Ego-dystonia: a review in search of definitions

Abstract

The ego-dystonic experience refers to the negative assessment that the subject makes of some of their thoughts or emotions, in the context of a conserved state of consciousness, as well as other aspects of their social and intrapersonal life that are relatively intact. Ego-dystonia is a widely used construct, but one that has not been defined in reasonably operational terms. Perhaps this explains why it is no longer used in contemporary classifications of mental disorders such as the ICD-11 and DSM-5. It is related to the awareness of the mental illness, with feelings of guilt and shame, but intuitively we perceive relevant differences between all these experiences. Psychoanalytic theory conceives the ego-dystonic as an alteration in the early structuring of the ego. Cognitive psychology conceives it as a dysfunction of the corrective mechanisms that harmonise the cognitive and the metacognitive. Evolutionary theory has not addressed the issue directly, but through the analysis of guilt, to which it attributes a high adaptive value, since it limits aggression and promotes reparative behaviours. Given the importance of the concept of self-attunement, it is surprising how little theoretical and empirical research there is on the subject, the clarification of which could represent a considerable advance in the field of mental health.

Resumen

La vivencia egodistónica se refiere a la valoración negativa del sujeto sobre algunos de sus pensamientos o emociones, en el contexto de un estado de conciencia conservado, al igual que otros aspectos de su vida social e intrapersonal que se encuentran relativamente intactos. La egodistonía es un constructo ampliamente utilizado, pero que no ha sido definido en términos razonablemente operativos. Tal vez ello explica por qué ha dejado de utilizarse en la clasificaciones contemporáneas de los trastornos mentales, como la ICD-11 y el DSM-5. Lo egodistónico se relaciona con la conciencia de enfermedad mental, con los sentimientos de culpa y la vergüenza, pero intuitivamente percibimos diferencias relevantes entre todas estas vivencias. La teoría psicoanalítica concibe lo egodistónico como una alteración en la estructuración temprana del Yo. La psicología cognitiva lo concibe como una disfunción de los mecanismos correctivos que armonizan lo cognitivo y lo metacognitivo. La teoría evolutiva no ha abordado el tema directamente, sino a través del análisis de la culpa, a la cual atribuye un alto valor adaptativo, dado que limita la agresión y promueve conductas reparativas. Dada la importancia del concepto de egosintonía, es sorprendente la escasa investigación teórica y empírica sobre el tema, cuyo esclarecimiento podría representar un avance considerable en el campo de la salud mental.

Introduction

The terms “ego-dystonic” and “ego-syntonic” are commonly used among mental health workers, yet the English version of the 11th revision of the World Health Organization International Classification of Diseases¹ makes no mention of them in any way. The 10th revision (2019) merely assigns the code F66.1 to ego-dystonic sexual orientation, a diagnosis that no longer appears in the latest revision. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V),² made an equivalent change and does not use the term “ego-dystonic” in any of its criteria.

“Ego-syntonic” suggests that a subject’s expressions of their personality are harmonious with their self-concept and goals without sparking heightened anguish or self-recrimination. For example, people may lack the ability to identify their problematic traits, and therefore perceive their dysfunctional traits to be appropriate. “Ego-dystonic”, for its part, refers to a subject’s expressions being inconsistent with their self-concept and goals and accompanied by an increase in anguish or self-recrimination. However, the topic of “ego-syntonia” as the subject’s perception is vast, and more complex than its mere definition. It is not unusual to see somebody describe something as “ego-dystonic” at one time and leverage the same characteristic to achieve an end at another.³

A response of heightened anguish and self-recrimination in view of the subject’s own expressions, beyond social, formative and complex aspects of such expressions, is what determines whether they are syntonic or dystonic, and the patient communicating or not communicating them contributes in particular to the diagnosis of obsessive symptoms in patients on the spectrum of schizophrenia, bipolar disorder and obsessive compulsive disorder.^4,5 It would be useful to design an operational definition that distinguishes ego-dystonia from habitual mental phenomena of self-reflection, such as self-criticism, discontent with specific or general aspects of one's personality or body, etc. Similarly, while ego-syntonia is linked to so-called “mental illness awareness”, the differences and similarities remain imprecisely defined.

In general psychiatric practice, ego-dystonia is mentioned in particular in the self-concept of subjects with personality disorders (defining it in terms of its opposite, i.e. ego-syntonia) and subjects with obsessive-compulsive disorder (OCD), which is the iconic example of ego-dystonia. It has been proposed that OCD be included in a wide range of disorders with the common denominator of “compulsivity”,⁵ which refers to subjects feeling passively forced into behaviours that they themselves consider undesirable. This category would then include subjects with OCD, Tourette syndrome, substance addiction, gaming and Internet use, and compulsive eating.⁶ According to this proposal, all these individuals would then be ego-dystonic for the symptoms in question.

On the whole, the latter reflection incites consideration of whether the ego-syntonia/ego-dystonia dynamic might be overused (when any “mental” symptom could be defined as ego-dystonic) or underused (when the experience qualifies only if it is accompanied by self-recrimination and intense anguish). It also prompts contemplation of whether ego-syntonia is overestimated in subjects with personality disorders. In any case, this comment illustrates the need to optimise the definition of ego-syntonia/ego-dystonia, which is the subject of this essay. It is also understood that conceptualisations of the self in the field of phenomenology of mental health are inextricably linked to the concepts that Freud used in 1923 to explain the self, defining its functions of impulse control, self-control, self-recognition, autonomy, etc.; this perennially necessary discussion falls outside the scope of our essay.

Ego-dystonia and psychoanalysis

Etymologically, the terms “ego-syntonic” (“in harmony with the ego”)⁶ and “ego-dystonic” (“impulses, desires and thoughts that are unacceptable or repugnant to the ego and the self”)⁷ are related to “ego” and “self”, this term being perhaps the most Freudian in medical/psychological semiology given that he coined it when he postulated his second topic.

The use of this root would seem to have its origins in the works of Johann Gottlieb Fichte. In 1794, taking Kant's second critique as a starting point, this German philosopher stated that every being is posited by the ego, which posits itself by establishing that “one whose being (essence) consists simply of the fact that one posits oneself as existent is the ego as an absolute subject. As stated, so it is; and as it is, so it posits itself”.⁸ According to Lenin,⁹ “The world is the not-I, created by our ‘I’, said Fichte”. While the dictionary of the American Psychological Association asserts that Freud coined the term “ego-syntonic” in 1914, a review of the Spanish versions of the works published by Sigmund Freud in that year was inconclusive in this regard.^10–13 Freud’s notion of the self (Selbst) is defined as “a restricted set of representations that make up for the subject an archaic model of the self and that functions as an actual object of love of the Self”.¹³ As explained by the Uruguayan psychologist Lagomarsino,¹⁴ the self then refers to narcissistic object choice: “The process of identification with the object produces a set of representations that the subject has of himself or herself; this model will be sought in the object and dressed in narcissistic libido. The beloved in the object will be the model, the Self, what oneself was”.¹⁴ In Klein's view, “…the self exists in a rudimentary form from birth, but the notion of self involves the capacity to feel oneself as an animated totality. This, then, is linked to the elaboration of the depressive position. A good structuring of the self involves the possibility of recognising oneself in one's different object relationships and defence mechanisms, as well as a decrease in pathological projective identification and tolerance of depressive and persecutory anxieties…”.¹⁴

Of course, the study of the self has a long tradition in psychoanalysis, but the name and postulates of Heinz Kohut are of particular importance. Lagomarsino continued:¹⁴ “Regarding the origin of the self, Kohut suggests that every person consists of a ‘virtual’ self which will be consolidated as a core self based on the empathetic response of the core 'selves' of the primary self-objects, which can be differentiated as follows: the object-self, which fulfils a mirror function, and the idealised omnipotent object-self. The experience of a cohesive core self is determinant of an enduring sense of identity. The two poles of the ‘self’ are determined by: a) ambitions conceived in the period of the predominance of the archaic grandiose self and b) ideals conceived in the period of the idealised parental ‘imago’. A stable sense of identity over time, an attribute of the healthy self, is established early as a result of a constant gradient of action-promoting tension between the two elements that constitute the core self. In economic terms, then, if the tension between ambitions and ideals is properly balanced, sufficient energy will be available for healthy output in the different fields of life. The cohesive strength of the self will depend on two points: a first point featuring a process of selective inclusion and exclusion of structures through a specific mechanism that Kohut called ‘transmuting internalisation’, and a second point that might compensate for the failings of the first…”.

It has been seen, then, that for the core of psychodynamic knowledge ego-dystonia (by opposition, disharmony of the ego) manifests with a self-response of heightened anguish and self-recrimination in view of the subject’s very individual thoughts and behavioural expressions, offering evidence that ego-dystonia and ego-syntonia are situated in the self.

From the same point of view, ego-dystonia could be said to fit within the definition of guilt: “a self-conscious emotion characterised by a painful evaluation of having done (or thought) something wrong and, often, by a disposition to take measures designed to undo or mitigate this wrong”.¹⁰

Freud, Klein and many of their followers wrote about guilt. Klein theorised about the existence of very early-onset guilt, thus laying the groundwork for conceptualising guilt as of two types: depressive guilt (requires an integrated self) or paranoid guilt (weak and immature self). In her view, this paranoid guilt was mostly instinctual. Perhaps the one to best illustrate the psychoanalytic approach to guilt was Leon Gringberg. Chapter seven of his book Culpa y depresión. Estudio psicoanalítico [Guilt and Depression: A Psychoanalytic Study]¹⁵ distinguishes two types of guilt: depressive guilt, characterised by being conscious, with concern for the object and the ego, and manifested through feelings of grief, longing and responsibility; and persecutory guilt, governed by the (unconscious) primary process and characterised by resentment, despair, fear and self-reproach.

Ego-dystonia and cognitive psychology

Cognitive psychology distinguishes two types of mental processes: cognitive and metacognitive. The former are, in general, automatic and unconscious, consisting of, for example, how information is stored in one's memory and how one remembers such information. Metacognitive mechanisms are the set of processes through which people are able to supervise, manage and consciously reflect on the cognitive processes that they use to perform a given task. Some metacognitive mechanisms are: asking questions internally during a given procedure, meditating, reflecting, conducting a self-assessment of strengths and weaknesses in performance, being self-aware about the type of learning that one uses best (visual, auditory, tactile or kinaesthetic), using mnemonics and applying study strategies.¹⁶

In the case of OCD, it has been argued that deficits are present in the following cognitive processes: response inhibition, cognitive flexibility, planning and goal-directed behaviours, working memory, and error monitoring. Ego-dystonia in subjects with OCD, as it is an evaluation of cognitive mechanisms themselves, is conceived of as a sign that metacognitive processes are preserved, since the subject feels that his/her obsessions and/or compulsions are strange and incongruous with him/herself.⁵

Ego-dystonia and evolution of the species

Daniel Dennet's Consciousness Explained¹⁷ proposed an evolutionary pathway towards the constitution of the ego, starting with the sum of two perspectives — heterophenomological and memetic — which complement one another to delineate a coherent image of the nature of the self called a “Joycean machine”, understanding therefore that consciousness is composed of simple and complex elements that form a programming which incorporates the vast capacities derived from the circuital interconnection of the various brain structures. What Dennet's work did not explain was why this virtual machine also produces self-recrimination in view of actions and thoughts raised only therein. The answer would seem to lie in Dennet's conceptualisation of the self as feedback in this same programming. However, if, as proposed by the North American philosopher following Robyn (p. 416), the self is a biologically constructed network of discourses like any other construction found in the animal world, what is the origin of the ego-dystonia that a subject feels when faced with thoughts or actions that are only bothersome to that subject?

In 1958, Spitz¹⁸ proposed that the organisation of the Freudian mental apparatus (which nothing precludes from considering analogous to Dennet's Joycean machine) features an evident parallelism between the biological and the psychological and that the three moments of organisation of the psyche (the social smile, fear of the unknown and the appearance of language), whose emergence is characterised by dependent differentiation, may account for the onset of psychiatric disease based on the deformation generated in the failure of early integration of the ego, but also does not raise the issue of self-recrimination in stages in which the psyche is more developed.

Individuals’ interactions with themselves would seem to be key to understanding the problem of harmony or disharmony of the ego. A concept intimately linked to the subject at hand is that of self, which according to Owens et al.¹⁶ is an organised, interactive system of thoughts, feelings, identities and motives borne of self-reflection and language that people attribute to themselves and that characterises specific human beings. However, this raises a problem for cognitive psychology, as it is not possible to objectively distinguish as true cognitive elements the set of representations that reflect a person's personality traits, organised by links, through representations created by personal experience or biography because they remain forever on the subjective plane, which cannot be distinguished within developmental psychology methodology.¹⁹ Spitz, with his psychodynamic roots, was able to sidestep this problem.

Evolutionary biology, for its part, describes guilt as the operating mechanism in “reciprocal altruism”. According to this, guilt is advantageous, as it limits and controls opportunistic behaviours involved in maintenance of social relationships; thus, guilt is adaptive and protects humans from one another. According to Trivers, guilt “…evidences a more enduring commitment to altruism, either because guilt teaches or because the cheater is unlikely not to feel the same guilt in the future…”.²⁰

Guilt has been defined by psychologists, psychiatrists and clinicians as an unpleasant emotional condition associated with transgression of personal or moral rules or customs. By this definition, guilt can be resolved with reparation, restitution or confession and forgiveness. According to Shapiro et al.,²¹ definitions of guilt include: self-reproach and remorse for one's behaviour; an impulse, such as fear or anxiety, that motivates compulsive responses; the dysphoric feeling resulting from the realisation that one has breached a personally important moral or social standard; and chronic self-blame and obsessive rumination about some objectionable or harmful behaviour.

Persecutory guilt in psychoanalysis appears to correspond to theoretical constructs closer to biological guilt versus depressive guilt. In this regard, Takashi et al.²² found that certain structures are activated in evaluation with functional magnetic resonance imaging associated with the process of evaluating the moral emotions of guilt and shame; these structures are the medial prefrontal cortex (MPFC), left superior (posterior) temporal sulcus (STS) and visual cortex. It was striking that, since the experiment was conducted in normal subjects presented with standardised stimuli compared to the guilt condition, the shame condition caused greater activation in the right (anterior) temporal cortex, bilateral hippocampus and visual cortex, approaching the normal masochism described by Kernberg (“the price paid for the integration of normal superego functions is the disposition to develop unconscious feelings of guilt when repressed childhood instinctual derivatives are activated”²³), and did not persist as self-reproach or cause excessive distress in the experimental subjects. They were feelings of guilt or shame, but they were not ego-dystonic feelings.

Another feeling to take into account along with guilt as an example of ego-dystonia is shame, a very unpleasant self-conscious emotion that arises from the feeling that there is something dishonourable, immodest or unseemly about one’s behaviour or circumstances.⁷

Palmero²⁴, following Damasio, included shame among the secondary emotions, referring to them as: “chemical and neural response patterns whose function is to contribute to maintaining life in an organism by providing adaptive behaviours”. It must be considered ego-dystonic, since it is inconsistent with the self-concept and objectives of those who feel it accompanied by heightened anguish or self-recrimination and, strikingly, it must be distinguished from social shame, since it is more conscious and less physiological in nature”.

In an extensive review, Weingarden et al. found that, in OCD, symptom-based shame may be particularly triggered by violent, sexual, or blasphemous obsessions, whereas in other obsessive-compulsive spectrum conditions, it is triggered by compulsions, beliefs or guilt.²⁵

The ego-dystonic nature of OCD raises intriguing questions about the relationship between observed behaviour and its subjective and metacognitive correlates. Ego-dystonia remains unexplained within the “modal hypothesis” of deregulation of cortico-striatal-thalamo-cortical pathways and within the advances that have been made by including other structures, which has broadened knowledge of these networks’ essential functions, interactions and regulation, thus yielding the cognitive triad, psychotropic drugs and surgical treatment which have demonstrated efficacy in the symptomatic treatment of the disorder.⁵

However, when obsessive symptoms improve with the greater or lesser success of various therapeutic strategies, ego-dystonia persists as a symptom that constantly emerges in normal life; this contributes to the need to delve ontologically and biologically into the problem raised.

Conclusions

Ego-dystonia or a lack of harmony in the self is a complex situation characterised by a heightened response of anguish and self-recrimination that subjects feel towards themselves in view of their very much individual thoughts and behavioural expressions. It takes place in what has been come to be called the self, and when in a given subject it lacks an accessible psychosocial correlate that a valid interlocutor can perceive as suitable, it appears to be related to deficiencies in the early organisation of the self. According to this conceptualisation, ego-dystonia would respond better to pharmacological interventions than to psychological interventions. Cognitive analysis indicates, at least in subjects with OCD, that mechanisms of self-appraisal and metacognitive mechanisms are relatively intact, but corrective interaction is deficient. We have established a clear relationship between ego-dystonia, guilt and shame. The latter two emotions have been appraised from the perspective of evolutionary theory as adaptive traits, since they enable social cohesion and incorporate reparative mechanisms that appear to be absent in the phenomenon of ego-dystonia.

From a psychotherapy point of view, ego-dystonia has not been addressed directly; rather, in general, it is expected to change as the primary elements of each specific mental disorder are addressed. Psychiatry and psychology will benefit from developing definitions of ego-dystonia that are operational, reliable, reproducible and valid, such that hypotheses with respect to pathogenesis and treatment can be tested.

Conflicts of interest

The authors declare that they have no conflicts of interest.