the stabbing pain of relentless guilt.

According to recent research, obsessive-compulsive personality disorder is associated with some of the highest direct medical costs and productivity losses of all the personality disorders. Other research has found high rates of suicide attempts in this disorder. This might seem paradoxical in light of the obsessive individual's strong sense of duty and obligation, but it is consistent with the patient's need for control. It is as if the patient concludes, “I would rather be dead than live with this guilt and shame!”

Much of the early psychoanalytic theorizing about my patient's condition—“regression to the anal stage,” for example—has not been borne out by modern-day studies. Some research points to a hereditary component in this disorder, and a few scattered studies implicate abnormal regulation of serotonin. But in large part—even 30 years after my residency—obsessive-compulsive personality disorder remains the undiscovered country in the realm of personality disorders. And alas, there are few if any well-validated treatments for this condition.

We used what we had at the time—mainly the old tricyclic antidepressants. My supervisors and I knew that in a relatively brief inpatient stay we were not going to alter my patient's underlying character structure. Nevertheless, I tried my best to chip away at his distorted cognitions and overvalued ideas, using the cognitive approach of Aaron Beck and Albert Ellis. I was pleased to find that after about 3 weeks on the unit, my patient's depressive symptoms had improved considerably with a robust dose of a tricyclic. And yet—I had the nagging feeling that this proud, self-flagellating man was hardly made whole by our work. I suspected that he would pick away at the crusted wound in his psyche for many years. And I suppose the sense that my patient had merely “sealed over” must have lodged in my conscience all these many years.

Nearly three decades after our work together, I met my patient again. Or rather, I had an encounter with a striking literary incarnation of him. In Philip Roth's recent novel Nemesis, the protagonist, Bucky Cantor, is caught in the maelstrom of the 1944 polio epidemic in Newark, N.J. Bucky is a young, overly conscientious athletic director who becomes convinced that he has spread the polio virus to a number of his adolescent charges. Eventually, he becomes extremely withdrawn and depressed, as Roth's narrator describes:

[Bucky] was largely a humorless person…someone…haunted by an exacerbated sense of duty but endowed with little force of mind…for that, he had paid a high price in assigning the gravest meaning to his story, one that, intensifying over time, perniciously magnified his misfortune. The guilt in someone like Bucky may seem absurd, but, in fact, is unavoidable. Such a person is condemned. Nothing he does matches the ideal in him.

One of his former charges tries to reason with Bucky, pointing out how excessively harsh he has been with himself. “Don't be against yourself,” Bucky's well-meaning friend implores, “there's enough cruelty in the world as it is.” But Bucky is unmoved by reason, which must have seemed to him like weakness and pity. How familiar all this sounded to me! True, Roth emphasizes Bucky's characterological gloominess more than his depression—but my patient and Bucky Cantor seemed cut from the same cloth of self-punishing perfectionism.

I do not want to sound too pessimistic about those, like my patient, who carry the burden of obsessive-compulsive character pathology. With long-term, dynamically oriented psychotherapy and perhaps medication, there is hope that these tormented individuals will find peace. Yet I was haunted by the verdict of Roth's narrator, near the end of this dark novel: “There's nobody less salvageable than a ruined good boy.”

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