Précis of The Rationality of Psychological Disorders: Psychobizarreness Theory

Yacov Rofé

Bar-Ilan University, Ramat Gan, Israel

Running head: Rofé: Psychobizarreness Theory

Abstract (long)

In his book, The Rationality of Psychological Disorders, Rofé (2000) reviews the three major schools of psychopathology and finds that they lack empirical validation and are unable to account for fundamental theoretical issues. Therefore, an integrative theory of psychopathology, termed Psychobizarreness Theory (PBT), was proposed. PBT defines neurotic disorders as bizarre behaviors, using five operational diagnostic criteria, and claims that these symptoms are coping mechanisms, which patients consciously and rationally select when confronted with unbearable levels of stress. Like psychoanalysis, PBT views repression as the key to understanding neuroses. However, in PBT repression is defined in conscious terms, in accordance with experimental and research data, and thus, the symptom constitutes a distractive maneuver employed to eliminate stress-related thoughts from attention. Hence, repression is the consequence rather than the cause of neurotic symptoms. Nevertheless, patients are unaware of their repressive endeavors due to sophisticated self-deceptive processes. Furthermore, PBT equates the process of symptom selection with economic decisions, whereby a certain ‘product’ is chosen according to the individual’s needs, available ‘merchandise’ and cost-benefit analysis. The theory also integrates the various forms of therapy into one theoretical model, accounting for their efficacy in conscious, rational terms. Overall, PBT synthesizes a large amount of research and clinical data and may settle the long and bitter dispute in the field of psychopathology.

Abstract (short)

This article presents a concise formulation of Psychobizarreness Theory (PBT) of neuroses, published by Rofé (2000) in his book The Rationality of Psychological Disorders. PBT distinguishes between bizarre behaviors, consisting of neuroses and psychoses, and non-bizarre behavioral deviations, such as simple phobia. Patients consciously and rationally select neurotic symptoms when confronted with unbearable levels of stress. The symptoms enable patients to block/repress stress-related thoughts from attention and enhance their control over their social environment. Patients become unaware of their deliberate involvement due to sophisticated self-deceptive mechanisms. This theory also integrates the various forms of therapy into one theoretical framework.

1. Introduction

In the first three chapters of his book, The Rationality of Psychological Disorders: Psychobizarreness Theory (PBT), Rofé (2000) demonstrates that the three major theoretical movements in psychopathology (i.e., psychoanalysis, behavioral-cognitive theories and biological models) encounter increasing difficulties in accounting for the development and treatment of behavioral disorders. Many studies question the existence of repression—the cornerstone of the psychoanalytic theory—and recommend that this concept be abandoned (Rofé 2000, Chapter 1). Other studies demonstrate that behavioral concepts do not adequately explain the development of behavioral disorders (Rofé 2000, Chapter 2). For example, anxiety disorders, such as agoraphobia and panic disorders, and often, simple phobia (e.g., spider phobia) develop in the absence of conditioning events. Similarly, cognitivists’ assumption that behavioral deviations are caused by catastrophic thoughts lacks empirical support, as extreme levels of anxiety are often experienced in the absence of catastrophic thoughts. Additionally, when behavioral deviations are accompanied by these thoughts, it does not necessarily reflect a causal relationship. In the same way, while the validity of biological theories for psychoses is not yet conclusive, most of the evidence indicates that neuroses are not biologically determined. Moreover, like cognitivists, biological investigators present mainly correlational data. Not only is most evidence relating to neuroses inconsistent with biological theories, but even with regard to psychoses the etiology is still an open question (Rofé 2000, Chapter 3).

In addition, traditional theories lack adequate concepts to integrate certain basic observations within their theoretical frameworks. For example, these theories have difficulty in accounting for sex differences, such as the fact that nearly all neurotic disorders (e.g., conversion disorder, dissociative disorders, eating disorders, agoraphobia and panic disorder) are far more prevalent among women. Similarly, they do not address age differences (e.g., the low prevalence of neuroses among children and their tendency to develop only certain neurotic disorders, such as school phobia and conversion disorder), socio-culture variability (e.g., differences in the prevalence of neuroses between western and non-western countries and among social classes within the same country) and diagnostic fluctuations in the prevalence of certain disorders. These fluctuations include the dramatic increase in eating and multiple personality disorders and the inflation in the number of personalities displayed by MPD patients, currently ranging between 2-60 (average 13.3) personalities (Putnam et al., 1986), as against the decline in conversion disorders, particularly in its classic forms (see Rofé 2000, Chapter 5).

Another fundamental problem common to all traditional theories concerns their inability to integrate the therapeutic efficacy of various methods. Power and Brewin (1997) expressed these problems as follows:

Some therapists simply bury their heads in the sand and continue their favorite techniques. Others, like ourselves, are puzzled and are asking if there are common mechanisms that apply across different therapies that might explain both their effectiveness and their (sometimes) lack of effectiveness (p. xi)?

Nevertheless, these theories have maintained significant scientific credibility, mainly because of the theoretical necessity for certain concepts and partial empirical support for some of their theoretical ideas and therapeutic techniques. For example, it is simply impossible to abandon the concept of repression, despite evidence that questions its validity, as no alternative concept can adequately account for patients’ unawareness regarding the underlying causes for sudden and bizarre behavioral changes (e.g., compulsive counting rituals and chocolate phobia; Neale et al. 1982 and Rachmann & Seligman 1976, respectively). Similarly, behavioral-cognitive therapeutic methods are the most effective therapeutic interventions for anxiety disorders (see Rofé 2000, Chapter 7). This alone justifies the maintenance of these theories despite their chronic empirical difficulties in accounting for the development of these disorders (see Rofé 2000, Chapter 2). The same rule applies to biological models, as no genuine theory of psychopathology can ignore the significant involvement of genetic and biological factors in the development of behavioral disorders and the efficacy of drug treatment.

In an attempt to resolve the aforementioned theoretical difficulties and to synthesize the important conceptual and empirical contributions of traditional theories into one theoretical paradigm, a new theory of psychopathology, termed PBT was proposed (see Rofé 2000, Chapters 4-10). Although PBT addresses neuroses, psychoses and simple phobia, this article will present the basic concepts of PBT and will focus on the development and treatment of neuroses.

2. The concept of bizarreness

A prerequisite for understanding neuroses is an operational definition of their abnormal component, so that these disorders can be distinguished from other behavioral deviations. Indeed, the lack of an operational definition for unconscious/repressed anxiety by which this concept was originally defined (e.g., Bayer & Spitzer 1985) led the authors of DSM-III (American Psychiatric Association 1980) to disperse its sub-classes among new diagnostic categories. Eventually, DSM-IV (American Psychiatric Association 1994) altogether excluded it as a diagnostic class. However, while it is undoubtedly correct that the classification of behavioral disorders should be made on a descriptive level, abandoning the concept of neuroses was too drastic a measure and could further complicate our understanding of behavioral deviations. It does not seem reasonable that senseless and disruptive behavioral disorders such as agoraphobia, panic disorder and OCD, should be classified together with simple phobia (e.g., spider phobia), in the category of anxiety disorders, as suggested by DSM. The former disorders have much more in common with other neurotic disorders, such as conversion disorder, dissociative disorders and eating disorders, despite their superficial similarity of anxiety with the latter type of deviations. This common characteristic can be defined in descriptive terms, thus justifying the reinstatement of neuroses as an independent diagnostic category. The fundamental descriptive characteristic of neurotic disorders is what laypeople would call ‘craziness’ and PBT terms bizarre. Bizarreness is defined by the following five operational criteria:

1. Impact on attention and Functioning: Bizarre behaviors daily preoccupy individuals’ attention and severely disrupt their functioning, regardless of the presence or absence of certain stimuli, and constitute a burden on the family and society.

2. Mode of onset: Usually the onset of bizarre behaviors is sudden, whereby the individual displays a dramatic disruptive behavioral change in the absence of a contingent event that is exclusively associated with and can account for the behavior. Even in cases where the onset is gradual, the patient demonstrates a progressive deterioration to the point of severe disruption, resembling sudden onset. Here, too, there is no unique observable event that coincides with or can account for the dramatic behavioral change.

3. Rarity: The prevalence of bizarre behaviors is low, usually below 2-3%.

4. State of unawareness: The individual is unaware of the underlying causes of the behavioral change and sometimes has no knowledge that this behavior is deviant even when questioned immediately after onset.

5. Social judgment: People stigmatize the deviant behavior as a reflection of a mental or physical illness.

As a rule, a behavior is diagnosed as bizarre if it meets all the above five criteria, and non-bizarre (e.g., simple phobia, depression and PTSD) if it fulfils fewer, usually no more than two, criteria (see Rofé 2000, Table 1, p. 104). Bizarre neurotic behaviors (e.g., see four case studies by Rofé 2000, pp. 107-115) may be manifested in all spheres of psychological functions, such as motor (e.g., conversion disorder), emotional (e.g., agoraphobia and panic disorder), eating (e.g., anorexia nervosa), memory (e.g., dissociative fugue) or thought (e.g., obsessive ruminations) responses or combinations of these behaviors. However, neurotic patients do not suffer from thought disorders, expressed by hallucinations, delusions and illogical verbalizations (e.g., disorganized speech), which are exclusive to psychoses. Although neurotics, and even normal individuals may sometimes display thought disturbances (e.g., visual hallucinations; Andreasen 1979; Tien 1991), they do not fulfill PBT’s five criteria for bizarreness.

Given the severe impact of bizarre behaviors on daily functioning, their sudden onset and patients’ state of unawareness, the traditional axiomatic belief that neuroses are the consequence of irrational mechanisms (e.g., the unconscious, conditioning or adverse neuro-chemical changes) was the most plausible assumption. However, in light of the increasing theoretical and empirical difficulties challenging the validity of traditional theories, PBT suggests that this assumption be abandoned. Instead, bizarre behaviors are viewed as pathological coping mechanisms, which are consciously and rationally chosen to enhance the individual’s coping abilities. This is achieved through two basic aspects of bizarre behaviors: 1) High attentional demands (criterion no. 1), which eliminate/repress stress related thoughts from attention; and 2) The social stigma of sickness (criterion no. 5), which allows patients to avoid/escape stress and manipulate the environment to increase social rewards. Yet patients are unaware of their self-involvement in adopting and maintaining the symptom through sophisticated self-deceptive processes. Thus patients’ state of unawareness does not reflect irrationality, as claimed by mechanistic theories, but is rather an expression of the individual’s creative ability.

3. Repression

3.1. Definition and central characteristics

Like Freud, who viewed repression as the “cornerstone on which the whole structure of psychoanalysis rests” (Freud 1924/1959, p. 16), PBT considers this concept to be the key to understanding neurotic disorders. However, based on experimental studies in this area (e.g., Holmes 1974; 1990), which found that repression is merely a conscious distraction, PBT defines this concept as a coping mechanism by which threatening materials are consciously prevented access to attention by actively implementing distracting maneuvers.

Erdelyi and Goldberg (1979) noted, in their attempt to defend Freud’s theory in light of Holmes’ experimental findings, that Freud himself viewed the essence of repression as distraction. These authors claimed that “the unconscious nature of repression was simply not a critical theme in Freud’s treatment of the topic” (Erdelyi & Goldberg 1979, p. 365) and that, at least sometimes, repression was portrayed as a conscious, deliberate act. However, while PBT’s concept of repression is to some extent consistent with Freud’s original idea, it is certainly inconsistent with psychoanalytic doctrine, which viewed repression as “an unconsciously purposeful forgetting” (Fenichel 1946, p. 148). Moreover, PBT also rejects the notion that people forget rather than remember traumatic experiences and that repressed memories are permanently stored in a mysterious inaccessible store (e.g., Wachtel 1977, pp. 28-29) as both these of concepts are contradicted by available empirical data (e.g., Pope et al. 1999; Rofé 2000, Chapter 1).

PBT further modifies the traditional concept of repression by differentiating between normal and pathological repression, based on the means by which distraction is attained. Numerous studies show that repression is normal, and may even enhance the individual’s ability to adjust, when the individual distorts reality by employing socially accepted means of distraction (see review by Rofé 2000, pp. 20-23). Repression becomes pathological when socially accepted distractive means become ineffective and the individual consciously employs bizarre behaviors in order to eliminate stress-related thoughts from attention. The distractive effects of these behaviors are so powerful that they can effectively compete with the devastating thoughts that control patients’ attention. Thus, a fundamental difference between PBT and psychoanalysis is that repression is the consequence rather than the cause of behavioral deviation.

Nevertheless, despite the deliberate adoption of the bizarre behavior, neurotic patients are unaware of their conscious repressive endeavors. However, while psychoanalysis attributes this state of unawareness to an autonomous unconscious entity, PBT restricts the state of unawareness solely to pathological repression, attributing this condition to sophisticated self-deceptive processes.

3.2. Emotional function of repression

Research data show that patients who display bizarre behaviors suffer from depression and that anti-depressants are effective therapeutic interventions (see Rofé 2000,pp. 105, 249-252). Thus, it seems that just like normal repression, which is employed as a coping means against emotional distress (e.g., Nolen-Hoeksema et al., 1993; Rofé 2000, pp. 20-22), pathological repression, caused by the adoption of bizarre behaviors, is utilized when emotional distress is beyond patients’ normal coping resources. Moreover, usually the underlying motivational factor of neuroses is depression rather than anxiety, as originally suggested by psychoanalytic and behavioral investigators (e.g., Eysenck 1976; Freud 1926/1964). Accordingly, patients are willing to abandon their symptoms when depression is alleviated by more adaptive means, such as anti-depressants. Bizarre behaviors only alleviate, but do not entirely eliminate depression, both because the symptom does not completely seal attention from stress-related thoughts and since the behavior itself constitutes a significant source of stress.

Typically, stressful life events precede the development of bizarre behaviors (see Rofé 2000 for case studies, pp. 107-115; and review pp. 120-121). However this factor is not sufficient to produce the necessary emotional distress required to motivate the adoption of a bizarre behavior. As noted by Barlow (1988), “a common finding across all disorders studied is that even acute stress, usually defined as a negative life event, correlates only modestly with psychopathology” (p. 218). Therefore, other factors, such as genetic predisposition to depression and anxiety, social support, personality characteristics, traumatic childhood experiences and the individual’s coping resources must be taken into account (see review by Rofé 2000, pp. 122-124).

In some cases bizarre behaviors are adopted in response to unacceptable impulses (see Rofé 2000, pp. 129-139), which may be a direct consequence of stressful life events, such as marital conflict (e.g., Neale et al., 1982, pp. 1-16; McAndrew 1989) or an independent stressor (e.g., unacceptable sexual demands; see Sherman 1938, pp. 226-227). In these cases, the motivating emotional factor directly affecting the choice of a neurotic symptom is anxiety, rather than depression.

4. Choice of symptom

Research and clinical evidence shows that neurotic symptoms are unequally distributed between the sexes and among different age and socio-cultural groups and that the prevalence of these disorders varies over the years (see Rofé 2000, pp. 28-30; 87; 163-164; 166-167). This variability poses a difficulty to traditional mechanistic theories, but may be resolved if choice of symptoms is viewed as a conscious and rational process. Indeed, relevant evidence suggests that like economic decisions, choice of symptom is affected by the individual’s unique needs (in neurosis distraction and controllability; see below), availability of suitable “merchandise” and cost-benefit analysis.

However, rationality must be evaluated not in absolute terms, but rather in accordance with the boundaries of information available to the individual and psychosocial and environmental constraints. As noted by Monzingo (1977) “since intelligence, information and foresight are limited, an individual may make a choice which appears to be rational … only to discover later that he was mistaken. Given these limitations, the limitations of an imperfect world, the outcome does not alter the fact that the choice when made was rational” (p. 264).

4.1. Controllability

Both animals and humans are motivated to gain control over their stressors, as a lack of control has a detrimental cognitive, emotional, and physical impact on the subject (see a review by Rofé 2000, p. 125). This is consistent with evidence indicating that a specific neurotic symptom is likely to be adopted if, in addition to inducing repression it can also reduce the noxious impact of the stress or enables the manipulation of the stressor or the social environment to comply with the patient’s needs. For example, conversion symptoms increase patients’ ability to escape military stress (e.g., Ironside & Batchelor 1945; Mucha & Reinhardt 1970) or marital conflict (e.g., Brady & Lind 1961). Similarly, dissociative fugue, agoraphobia and OCD may distance patients from the stressor and thereby reduce its noxious emotional impact (e.g., see Rofé 2000, cases 1-3, pp. 107-114). Likewise, the symptom may increase the dispensation of social rewards (e.g., Blanchard & Hersen 1976, Brady & Lind 1961). For example, Rachman and Hodgson (1980) noted that as the incapacitation of OCD patients intensifies, the demands made on spouse, parents and children increase. “Not only are they required to take over many of the patient’s functions – domestic, personal, financial and social – they have to devote increasing time and effort to the protection and comforting of the affected person” (p. 62). This theoretical account is consistent with the family system theory of eating disorders, claiming that the “sick rule” provides an alternative focus of attention, thereby holding the family members together (e.g., Minuchin et al., 1975).

When stress is an unacceptable impulse, such as an intolerable hostile drive, patients will seek symptoms that reduce the likelihood of losing control. Usually this need motivates the adoption of OCD, where patients exercise control over the impulse through the strategy of “reaction formation” (e.g., Fenichel 1946, p. 151). Patients intentionally display obsessive thoughts and compulsive rituals that are antithetic to the impulse and can therefore reduce the threat of losing control. For example, Neale et al. (1982) described a woman who harbored strong hostility towards her children following severe marital conflict and disciplinary problems. Consequently, she developed obsessive concerns regarding the safety of her children and bizarre ritualistic behaviors that she believed would prevent disastrous outcomes to her children. This response strategy reduced the likelihood of impulsive behaviors since “instead of injuring the children, she spent a good deal of her time every day performing irrational responses aimed at protecting them” (p. 12).

Another coping strategy that patients frequently employ when faced with unacceptable impulses is obsessive ruminations. Patients intentionally produce extremely unacceptable repetitive thoughts that lack appropriate emotions. In psychoanalysis, these thoughts were seen as a genuine expression of a threatening impulse where the emotional component was unconsciously isolated (repressed) from its cognitive basis (e.g., Fenichel 1946, p. 146). In contrast, according to PBT patients choose obsessive thoughts rather than other neurotic disorders especially because they provide effective control over the unacceptable impulse. Unacceptable emotionally charged thoughts are deliberately replaced with bizarre obsessive thoughts that lack emotional basis. As a result, they are less likely to motivate dangerous impulsive behavior. In addition, the obsessive thoughts intensify self-awareness of being potentially dangerous, which motivates patients to take appropriate preventative measures to reduce the likelihood of potential harm (e.g., removing dangerous objects, such as knives, from home). Furthermore, the publicity of these thoughts, which is typical of obsessive ruminations, reduces fear of losing control as it motivates others to supervise the patient’s behavior (see case study in Rofé 2000, pp. 133-134). The obsessive thoughts are isolated from an appropriate emotional basis and appear foreign to the self both because they are artificial, rather than genuine spontaneous experiences, and since patients are unaware of their self-involvement due to self-deceptive processes. Thus, like repression and reaction formation, PBT accounts for the psychoanalytic defense mechanism of isolation in conscious, rational terms.

Lewis (1981) noted that Freud was puzzled by the fact that obsessive patients perceive their aversive thoughts as “crazy” and yet they are powerless to stop them from penetrating the conscious:

In any rational system, knowing that ideas are crazy should be adequate to demolish them, but in the obsessional neurosis the patient’s intellect is powerless to do more than observe his ‘craziness’ (Lewis 1981, p. 101).

However, PBT views obsessive thoughts as one of the wise cognitive maneuvers, which patients consciously employ to cope with intolerable internal stress.

Reaction formation and isolation have an effective controllability value before, but not after, the unacceptable impulse has been acted upon. In the latter case, patients tend to adopt ritualistic bizarre behaviors that have a personal and cultural symbolic meaning of atonement or cleansing (e.g., praying or excessive washing) – which psychoanalytic theory termed undoing (Freud 1926/1964, pp. 88, 119-120, 164) – in an attempt to counteract the aroused feelings of anxiety and guilt (see case studies by Rachman & Hodgosn 1980, pp. 255-256; and Sherman 1938, pp. 226-227).

Sometimes patients choose other types of neuroses to reinforce control over an intolerable impulse. For example, Abse (1959, p. 282) described a man who developed hysterical leg paralysis after his wife left him for another man. The husband had felt a strong impulse to pursue his wife in order to kill her and her lover. Another example is panic disorder that distances the patient from the hated person (see case study by Rofé 2000, p. 137).

While in most cases patients aim to reduce the risk of losing control, sometimes, apparently when the impulse is especially strong and the inhibitory forces are low, patients may seek control over their internal stressors by choosing symptoms that allow them to act out the impulse while attributing the cause to factors external to the self. For example, patients may implement their unacceptable sexual (see case studies in Rofé 2000, pp. 137-139) or hostile (e.g., see case study by Perr 1991) drives by developing MPD.

4.2. Availability

The second principle that affects the choice of symptoms is availability. The symptom is selected from experiential resources that become salient in attention through the individual’s specific coping needs and environmental cues. These resources can be classified into a number of categories, as specified below.

Somatic defects: Patients often utilize their physiological defects to develop neurotic disorders when appropriate to their pathological coping needs. For example, not only is there a strong relationship between conversion disorder and organic defects, but even the “selection of a specific type of symptomatology appears to be determined by the patient’s own past experiences with illness or injury” (Carden & Schramnel 1966, p. 27). Availability may also account for the significant relationship between respiratory diseases (e.g., asthma) or a cardiac malfunction of mitral valve prolapse and panic disorder (see review by Rofé 2000, pp. 141-143).

Behavioral repertoire: Sometimes bizarre behaviors are a deliberate exaggeration of routine behaviors. For example, a significant relationship exists between dieting and eating disorders (Rofé 2000, pp. 143-144). Accordingly, the higher prevalence of eating disorders among women may be partly due to the fact that women are more preoccupied with weight and dieting (e.g., Stice 1994). Likewise, both homosexual males, who place a higher value on their appearance (e.g., Carlat, Camargo, & Herzog 1997) and men whose occupation demands strict weight control and a thin appearance, such as dancers, actors, models, and athletes (e.g., Stice 1994), are at a higher risk for developing eating disorders. Both groups utilize their dieting repertoire to develop eating disorders when a need for a pathological coping mechanism arises. The increased availability of dieting practices and the quest for a slim appearance may partly account for the dramatic increase of eating disorders in modern times (e.g., Polivy & Herman 1987).

The effect of behavioral repertoire is also evident in OCD. For example, the high rate of compulsive cleaning among women was attributed to the fact that in our culture most women are responsible for running the household (Emmelkamp 1982, p. 167). Similarly, it is likely that the over representation of religious individuals among OCD patients (e.g., Rasmussen & Eisen 1992) is the result of the increases availability of rituals in their behavioral repertoire.

Family history: Modeling of family members is an important source of availability. For example, Mucha and Reinhardt (1970) found that 70% of conversion disorder patients had parents who suffered from illness in the same organ system affected by their hysterical symptoms. Similarly, Dell and Eisenhower (1990) reported that 73% of patients with MPD had at least one parent who suffered from a diagnosable dissociative disorder and 36% of the mothers had MPD. Modeling of family members was also observed with respect to eating disorders and OCD (see review by Rofé 2000, pp. 148-150).

Peer group: As demonstrated in several cases of mass hysteria, peers who display deviant behaviors may serve as models for imitation when the symptoms satisfy the individual’s coping needs (e.g., see Nandi et al. 1985). This effect is evident in other psychiatric disorders as well. For example, as pointed out by Striegel-Moor et al. (1986), “a college woman who purges almost always knows another female student who purges, whereas a woman who does not purge rarely knows someone who does” (p. 256).

Mass media: Numerous studies show that increased exposure to eating disorders and MPD through mass media may account for the dramatic increase in the prevalence of these disorders in more developed countries and fluctuations in their distribution among different sex and socio-economic groups (see review by Rofé 2000, pp. 151-153). For example, Andersen and DiDomenico (1992), upon examining the underlying causes of sex differences in eating disorders, found that women’s magazines contained 10.5 times more articles and advertisements promoting weight loss than men’s magazines.

Education: Choice of symptom is also affected by the individual’s training (see Rofé 2000, pp. 153-154). For example, subjects associated with the field of medicine, such as physicians, nurses, and medical secretaries, are more likely to develop complicated hysterical ‘diseases’ (e.g., Ziegler et al. 1960). Accordingly, a significant percentage of MPD patients had training in the mental health field (17%), aspired to become mental health professionals (17%) or had extensive psychiatric or medical knowledge (28%; see Spanos 1996, p. 242).

Suggestion: Pre-neurotic patients, preoccupied by the need to develop a bizarre symptom, may be motivated to choose a particular disorder, such as MPD (e.g., Spanos 1996), following suggestions by an authoritative person, such as a therapist or religious mentor (see Rofé 2000, pp. 154-155). For example, Spanos et al. (1985) reviewed clinical data showing that “therapists sometimes encourage patients to adopt the multiple role, provide them with information about how to enact that role convincingly, and perhaps, most important, provide ‘official’ validation for the different identities that their patients enact” (p. 363).

Unique personal experiences: In the aforementioned categories of availability, the symptom was not unique to the individual, as other patients display similar behaviors (e.g., anorexia nervosa). However, there are cases in which the symptom is idiosyncratic and constitutes a deliberate exaggeration of a personal aversive experience, that the patient has or has had toward a certain stimulus, to a bizarre level. The stimulus becomes salient in the individual’s attention when facing unbearable stress, due to its environmental or symbolic relationship with the stressor. For example, Brandt and Mackenzie (1987) reported a case study of a woman who, as a child, saw a rat in the family garage while being sexually abused by her brother for the first time. Years later, at age 26, she developed an intrusive fear of contamination, accompanied by compulsive hand-washing, upon discovering that her husband had been engaged in an extramarital affair. The symptoms were exacerbated during pregnancy and she would not allow her husband to touch her. Thus, feeling sexually abused once again, the familiar feelings of revulsion associated with the rat incident, which may have symbolically represented her disgusted attitude toward her husband, were inflated to a bizarre level for the purpose of pathological coping. As in the psychoanalytic case of Little Hans (Freud 1909/1964), instead of focusing on her husband’s stress-provoking behavior, the woman chose to alienate herself from the painful situation by directing her feelings of disgust toward the available representative of her sexual mistreatment (i.e., the rat).

4.3. Cost-benefit analysis

In the decision-making process, patients weigh the coping benefit of distraction and controllability of an available symptom as against the expected cost, mainly concerning social stigma and impact on overall adjustment. As a rule, a specific symptom, or other modes of coping, is only likely to be adopted if it reduces the patients’ emotional distress and they can absorb the cost.

As with suicide (e.g., Sanborn 1990) and drug abuse (Robbins 1989), cost-benefit analysis can also account for sex differences in neuroses. Socialization processes encourage men “not to be sissies” (Sanborn 1990, p. 151) and to avoid inappropriate feminine coping strategies (Eisler & Blalock 1991). Additionally, numerous studies show that unemployment has a much stronger aversive impact on men’s well being than on women’s (see review by Rofé 2000, p. 163). Consequently, men tend to avoid neurotic disorders, such as agoraphobia, panic disorder, MPD, and conversion disorder, because of the higher cost of both social stigma and damage to work ability (see Rofé 2000, pp. 162-163).

OCD is the only neurotic disorder that is equally prevalent between the two sexes, due to its equal cost to both men and women (see review by Rofé 2000, pp. 28-29). Social embarrassment is relatively low for OCD patients as they have the freedom to avoid symptoms when inconvenient, without being perceived as malingerers. As noted by Rachman and Hodgson (1980), “without any effort a compulsive cleaner or checker can abbreviate, extend, curtail or postpone a compulsive act” (p.15). Additionally, several case studies indicate that OCD poses a minimal threat of unemployment for working individuals (Rachman & Hodgson 1980, pp. 60-61).

The cost-benefit principle may also account for age differences in the prevalence of neurotic disorder. Conversion disorder is relatively more common than other neurotic disorders among children (e.g., Proctor 1958), not only because of their higher familiarity with physical illnesses than other psychiatric symptoms, but also because it enables an easy escape from scholastic stressors and solicits attention from parents and teachers (e.g., Clarizio & McCoy 1983).

Similarly, children prefer to develop school phobia (e.g., Last & Francis 1988), rather than agoraphobia and panic disorder, which are rare among children (e.g., Wittchen & Essau 1993), as it provides more control over their scholastic stressors. However, after the school years, when cost-benefit considerations have changed, the school phobia might develop into agoraphobia if the need for a bizarre coping strategy persists (e.g., Deltito & Hahn 1993).

Sometimes, a stressor may motivate the selection of a particular disorder as a result of cost-benefit analysis. Accordingly, patients tend to choose OCD as a coping mechanism against unacceptable impulses (e.g., Miller 1983) as its symptoms provide an effective measure of control (see controllability) at a relatively low cost in terms of social embarrassment and damage to work ability.

When two symptoms provide equal benefit, the least costly will be chosen. For example, conversion symptoms are more frequently found on the left side of the body than on the right. While psychoanalysts attributed these findings to the right hemisphere, which they posited as the location of the unconscious, Kihlstrom (1984), who rejected this claim, noted that “a more parsimonious explanation… is that the symptoms are lateralized where they will do the least harm” (p. 160).

In conclusion, controllability, availability and cost-benefit analysis account for the variability in the distribution of neurotic disorders, such as sex, age, socio-economic differences and diagnostic fluctuations (e.g., the rising prevalence of MPD and eating disorders), thus synthesizing a vast amount of data from different schools of thought. While the choice of symptoms is determined by current stressors, PBT incorporates the psychoanalytic idea that unacceptable impulses play a major role in neuroses. This choice is also affected by the patient’s biological weaknesses, behavioral repertoire, cognitive knowledge available from various channels of communications or as a consequence of childhood traumatic experiences. Yet, this choice is conscious and rational, as the patient weighs the benefit versus the cost involved in the decision process.

5. Unawareness: A self-deceptive process

Unawareness is a central component of neurotic disorders. In fact, repression, resulting from the adoption of the bizarre symptom, would not be possible if patients were aware of this process. Thus, the most important challenge of a conscious approach to psychopathology concerns the state of unawareness of self-involvement. How can the conscious be so actively involved in producing and monitoring bizarre behaviors and yet be so deeply and sincerely unaware of these activities? As specified below, the enhanced knowledge of cognitive psychology indicates that this process is the consequence of sophisticated self-deceptive processes. This concept precludes the existence of a scientifically unfounded omnipotent entity that, like spiritual possession, can dictate the individual’s life (e.g., see Greenwald 1992; Rofé 2000, Chapter 1). Moreover, unlike the unconscious, unawareness plays no etiological role in the development of neurotic disorders, as it follows rather than precedes the onset of neuroses. The production of this state is a complicated cognitive process, composed of three stages: Generation, preservation and stabilization.

5.1. Generation of unawareness

Neurotic patients generate a state of unawareness regarding their self-involvement through two sets of variables: 1) Encoding-Inhibitory factors that weaken the transference of the knowledge of self-involvement (KSI) from short- to long-term memory; and (2) Memory-Inhibitory mechanisms that cause the forgetting of the KSI.

Encoding-Inhibitory Factors: Clinical and research evidence suggests that five factors weaken the encoding of the KSI: Impaired cognitive functioning, directed forgetting, hypnotic trance, self-deceptive distraction and brief rehearsal period.

Many studies demonstrate that extreme emotional distress, such as anxiety or depression, impairs the individual’s cognitive functioning and causes poor learning and memory conditions (see Rofé 2000, p. 174). Accordingly, since the pre-neurotic patient is subjected to a high level of emotional distress (see Rofé 2000, pp. 105-107), the encoding of the KSI is likely to be weak.

Another disruptive factor is a hypnotic-like trance produced by the adoption of a bizarre behavior. An increasing number of studies show that hypnosis is a conscious-voluntary response that depends on the subject’s willingness to concentrate intensively and exclusively on the hypnotic suggestion (e.g., Lynn, 1997, Spanos 1986, 1996). From this perspective, the patient’s cognitive state during the actual display of the symptom is comparable to a hypnotic trance. This theoretical position is consistent with Van Pelt’s (1975) theory on psychoneurosis. Relating to neurosis as a deliberate behavior, the author noted that:

The naturally occurring psychoneuroses are the result of accidental self-hypnosis and suggestions… A patient suffering from a psychoneurosis behaves in every way as though under the influence of a post-hypnotic suggestion… (pp. 28-29).

Similarly, Ravenscroft (1965) noted with reference to spiritual possession, which is a form of bizarre behavior prevalent in non-western countries, that “such behavior has a striking similarity to many of the classic phenomena of hypnosis and strongly suggests the possibility of an underlying hypnotic mechanism” (p. 157). Thus, bizarre behaviors can be seen as powerful hypnotic tools that intensively preoccupy the individual’s attention, and thereby severely disrupt the encoding process of the KSI (see case no. 1, Rofé 2000, pp. 107-108, 175).

An additional interference factor relates to numerous studies on directed forgetting (see Rofé 2000, 175), indicating that subjects can deliberately disrupt the encoding process by directing attention away from the anxiety-provoking information, such as the KSI.

Clinical evidence suggests that patients can also disrupt the encoding process by self-deceptive distraction. People tend to internalize socially accepted beliefs regarding the etiology of various disorders, such as psychoanalytic concepts in western society (e.g., Spanos et al. 1986) and spiritual possession in less developed countries (e.g., Kua et al. 1986). Moreover, “In the absence of a culturally supplied rule, implicit causal theory, or assumption about co-variation, people may be able to generate hypotheses linking novel stimuli and novel responses” (Nisbett & Wilson 1977, p. 248). Accordingly, clinical evidence indicates (see Rofé, 2000, p.177) that as part of self-distractive maneuvers, neurotic patients disrupt the encoding of the KSI by intensively focusing, during the decision-making stage and actual display of the symptom, on certain beliefs that seemingly account for their sudden behavioral changes.

The last interference factor relates to the rehearsal period during the encoding stage. Mensink and Raaijmakers (1988) noted, in their model of interference and forgetting, that “the amount of elaborative rehearsal will be proportional to the length of time an item is studied (rehearsed) in STM (short-term memory)” (p. 436). In neurosis, the rehearsal period is necessarily brief due to two main factors.

First, the period in which a decision is made to adopt a specific symptom is brief. Patients do not thoroughly review various response options and choose the most suitable symptom. Rather, the choice is made spontaneously, without prior planning. For example, Malamud (1944) reported a case of hysterical blindness that developed immediately after a car accident in which the patient sustained minor injuries. Similarly, Leonard, (1927) developed his sudden panic attack in response to a train that he accidentally encountered (see Rofé 2000, pp. 107-111). Likewise, Rachman and Seligman (1976) revealed a severe chocolate phobia developed by a woman who accidentally saw a bar of chocolate present in a room containing her mother’s coffin. In all these cases the decision to develop the bizarre behavior was made on the spot. It seems likely that a spontaneous decision occurs in all types of neuroses.

Second, simultaneously with the display of the symptom, memory-inhibitory mechanisms enter the process, facilitating forgetfulness and blocking retrieval of the KSI.

Memory-Inhibiting Mechanisms: The low strength memory of the KSI enables memory-inhibiting mechanisms to cause successful forgetting of this information, thus creating a state of unawareness. One factor that inhibits the memory of KSI is hypnotic amnesia. An increasing number of studies suggest that hypnotic amnesia is the consequence of active distractive maneuvers where the subject deliberately ignores the target relevant cues and attends exclusively to other matters (e.g., Spanos 1986, 1996; Wagstaff & Frost 1996). Accordingly, given the powerful hypnotic and distractive values of the symptom, neurotic patients can create a state of unawareness by focusing intensively and exclusively on the bizarre behavior and related thoughts both during the actual presentation and immediately afterward (see Rofé 2000, case no. 1, pp. 107-111).

The second factor that contributes to the generation of unawareness is state-dependent memory. Numerous studies indicate that remembering becomes difficult when the retrieval conditions are different from the original learning situation in terms of emotional, cognitive or environmental state (see Rofé 2000, p. 179-180). This factor is relevant to neuroses since the coping value of the symptom should radically reduce the patient’s emotional distress. In addition, the symptom must also cause a radical change in the patient’s cognitive state, since he or she becomes pre-occupied with symptom-related thoughts rather than with stress-related thoughts. This factor is especially strong in multiple personality disorder (MPD) due to the striking differences in personality traits that patients display. Furthermore, in some cases the symptoms result in environmental changes as well, as in agoraphobia and panic disorder where the patient escapes the situation where the symptom was originally created (see Rofé 2000, case no. 1, pp. 107-117). Consequently, changes in the patients emotional, cognitive or environmental condition should weaken the retrieval of the KSI.

Another memory-inhibiting factor that enables the creation of unawareness is suppression. Experimental studies of directed forgetting show that individuals can intentionally interfere not only with the encoding process but the retrieval process as well (e.g., Basden et al. 1993; Myers et al. 1998). This means that patients can facilitate the forgetting of the KSI after the encoding stage by intentionally suppressing thoughts regarding self involvement and avoiding situations that might be reminiscent of this information (see Rofé 2000, case no. 3, pp. 112-114).

In conclusion, it seems that the phenomenon of unawareness that characterizes neurotic patients immediately after the onset of the bizarre behavior is the consequence of inhibitory factors during the encoding stage and memory-inhibiting mechanisms that block the retrieval of this information.

5.2. Preservation of unawareness

Patients’ unawareness regarding the underlying causes of the behavioral change may stimulate self-probing of a conspicuous behavioral change (e.g., Leonard 1927, p. 308; McAndrew 1989) that if not properly addressed may endanger the state of unawareness of self-involvement. However, this threat is prevented by self-deceptive beliefs that patients develop immediately after the generation of unawareness. Depending on the type of behavior, the self-deception may pertain to either illness or denial.

Self-Deceptive Illness: Inevitably, upon generation of unawareness, most neurotic patients have an extrospective observation of a socially and personally undesirable behavioral change. Patients also have a strong introspective observation of loss of control, as seen, for example, in panic disorder (e.g., McNally et al. 1995) and bulimia nervosa (DSM–IV, American Psychiatric Association 1994). Necessarily, patients develop a self-deceptive diagnosis of illness on the basis of these two observations, namely, that their behavior is controlled by factors beyond the self (e.g., the unconscious or adverse neurochemical changes; see Ollendick 1995, p. 529). Potentially, they could disregard their extrospective and introspective observations, as people often do when initially confronted with alarming signals normally associated with physical illness (e.g., Cohen & Lazarus 1973; Langer et al. 1975). However, it is unlikely that neurotic patients would do so due to the negative emotional consequence of such a strategy. Unlike physical illness where denial reduces anxiety, for this group of neurotic patients, relief is only obtained by intentionally focusing on and negatively interpreting the symptom.

A rare case study describing the production of a self-deceptive diagnosis of illness was reported by Leonard (1927), a poet and university lecturer who suffered from agoraphobic symptoms, in his autobiographic account. Leonard was totally unaware of the underlying causes of his first panic attack. Then, upon observing a dramatic change in his behavior and experiencing a total loss of, he became convinced that he suffered from a serious illness. Initially the patient thought that he suffered from sunstroke (“I think it is sunstroke”; Leonard 1927, p. 308), but he soon rejected this diagnosis (“I know from the symptoms it cannot be sunstroke”; Leonard 1927, p. 308). Continuing the diagnostic evaluation, Leonard arrived at the conclusion that he was in “a critical condition” and said in a low voice “father and mother, this looks like the end. I guess I am dying” (Leonard 1927, p. 308). Nevertheless, despite this frightening assessment, Leonard experienced “sudden relief” (p. 309) and he managed to sleep well that night (p. 308). Thus, Leonard did not have any motivational incentive to deny the diagnosis of illness, as people tend to do when faced with the suspicion of physical illness.

The deceptive self-diagnosis of illness is sufficient to preserve the unawareness of self-involvement, enabling the symptom to fulfill its distractive function. Nevertheless, as noted by Nisbett and Wilson (1977), when people are unaware of the underlying causes of their behavior, they employ implicit cultural theories to account for their responses. Consequently, by producing a self-deceptive explanation concerning the etiology of their “illness,” patients benefit from an additional barrier that blocks the accessibility of the KSI into attention. Western patients employ a “scientifically” self-deceptive explanation, as did Leonard (1927, pp. 323-324) who was highly familiar with Freud’s work and attributed his panic attack to the unconscious. In contrast, those from less developed countries are likely to employ the culturally accepted explanation of spiritual possession for the same purpose (e.g., see Kua et al. 1986; Wijesinghe et al. 1976).

Therapy provides a wealth of “scientific” information for the development of a self-deceptive explanation or strengthening of an existing belief. This may account for patients’ ready acceptance of therapists’ suggestions. As noted by Marmor (1962):

The fact is that patients treated by analysts of all these schools may not only respond favorably, but also believe strongly in the insights which they have been given. Even admittedly ‘inexact interpretations have been noted to be of therapeutic value!’ (p. 289).

This tendency to comply with therapists’ suggestions has been attributed to analysts’ ability to “induce, alter, and control their client’s self-insights” (Bandura 1969, p. 94). However, it seems that investigators over-emphasized the effect of this factor, neglecting to take into account patients’ interest and willingness in being deceived. This claim accounts for patients’ tendency to favor therapists whose belief system concurs with their own (e.g., patients in less developed countries prefer witch doctors to western therapists; see Pattison & Wintrob 1981; Witztum et al. 1996). The need for self-deceptive evidence may also account for the fact that patients spend much of their time, money and energy on therapy even when it is ineffective (e.g., psychoanalysis; see Eysenck 1994). For example, Leonard (1927) who spent several years in psychoanalytic therapy with no satisfactory results noted that he had “even now not lost all faith in the method, nor all faith that it may yet work out in this case. But the fact is that it has not” (Leonard 1927, p. 414; italics added).

Self-Deceptive Denial: Some neurotics deny that their behavior is maladaptive, inventing fictitious rationale to account for their symptoms. This includes anorexia nervosa where patients vigorously defend their “emaciated body as not too thin but as just right, as normal” (Bruch 1973, p. 89) and some obsessive-compulsive patients (e.g., compulsive cleaners) who deny that their behaviors are excessive or unreasonable (e.g., Rachman & Hodgson 1980, p. 19). Like the illness group, denial subjects base their deceptive diagnosis on extrospective and introspective observations soon after the generation of unawareness. Patients observe a behavioral change that is socially desirable and sometimes even admired by their family and friends, at least at the onset stage (e.g., anorexia; see Branch & Eurman 1980). As a result, it is unlikely that patients will experience a loss of control. Rather, the newly adopted behavioral change results in substantial emotional relief. Hence, based on the extrospective observation of socially encouraged behavior and the introspective evidence of emotional relief, patients would inevitably develop a belief that their behavior is normal and invent a fictitious rationale to justify the behavioral change. For example, an excessive cleaner stated that “he realized that he washed more than other boys, but that in his case there were real reasons. He believed that his skin was of such a texture that it retained dirt and germs, and therefore was forced to wash and scrub himself” (Sherman 1938, p. 19). Thus, although patients in the denial group are aware that they intentionally produced the behavioral change, the denial strategy enables patients to preserve their unawareness regarding the anxiety-provoking causes that truly motivated them to adopt the symptom.

Given the subjectively solid evidence, it is no wonder that patients in the denial group would resist any social pressures to nullify the behavioral change (e.g., see Bruch 1978, p. 2). This can also account for the anorexic's "relentless pursuit of thinness and denial of even advanced anorexia as being 'too thin'" (Bruch 1973, p. 236). Nevertheless, several studies indicate that denial patients are likely replace their self-deceptive denial with a self-deceptive diagnosis of illness when they cannot avoid observations that sharply contradict their earlier beliefs (see Rofé 2000, pp. 189-191).

5.3. Stabilization of Unawareness

The generation and preservation stages account for unawareness only at the onset, but not subsequently upon repeated display of the symptom. This section outlines the situations that motivate repeated manifestation of the symptom (stress, belief-challenging conditions, and interval between episodes) and discusses the self-deceptive maneuvers that stabilize the state of unawareness.

Symptom-activating situations: Much evidence indicates that patients re-activate their symptoms whenever confronted with a stressful life event that aggravates their emotional states (see Rofé 2000, pp. 192-194). For example, Blanchard and Hersen (1976) describe a case study of hysterical epilepsy where the patient re-displayed her symptom when re-confronted with marital conflict. In another case, agoraphobic symptoms were exacerbated with the aggravation of the patient’s level of depression (Marks 1987, p. 338).

The second factor that stimulates re-activation of the symptom is belief challenging conditions where failure to respond may invalidate the belief and hence subvert the maintenance of the patient's coping mechanism. For example, in order to preserve their beliefs, agoraphobics (see case studies by Leonard 1927; Marks 1987, pp. 325-326) and obsessive-compulsive cleaners (see Rachman & Hodgson 1980) must display escape behavior whenever confronted with belief challenging situations (e.g., public places and dirt, respectively). Similarly, panic patients, who attribute their symptoms to coronary heart disease (e.g., see Clark 1986; Margraf & Ehlers 1991), must display panic attack in response to situations enhancing their bodily sensations (e.g., chemical substances and strenuous exercise; see Barlow 1988, Rapee 1995). Likewise, Levy and Jankovic (1983) could manipulate the symptoms of a conversion disorder patient by experimentally challenging her belief. The patient displayed a variety of dramatic pseudo-neurological symptoms when given a placebo that she believed was a certain drug that was supposed to magnify her symptoms and displayed normal behavior when given the drug while thinking it was something else.

Another situation that motivates symptom manifestation is the interval of time between episodes. Prolonged intervals threaten the maintenance of the self-deceptive belief and the controllability value of the symptom as they indicate that the patient has recovered from the disorder. Thus, in order to maintain the coping value of the symptom, patients must routinely display the bizarre behavior at a rate that sufficiently convinces themselves and others that they are still a “case.” This hypothesis may explain why patients become anxious when they forget or are unable to maintain their desired level of frequency of symptom display (e.g., see Neale et al., 1982, p.

2).

The self-deceptive cycle: Despite the continued involvement of the conscious in redisplaying the symptom, neurotic patients succeed in remaining unaware. This routine cycle where the individual is initially aware at the decision-making stage and unaware immediately after each symptom display is depicted in Figure 1.

No. 1 in the figure illustrates the three situations that stimulate the conscious to re-activate the symptom: Stress, belief-challenging conditions, and intervals between episodes. No. 2 describes a conscious response set, whereby the patient makes a rapid cost-benefit assessment and decides either to release (No. 3) or inhibit the symptom. For certain disorders where patients continuously display the symptom, such as hysterical paralysis, there will be no assessment during the normal course of symptom display. Assessment, and hence probable symptom inhibition, will only take place when the patient encounters a situation whereby the cost involved in maintaining the symptom may outweigh the benefits (e.g., see case study of hysterical paralysis by Goldblatt & Munitz 1976). In other disorders, where failure to display the symptom does not necessarily indicate its invalidation, patients are likely to inhibit the symptom when its display is inconvenient, even though normally the situation would otherwise have necessitated display. For example, as noted with regard to OCD, patients freely inhibit the exhibition of their symptom when it is socially embarrassing or threatens their work. Similarly, Varma et al. (1981) described a case study of an MPD patient, where the switch to another personality occurred only at home and “never during even prolonged visits with relatives” (p. 115). Sometimes patients will modify or inhibit the symptom when the cost is too high and employ self-deceptive excuses to rationalize the change (see Rofé 2000, pp. 110, 197).

For a brief period, patients are conscious of their self-involvement (No. 4) in re-activating the symptom. Yet a complex psychological process, consisting of re-generation and re-preservation of unawareness, which patients routinely activate after each new symptom display, constitutes a barrier that prevents patients from being aware of the KSI (knowledge of self-involvement). Unawareness is re-generated through factors that inhibit encoding and retrieval of the KSI. One of the encoding-inhibitory factors is short exposure time, resulting from the response set that facilitates the decision-making stage. In addition, the encoding of the KSI is accompanied by anxiety arousal, which, as indicated, impairs memory performance. A third factor is active distraction, whereby the patient intensively focuses on both the symptom (No. 5) and the self-deceptive belief (No. 6), thereby interrupting encoding. Encoding may be further interrupted by directed forgetting, whereby the individual intentionally diverts attention from the KSI.

Even if some encoding does occur, the memory strength would be so weak that it would become completely unavailable for retrieval due to memory-inhibiting mechanisms. Factors affecting retrieval mainly include: i) state-dependent memory resulting from emotional and cognitive changes following the display of the symptom; ii) hypnotic amnesia caused by patients’ intense pre-occupation with the self-deceptive belief and the symptom; and iii) suppression whereby patients intentionally avoid thoughts and situations that may be reminiscent of the KSI.

Patients re-preserve the state of unawareness generated by the above process by repeating the process of self-observation mentioned in the original preservation stage. Based on the extrospective observation of maladaptive behavior and the introspective experience of loss of control (No. 7 & 8, respectively), with each new display, patients in the self-deceptive illness group will have additional deceptive proofs to revalidate their self-deceptive belief (No. 6). A similar process occurs in the self-deceptive denial group. Based on their observations of socially accepted behavior and evidence of emotional relief (No. 9 & 10), with each new display, these patients will also obtain additional deceptive proof to revalidate their belief (No. 6). This deceptive cycle, where the conscious begins with awareness and ends with unawareness, may resolve Seligman’s (1988) dilemma regarding the resistance to extinction of panic disorder. The author noted that:

A person who has had panic disorder for a decade may have had about 1000 panic attacks. In each one, on the cognitive account, he misinterpreted his racing heart as meaning that he was about to have a heart attack, and this was disconfirmed. Under the laws of disconfirmation that I know, he received ample evidence that his belief was false, and he should have given it up… But neither theory explains why the belief did not extinguish in the face of disconfirmation long ago (p. 326).

Thus, in contrast to cognitive and conditioning theories, which predict extinction of the false belief after repeated displays of the symptom in the absence of negative consequences, PBT’s deceptive cycle indicates that repeated displays will actually strengthen, rather than weaken the self-deceptive belief.

6. Therapy

Despite striking differences in theoretical backgrounds and techniques, various forms of therapy are effective in treating neuroses (see review by Rofé 2000, Chapter 7). This section aims to integrate these findings into PBT’s theoretical framework by showing that the efficacy of a therapy depends on its ability to undo those factors, which according to PBT originally motivated the adoption and maintenance of the symptoms.

6.1. Undoing distraction

As noted above, distraction, the major coping function of bizarre behaviors, can only be achieved if patients are unaware of their active involvement in displaying the symptom. Hence, since the preservation of unawareness depends on the self-deceptive belief, a therapy that can invalidate this belief or nullify its deceptive value will sabotage the patient’s ability to preserve a state of unawareness upon displaying the symptom. This therapeutic intervention may undo the distractive value of the symptom and motivate patients to abandon it. The undoing of distraction can explain the efficacy of a number of therapeutic techniques such as exposure therapy, cognitive therapy, psychoanalysis and religious therapy.

Exposure therapy: Exposure therapy is the most effective treatment for certain anxiety disorders, such as agoraphobia and OCD (see Rofé 2000, Chapter 7). Although it is a behaviorist technique, developed following experimental studies with animals, research evidence indicates that its efficacy is the consequence of cognitive, rather than conditioning processes (e.g., Hoffart 1993; Rofé 2000, Chapter 7). However, it is even difficult to accept cognitivists’ explanation, claiming that exposure therapy re-educates patients to think rationally. For example, it does not seem plausible (without assuming the existence of uncontrollable mechanisms such as the unconscious or neurochemical changes) that adult individuals with normal cognitive development would suddenly think that a public place such as a supermarket could be dangerous, and then need the assistance of a therapist to educate them to think otherwise. Indeed, a large body of evidence argues against the validity of both behavioral and cognitive explanations regarding the development of anxiety disorders (see Rofé 2000, Chapter 2) and the therapeutic efficacy of exposure therapy (see Rofé 2000, Chapter 7).

As an alternative, PBT suggests that exposure therapy invalidates the patient’s self-deceptive belief. Patients are exposed to situations that challenge their beliefs (e.g., supermarkets and dirt) but are not allowed to exercise their ritualistic escape behavior that produces the deceptive proofs that would revalidate their deception (see Figure 1). Since exposure continues until anxiety is reduced, patients are inevitably confronted with extrospective observations of normal behavior and introspective experiences of self-control, which invalidate the self-deceptive belief. Hence, since a state of unawareness cannot be maintained without the self-deceptive belief, the symptom loses its distractive value. Unless patients employ self-deceptive excuses to defend their self-deceptive beliefs (e.g., see Hoffart 1993) they will have to abandon the symptom. Although cognitive therapy also claims that exposure therapy invalidates the patient’s belief (see Rofé 2000, Chapter 7), there is a striking difference between the two theoretical paradigms. Cognitivists view anxiety disorders as reflections of irrational mechanisms, claiming that exposure therapy repairs patients’ maladaptive thinking. In contrast, PBT defines these behaviors as rational coping mechanisms and asserts that exposure therapy simply prevents patients from utilizing their rational resources for maintaining their self-deceptive belief that their behavior is out of their control.

Cognitive Therapy: Cognitive therapy, the most effective intervention for panic disorder (Clark 1988; Rofé 2000, Chapter 7), focuses patients’ attention, using either verbal or experimental procedures, on the sequence of bodily sensations and catastrophic misinterpretations. The patient is then led to conclude that “the sensations are not themselves dangerous, it’s just what you think about them that can make them frightening” (Salkovskis et al. 1991, pl. 163). Thus, cognitive therapy increases patients’ awareness of the catastrophic misinterpretation of bodily sensations and confronts them with evidence that is incompatible with the belief that these sensations signify a cardiovascular disease (e.g., Clark 1988). In contrast, PBT contends that the misinterpretation is deliberate, aiming to provide deceptive proof for the self-deceptive belief of heart disease. Accordingly, when cognitive therapy focuses patients’ attention on the harmless nature of their bodily sensations, it sabotages the apparent reality basis of patients’ self-deceptive belief. Consequently, as with exposure therapy, patients are unable to maintain their state of unawareness in the absence of a self-deceptive belief. Hence, the symptom loses its distractive values and patients are motivated to abandon it.

Psychoanalysis and religious therapy: Both exposure and cognitive therapy confront patients with specific stimuli that can experimentally challenge their self-deceptive belief. However, it is not always possible to challenge patients’ beliefs by reality testing, as with MPD and spiritual possession where patients attribute their symptoms to the unconscious (e.g., Spanos et al. 1985) and supernatural forces (e.g., Pattison & Wintrob 1981), respectively. In these cases a more effective method for sabotaging the patient’s deceptive endeavors is a therapeutic ritual (e.g., psychoanalytic techniques or religious ceremonies) conducted by a prestigious therapist (or healer), to whom the patient attributes the ability to undo the underlying maintaining forces(e.g., repressed traumas or evil spirits). Consequently, when the deceptive therapeutic ritual is completed patients are left with no deceptive measures to preserve a state of unawareness. As a result, the symptom loses its distractive value and patients are thereby motivated to abandon the symptom. This theoretical approach may explain the fact that while psychoanalysis is a less ineffective therapy for anxiety disorders than behavioral therapy (e.g., Eysenck 1994), psychoanalysis constitutes the most effective intervention for MPD (e.g., Kluft 1987; Putnam & Loewenstein 1993). Similarly, it is no wonder that religious figures, are effective therapists for spiritual possession or situations where patients believe that their maladaptive behavior is controlled by supernatural forces (e.g., Hoffman et al. 1990; Pattison & Wintrob 1981; Wijesinghe et al. 1976).

Thus, there seems to be one common mechanism for all the aforementioned therapeutic methods (exposure, cognitive, psychoanalysis and religious therapy). They all motivate patients to abandon the symptom by diminishing its distractive value. This is achieved either by invalidating the self-deceptive belief through a reality-testing technique or nullifying its deceptive value via deceptive ritual therapy.

6.2. Undoing controllability

Another type of therapeutic measure that may motivate patients to abandon the symptom is behaviorist technique that nullifies the symptom’s controllability value. For example, while soldiers are more likely to develop deviant behaviors when the symptom allows escape (i.e., the soldier is evacuated and treated behind the military zone; Dohrenwend & Dohrenwend 1969; pp. 114-115), they are less likely to do so when the controllability value of the symptom is reduced by treating the patient in close proximity to the combat zone (Solomon & Benbenishty 1986).

Another example is extinction procedures, which nullify the symptom’s ability to manipulate the social environment to comply with patients’ demands for attention and social rewards. Although these techniques were also employed with anxiety disorders such as OCD (see Rofé 2000, p. 229), they were typically used with conversion disorder (e.g., Blanchard & Hersen 1976; Goldblatt & Munitz 1976) and anorexia nervosa (e.g., Touyz & Beumont 1997). The reason for this might be that unlike anxiety disorders, in the case of the latter two disorders it may be easier to undo the controllability value of the symptom rather than to challenge the patient’s self-deceptive belief.

6.3. Undoing motivational factors

In light of PBT’s assumption that the emotional function of bizarre behavior is primarily to relieve depression and studies indicating that depression is characteristic of all types of neuroses (Rofé 2000, pp. 105-106), it is not surprising that antidepressants are an effective therapeutic measure (Rofé 2000, pp. 249-251). This theoretical approach, which views drugs merely as pain relievers, is no less plausible than the biological theory which regards neurosis as an organic illness and accounts for the therapeutic effects of medication in these terms. Not only does this approach lack supporting evidence, it is also confronted with theoretical difficulties (Rofé 2000, Chapter 3). For example, biological concepts would not only have difficulty explaining the success of psychological interventions in treatment of neuroses, but even more so their superiority to drug therapy (Rofé 2000, pp. 68-69, 75-76; and Chapter 7).

Another therapeutic method that deals with underlying motivational factors (i.e., depression and stress) is coping skills training (see review by Rofé 2000, pp. 222-226; 229-233). Most studies examined the effect of this method in combination with behavioral-cognitive methods, such as exposure and extinction/punishment procedures, which treat the symptoms, rather than their underlying cause. Although coping skills training alone can result in significant therapeutic effects, the aforementioned evidence suggests that this method is most effective when combined with symptomatic treatment. Apparently, patients are so comfortable with the coping benefit of their symptoms that they do not feel the need to improve their coping skills. However, once therapy undoes the controllability or distractive value of the symptom, the utility of the coping skills training is much greater, providing patients with the alternative that they might then need.

6.4. Undoing unawareness: Insight therapy

In some cases, patients can be motivated to abandon the symptom by therapeutic techniques that induce insight regarding their self-involvement in adopting and maintaining the symptom. For example, Symonds (In Merskey 1979) told his dissociative fugue patients “I know from experience that your pretended loss of memory is the result of some intolerable emotional situation” (pp. 264-265). The therapist further stated that if the patient would tell the whole story he would respect the patient’s confidence, even to the point of telling the patient’s doctor and relatives that he or she has been cured by hypnotism. Symonds reported that all of his subjects admitted to having faked their symptoms.

It is unlikely that Symonds’ method would be effective in inducing insight in other types of neuroses, such as anxiety disorders, where the self-deceptive belief is more strongly established (see Rofé 2000, pp. 203-204). In these cases, a more lengthy and sophisticated intervention, gradually focusing patients’ attention on their self-deceptive maneuvers and causing awareness of current underlying stressors, may result in an effective therapeutic outcome. Such a direction is especially relevant, as it lends itself to empirical testing of PBT’s theoretical claims (see Rofé 2000, pp. 320-322).

6.5. Variability of therapeutic efficacy

The above discussion only addresses the variability between different therapeutic methods, but not the variability in the efficacy of a given therapy. For example, while early behaviorists (e.g., Giles 1983) optimistically predicted that the prospect of success would be between 89.5% and 94.2%, the success rate is much lower than expected. About one third of patients in exposure therapy for agoraphobia and OCD either drops out, fails to improve or experiences a relapse. Another third demonstrates a moderate improvement and only about one third displays a high level of improvement. A similar trend is found for cognitive therapy, extinction/punishment therapy and drug treatment (Rofé 2000, Chapter 7).

While mechanistic theories would have difficult in accounting for therapeutic failures, PBT’s conscious approach to psychotherapy can resolve this problem. Patients consciously assess the therapeutic intervention and decide whether to maintain or abandon the symptom. Some patients choose to drop out of therapy because, lacking adequate coping abilities, they “know in some way” (Hafner, 1976, p. 382) that it may aggravate their clinical syndrome. The more compliant patients, who as above still need the symptom, remain in therapy but either fail to improve, using self-deceptive excuses to ward off the therapist’s attack on their coping mechanism (e.g., see Hoffart 1993), or temporarily improve but suffer a relapse afterwards (see Rofé 2000, Chapter 7). This theoretical approach may account for the fact that coping skills training that addresses the patient’s psychological needs reduces both dropout and relapse (see review by Rofé 2000, pp. 218, 222-226; 229-230).

Patients who demonstrate a moderate improvement choose a more sophisticated way to cope with the therapist’s threat to their pathological coping mechanism. As specified above, bizarre behaviors are displayed not only when patients are exposed to stress, but also in situations where no coping response is truly needed. These include belief challenging conditions and intervals between episodes, which motivate the patient to display the symptom in order to preserve the validity of their deceptive belief. Thus, following therapy, patients who still need the symptom can continue to display it when confronted with stress and avoid doing so in the latter two situations, utilizing the therapy to rationalize the reduction in their symptomatic behavior.

Only a minority of patients, about one third, shows a high level improvement in response to treatment such as exposure therapy. Research data indicate that these patients include those equipped with better coping skills who can manage without the bizarre behavior when the symptomatic treatment undoes the coping value of these behaviors (Rofé 2000, Chapter 7, pp. 221-222).

6.6. Spontaneous Remission and Placebo

The underlying mechanisms of spontaneous remission and placebo remain unclear, despite theoretical efforts to explain these phenomena in mechanistic terms (see review by Eysenck 1994). This inadequacy is demonstrated by the following two case studies. In one case, agoraphobic symptoms were suspended for about three months when the patient left her husband, resurfaced when they were reunited and then permanently disappeared after divorce (Wolpe 1982, pp. 286-287). The second case was reported by Carl Gustav Jung (1963). In an attempt to demonstrate to his students the effects of hypnosis, Jung had informed a middle-aged female patient, who had been suffering from painful paralysis of the leg for seventeen years, that he was going to hypnotize her. Without any hypnotic manipulation, the patient immediately fell into a deep trance and talked without pause for more than half an hour, resisting Jung’s attempts to wake her. Soon afterward, she cried out that she was cured, threw away her crutches and proceeded to walk. Jung, whose psychoanalytic terms could not account for this shocking result, announced in an attempt to explain the situation to his students, “now you’ve seen what can be done with hypnosis” (p. 120). Mechanistically, nothing happened in terms of psychoanalysis (e.g., removal of repression; see Eysenck 1994) or behavioral-cognitive concepts (e.g., extinction trials; Seligman 1988) that can account for spontaneous remission in the first case and the placebo effect in the second case.

PBT claims that both spontaneous remission and placebo occur when the stress is removed or when the patient becomes adjusted to it. Some patients, like in the first case, will spontaneously abandon the symptom. Others, like in the second case, may experience strong dissonance and would hesitate to spontaneously abandon the symptom. As noted by Ullman and Krasner (1975)

Once the person has made the act, and performed the new role, he cannot shift back into his prior role… The person may continue to play the role because not doing so would cast doubt on his prior behavior in that role. That is one reason why a placebo may be effective: It gives the person an “out,” saves face and avoids many of the aversive consequences of “giving up” the “sick” behavior. [Italic added]. (p. 256)

Thus, sometimes therapy is no more than a placebo, providing the patient with the excuse he may need to abandon the symptom.

7. Discussion:

Although PBT’s conscious, rational approach to psychopathology radically differs from traditional mechanistic theories, it synthesizes some basic concepts of these models, modifying them in accordance with research and clinical data. Thus, like psychoanalysis, PBT emphasizes the crucial importance of repression and unawareness in understanding neuroses. However, based on Holmes’s (1974; 1990) experimental findings and in accordance with Freud’s essence of repression (e.g., Erdelyi 1993; Erdelyi & Goldberg 1979), PBT defines repression as a conscious distraction. A more basic distinction is PBT’s claim that repression is the consequence rather than the cause of behavioral disorders. Similarly, unawareness is viewed as a rational maneuver that plays no etiological role in the development of neuroses. Hence, PBT’s concept of repression excludes the Freudian component of memory and denies the existence of the unconscious. The modified concept is therefore not vulnerable to the criticism, generated by the increasing evidence showing that people remember rather than forget traumatic incidents (e.g., Pope et al., 1999), or that there is no evidence for the existence of an omnipotent autonomous entity functioning outside the conscious (e.g., Greenwald 1992; Gross 1978).

The new theory also acknowledges cognitivists’ claims that the individual’s belief system plays a vital role in the development and treatment of neuroses (e.g., Clark1986; 1988). However, PBT accounts for this effect in conscious, rational, rather than mechanistic terms. Likewise, biological factors may contribute to the development of neuroses either by aggravating the negative impact of stress or motivating patient to utilize their available biological weaknesses when these are suitable to their pathological needs.

PBT’s integrative capacity is also evident in therapy, where the invaluable contributions of behavioral-cognitive methods, drug treatment, psychoanalysis and other methods of intervention are incorporated within its theoretical framework.

PBT also facilitates the understanding of the distribution of neurotic disorders. Thus, by accounting for choice of symptoms in conscious, rational terms, PBT is able to address sex, age and socio-cultural differences in the prevalence of neurotic disorders and dramatic fluctuations in the frequency of some of these disorders in recent years.

On a philosophical level, the widespread idea that the human being is virtually irrational is called into question. This idea, originally promoted by Freud and later adopted by traditional mechanistic theories, was based on clinical observations indicating that illogical behaviors seemingly characterize neurotic patients. However, when patients’ unbearable emotional distress and limited response options are taken into account, their behaviors can be viewed as rational. Moreover, their unawareness may actually reflect the unusual sophistication of the human being in concealing information from themselves when this is vital to their existence.

PBT also has important practical implications for therapy as it supports an eclectic approach. However, it exchanges “technical eclecticism,” that “permits one to select techniques from any discipline without necessarily endorsing any of the theories that spawned them” (Lazarus 1995, p. 31), for “theoretical eclecticism.” Thus, PBT supplies clinicians with a set of theoretical concepts that provide a rationale for selecting one, rather than another therapeutic method in a given therapeutic situation. Hence, as stated above, MPD patients should turn to a psychoanalyst, panic and OCD patients to a behavioral-cognitive oriented therapist and spiritually possessed patients to a religious healer.

Currently, PBT lacks studies that have directly tested its validity. Yet, judging from the historical background of traditional theories, the empirical validation of PBT will be a lengthy process requiring a large research effort. However, the decision to accept or reject a theory must take into account the lack of supporting evidence for rival theories, the increasing amount of contradictory data and, most importantly, the existence of an alternative theory that can address these difficulties. Thus, while research is certainly an important target for investigators in this field, and several research projects were proposed (Rofé 2000, pp. 329-322), it would be premature to determine PBT’s scientific value based on a temporary lack of direct empirical evidence. As noted by Conant (1948), “a theory is not overthrown by data but by a better theory.” A similar position was expressed by Kuhn (1962) who noted that

The decision to reject one paradigm is always simultaneously the decision to accept another, and the judgment leading to that decision involves the comparison of both paradigms with nature and with each other (p. 77).

Psychopathology today stands at a crossroad. One possibility is to continue the traditional line of thinking, claiming that behavioral disorders are mechanistically determined. However, despite tremendous research efforts, we still have no true insight into the mechanisms controlling the development and treatment of neurotic disorders. In fact, the controversy among traditional theorists has not changed much since the beginning of the previous century. Thus, in the wake of this theoretical standstill, we may be able to achieve a breakthrough in psychopathology by accepting PBT’s integrative approach. While an intensive research effort is undoubtedly required, this new approach certainly constitutes a provocative endeavor presenting a definite challenge to traditional theories of psychopathology.

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