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WPA/ISSPD Educational Program on Personality Disorders

Editors

Erik Simonsen, M.D., chairElsa Ronningstam, Ph.D.

Theodore Millon, Ph.D., D.Sc. December 2006


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International Advisory panel

John Gunderson, USARoger Montenegro, ArgentinaCharles Pull, Luxembourg

Norman Sartorius, SwitzerlandAllan Tasman, USAPeter Tyrer, UK


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Authors Module I

Renato D. Alarcon, USAJudith Beck, USA

G.E. Berrios, UKVicente Caballo, SpainAllen Frances, USAGlen O. Gabbard, USASeth Grossmann, USA

W. John Livesley, CanadaJuan J. Lopez-Ibor, SpainTheodore Millon, USAJoel Paris, CanadaRobert Reugg, USAMichael Rutter, UK

Erik Simonsen, DenmarkPeter Tyrer, UKIrving Weiner, USADrew Westen, USA

Reviewer Module I

Melvin Sabshin, USA/UK

Authors Module II

Anthony W. Bateman, UKRobert F. Bornstein, USA

Vicente Caballo, SpainDavid J. Cooke, UKPeter Fonagy, UKStephen D. Hart, CanadaElisabeth Iskander, USA

Yutaka Ono, JapanJ. Christopher Perry, CanadaBruce Pfohl, USAElsa Ronningstam, USAHenning Sass, GermanyReinhild Schwarte, GermanyLarry J. Siever, USAMichael H. Stone, USASvenn Torgersen, Norway

Reviewers Module II

David Bernstein, USASigmund Karterud, Norway

Cesare Maffei, ItalyJohn Oldham, USAJames Reich, USA


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Authors Module III

R.E. Abraham, The NetherlandsClaudia Astorga, ArgentinaMarco Aurlio Baggio, Brazil

Yvonne Bergmans, CanadaMirrat Gul Butt, PakistanH.R. Chaudhry, PakistanDirk Corstens, The NetherlandsKate Davidson, UKMircea Dehelean, Romania

Andrea Fossati, ItalyE. Gmez Gazol, SpainDishanter Goel, IndiaH. Groen, The NetherlandsSabine C. Herpertz, Germany

T.M.J. Huyen, The NetherlandsMerete Johansen, ScandinaviaSigmund Karterud, ScandinaviaMorten Kjlbye, DenmarkNestor Koldobsky, ArgentinaD. Lecic-Tosevski, Serbia and MontenegroPaul Links, CanadaCesare Maffei, Italy

J.M. Mburu, KenyaAurel Nirestean, RomaniaJoel Paris, Canada

Gabriele Partscht, GermanyA. Prez rdaniz, SpainJames Reich, USADanilo Rolando, Uruguay

Janine Stevenson, AustraliaM.M. Thunnissen, The Netherlands

Jitindra Kumar Trivedi, Indiayvind Urnes, ScandinaviaSergio Valdivieso Fernndez, Chile

Reviewers Module III

Anthony Bateman, UKRobert Bornstein, USA

Vicente Caballo, Spain

Glen O. Gabbard, USAYutaka Ono, JapanElsa Ronningstam, USAHenning Sass, GermanyErik Simonsen, Denmark

Allan Tasman, USA


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Editorial introduction

In 2002 at the World Congress in Yokohama, the World Psychiatric Association, under the guidanceof the International Society for the Study of Personality Disorders (ISSPD), established a new

division on personality disorders as an official branch of the world organization. In accordance withthis decision, the new division, entitled WPA Section on Personality Disorders, has been given theopportunity to develop a formal WPA educational program on personality disorders to be publishedon the website. An editorial steering committee (Erik Simonsen, Theodore Millon, and ElsaRonningstam) was created to formulate, organize, and coordinate the development of the program.

The program was designed to provide useful information about characteristics of personalitydisorders as conceived in the ICD and DSM.

An outline of topics was developed and a set of authors was selected. The ISSPD Board andthe Board of the WPA Section on Personality Disorders approved the proposal. Members of theISSPD and WPA Section on Personality Disorders were then encouraged to take part in thedevelopment of the program. The project has been financially supported both by the ISSPD and

WPA.The program represents the contributions and collaborations of researchers and clinicians

from around the world. The response of our colleagues has been both generous and outstanding inquality. The target audience for the program is planned to be broad, ranging from medical andpsychology students, psychiatric nurses and social workers, primary care clinicians, psychologists,psychiatrists, and the staff in academic institutions.

The structure of the program is comparable to other WPA Educational programs. The firstmodule provides information on history, concepts and methodological issues. The second moduledescribes detailed diagnostic and clinical descriptions of each disorder, prevalence, age and genderissues, etiology and pathogenesis, course and prognosis, and comorbidity and treatment. The thirdmodule presents a series of clinical vignettes that illustrate their features in concrete and realistic

forms. After each section you will find curriculum suggestions for classroom teaching andworkshops.

The program was written by several authors who are acknowledged at the following pages.The program has been approved by the WPA Educational Committee under the vigorous leadershipof Allan Tasman, who has been very supportive throughout the process.

On behalf of the editors, I would like to thank all the contributors for their steadfast efforts inmaking this possible. The material is easily accessible on the internet. Hopefully, the material will beused worldwide to advance the understanding of diagnosis and management of personalitydisorders. We would appreciate a feedback from those who used the program. Our plan is to makean update every 3rdyear.

Erik Simonsen M.D.Editor, Committee chairChairman, WPA Section on Personality [email protected]


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Foreword

Few problems in the field of psychiatry are more complex to address than personality disorders. Thedilemma starts, in fact, with trying to decide what is the personality, and how we understand theinfluences that determine the mature personality? Contemporary views assume a complexinteraction between genetic factors, with a present emphasis on temperament, and life experiences.

While most believe that what will become the mature personality is, for most people, essentiallydetermined by late adolescence, we know that a variety of adult life influences can exert modifyingeffects throughout the life cycle. Thus, the conceptualization that personality reflects a matrix ofqualities of character and patterns of reactivity has become generally accepted, though still difficultto quantify.

Moving from a general framework of understanding to a definition of specific aspects ofpersonality has, therefore, been more difficult. This leads to the greater difficulty for our field, whichis the differentiation of normal from abnormal personality. It is within this area of inquiry that thedefinition of personality disorders lies. Complicating this definition is the fact that not only geneticheritage and life experiences exert influences on personality development and structuralization, butalso a wide range of cultural and ethnic variables also play a substantial, though thus far also notquantifiable, effect.

If, given all of the dilemmas enumerated above, we can arrive at a consensus about what is apersonality disorder, this leads to the next dilemma of how we can best assess personality disorders.

There is little agreement in this area, best conceptualized through the ongoing debate about whetherdiagnosis of personality disorders should occur within a dimensional or categorical approach. Afurther complication arises due to the fact that advocates for either categorical or dimensionalapproaches have thus far not reached a consensus on the optimal approach even within their owndomain of study.

Finally, how to treat something defined as a disorder, but which is embedded in the person ofthe individual seeking treatment, and thus not easily amenable to modification, remains one of themost complex clinical problems in the field of psychiatry. The conceptual and diagnostic dilemmashave made research in the area of personality disorders treatment quite difficult, as comparisonsacross studies are difficult to make. An additional level of complexity occurs because we well knowthat personality disorders and other psychiatric disorders often co-exist, but unfortunately not in

ways which lead us to easy construction of frameworks for treatment planning. Molecular geneticsholds out the promise that if we identify genetic predispositions for a variety of psychiatric illnesses,that we can use this knowledge to develop more effective treatments for them. Few would suggest asimilar likely outcome in the area of personality disorders.

Our psychological task, then, is to provide state-of-the-art information which can be used byclinicians at any stage of training in understanding personality disorders and developing a treatmentplan. This monumental task has been handled with aplomb by the workgroup responsible for thepreparation of the work you are reading. Calling upon an outstanding group of experts in all aspectsof personality studies around the globe, Eric Simonsen, M.D., and colleagues have produced a workthat is comprehensive, yet organized in a way that makes access to the material easy for individualsat any stage of their professional career. Their work is an excellent illustration of ways in which the

WPA can productively collaborate with other international organizations, in this case theInternational Society on the Study of Personality Disorders (ISSPD). The work is designed in threemodules. Module 1, Conceptual and Methodological Foundations, reviews the scholarlycontributions to our understanding of personality and how we might classify personality andpersonality disorders and reviews a variety of therapeutic management approaches. Module 2addresses each personality disorder and reviews diagnostic criteria, etiology, epidemiology,comorbidity, and treatment. Module 3 presents a casebook to illustrate the range of personality


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disorders. The vignettes are concise, yet illustrative, and accompanied by expert commentary.Recommended readings and curricular recommendations also are included for all three modules.

While no one work can possibly encompass the entire field of personality disorders, andwhether the reader is interested in a specific topic or an in-depth review, there is little question thattime spent with this material will be universally felt to be very useful.

Allan Tasman, M.D.Secretary for Education

World Psychiatric Association


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Table of Contents

MODULE I: ................................................................................................................................................ 13CONCEPTUAL AND METHODOLOGICAL FOUNDATIONS.................................................... 13I. INTRODUCTION.....................................................................................................................................13

A. Scope of the Problem ........................................................................................................................... 13B. Social Costs.............................................................................................................................................14

II. DEFINITIONS.........................................................................................................................................14A. Differentiating Normality and Abnormality...................................................................................... 16

III. HISTORICAL REVIEW ....................................................................................................................... 17IV. CLASSIFICATION ALTERNATIVES..............................................................................................21

A. The Current Official Systems .............................................................................................................. 21B. On the Reality of Personality Syndromes ...................................................................................... 23C. Structuring a taxonomy of personality disorders?.............................................................................24

V. DEVELOPMENTAL PATHOGENESIS........................................................................................... 27A. The Role of Biogenic Influences......................................................................................................... 28B. The Role of Psychogenic Influences...................................................................................................29C. The Role of Sociogenic Influences ..................................................................................................... 31

VI. DIAGNOSTIC ASSESSMENT............................................................................................................ 36

B. Rating scales and Checklists.................................................................................................................38C. Self Report Inventories.........................................................................................................................39D. Projective techniques............................................................................................................................40

VII. THERAPEUTIC MANAGEMENT.................................................................................................. 40A. Psychodynamic Therapies .................................................................................................................... 41B. Cognitive Therapies...............................................................................................................................43C. Biological Treatments............................................................................................................................44D. Combining Pharmacology and Psychotherapy.................................................................................46

References are listed in order of appearance in text .................................................................................. 48

Suggested Additional Reading List Module I .......................................................................................... 55Curriculum Suggestions Module I.............................................................................................................56


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MODULE II: THE PERSONALITY DISORDERS..............................................................................57INTRODUCTION........................................................................................................................................ 57

General Diagnostic Criteria.......................................................................................................................59Antisocial Personality Disorder ................................................................................................................ 60Avoidant Personality Disorder ................................................................................................................. 67Borderline Personality Disorder...............................................................................................................74Dependent Personality Disorder..............................................................................................................84Histrionic Personality Disorder................................................................................................................90Narcissistic Personality Disorder..............................................................................................................95Obsessive-Compulsive Disorder............................................................................................................104Paranoid Personality Disorder................................................................................................................110Passive-aggressive Personality Disorder................................................................................................117Sadistic Personality Disorder .................................................................................................................. 123Schizoid Personality Disorder.................................................................................................................129Schizotypal Personality Disorder............................................................................................................135

Suggested Additional Reading List Module II.......................................................................................142Diagnostic Instruments ................................................................................................................................ 143Curriculum Suggestions Module II ......................................................................................................... 144


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MODULE III: CASE VIGNETTES ........................................................................................................ 145INTRODUCTION...................................................................................................................................... 145

CASE 1: Ronny: Paranoid personality disorder.............................................................................147CASE 2: Theo: Paranoid Personality Disorder..............................................................................151CASE 3: Sara: Borderline Personality Disorder.............................................................................154CASE 4: Jane: Borderline Personality Disorder............................................................................. 158CASE 5: Ellen: Borderline Personality Disorder...........................................................................163CASE 6: Peter: Narcissistic Personality Disorder..........................................................................166CASE 7: Carmen: Histrionic Personality Disorder .......................................................................170CASE 8: Patrick: Avoidant Personality...........................................................................................174CASE 9: Saskia: Avoidant Personality Disorder............................................................................178CASE 10: Sally: Dependent Personality Disorder..........................................................................182CASE 11: Brian: Obsessive-Compulsive Personality Disorder....................................................185CASE 12: Gregorio: Mixed Personality Disorder...........................................................................189CASE 13: John: Antisocial Personality Disorder............................................................................194CASE 14: Sergio: Antisocial/Dissocial Personality Disorder........................................................198CASE 15: Marcel: Dissocial Personality Disorder..........................................................................204CASE 16: Mr. M: Antisocial Personality Disorder.........................................................................209CASE 17: Alejandro: Borderline Personality Disorder.................................................................. 213CASE 18: Anna Z: Borderline Personality Disorder .....................................................................216CASE 19: John: Schizoid Personality Disorder ..............................................................................221CASE 20: Jim: Narcissistic and Antisocial Personality Disorder .................................................224CASE 21: Borderline Personality Disorder .....................................................................................228CASE 22 Marcello: Avoidant Personality Disorder......................................................................232CASE 23: Erik: Narcissistic Personality Disorder..........................................................................235CASE 24: Mary: Borderline Personality Disorder..........................................................................239CASE 25: Francisc: Anxious/Avoidant Personality Disorder......................................................244CASE 26: Lola: Borderline Personality Disorder ...........................................................................248CASE 27: Paranoid Personality Disorder........................................................................................253CASE 28 Jane: Obsessive-Compulsive Personality Disorder......................................................258CASE 29 AB: Borderline Personality Disorder .............................................................................262CASE 30 Mr FA: Narcissistic Personality Disorder......................................................................265CASE 31 Anja: Borderline Personality Disorder ............................................................................270

Curriculum Suggestions Module III........................................................................................................274/dm


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MODULE I:

CONCEPTUAL AND METHODOLOGICAL FOUNDATIONS

Editor: Theodore Millon, Ph.D., D.Sc. Reviewer: Melvin Sabshin, M.D.

I. INTRODUCTION

A. Scope of the Problem

Treating psychopathology requires an understanding of personality. Research on the DSM and ICDdisorders is making it increasingly clear that (a) anxiety, depression, eating disorders, substanceabuse, sexual disorders, and other DSM Axis I Clinical Syndromes occur more often in the contextof Personality Disorders (PDs)1; (b) patients with multiple clinical syndrome diagnoses often havePDs2; and (c) even those patients who lack personality disturbances severe enough to warrant aDSM or ICD personality diagnosis often have clinically significant pathology, such as difficulties withintimacy, management of aggression orself-assertion, rejection-sensitivity, etc3.

There is little question that inclusion of a PD axis in the DSM and ICD, and its refinementthrough two decades of research, has been a crucial step in the evolution of more clinically andempirically useful diagnostic manuals. Knowing that a patient has major depression is certainlyimportant, but adding the "qualifier" that the patient also has borderline PD is equally importantbecause it has significant implications for prognosis and treatment.

PDs have historically been in a tangential position among diagnostic syndromes, never havingachieved a significant measure of recognition in the literature of either clinical psychiatry orabnormal psychology. Prior to the DSM-III and ICD-8, they were categorized in the officialnomenclature with a mlange of other miscellaneous and essentially secondary syndromes. Today,PDs occupy a place of diagnostic prominence, having been accorded a contextual role in themultiaxial schema of the DSM. Personality pathologies comprise one of two required mentaldisorder axes in the DSM. Henceforth, clinicians must not only assess the patient's currentsymptomatology, indicated on Axis I, but also evaluate those pervasive features which characterizethe patient's enduring personality pattern, recorded on Axis II. In effect, the revised Americanmultiaxial format requires that symptom states no longer be assessed as clinical entities isolated fromthe broader context of the patient's lifelong style of relating, coping, behaving, thinking, and feeling -that is, his or her personality. In fact, there are clinical theorists who assert that it is the patientspersonality that should be evaluated first; only secondarily should the patients clinical state beconsidered. There are substantive reasons for attending to the PDs first, beyond the pragmatics ofadhering to official nosological requirements. Lifelong personality traits appear to serve as asubstrate, as well as a context for understanding more florid and distinct forms of psychopathology.Since the early 1960s, most societies have been increasingly committed to the early identification andprevention of mental disorders. This emphasis has led clinicians to attend to both premorbidbehavioural signs and the less severe variants of emotional disturbance. Ordinary anxieties, minorpersonal conflicts, and social inadequacies are now seen by many clinicians as the forerunners ofmore serious problems. A significant impetus to this movement is the emergence of communityhealth centres whose attentions are directed to the needs of the less seriously disturbed. As a resultof these developments, the scope of clinical psychopathology was broadened far beyond itshistorical province of Hospital psychiatry. As a field, it now encompasses the full spectrum ofmild to severe mental disorders. With personality as a contextual foundation, diagnosticians havebecome more proficient in understanding personality dynamics and can more clearly trace thesequences through which both subtle and dramatic clinical symptoms unfold. Yet, it is necessary


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that we recognize at the outset of this module how much more needs to be learned about theorigins, development, structure and treatment of these disorders.

B. Social Costs

PDs have been estimated to affect at least 10% of the population, and constitute a large percentageof the patients seen by psychiatrists. Yet unlike other diagnoses, PDs may or may not be associatedwith subjective symptoms. While some categories show high comorbidity with symptomaticdiagnoses such as anxiety and depression, some PDs produce distress in other people rather than inthe patient. But in either case, the overall functioning of patients with PDs is often marginallysocial, comparable in many cases to levels seen in patients with chronic conditions such asschizophrenia.

Numerous studies suggest that PDs are underappreciated causes of social cost, morbidity, andmortality. PDs are associated with crime, substance abuse, disability, increased need for medical care,suicide attempts, self-injurious behaviour, assaults, delayed recovery from Axis I and medical illness,institutionalization, underachievement, underemployment, family disruption, child abuse and

neglect, homelessness, illegitimacy, poverty, STDs, misdiagnosis and mistreatment of medical andpsychiatric disorders, malpractice suits, medical and judicial recidivism, disruption of psychiatrictreatment settings, and dependency on public support. The amount of social cost and disruptioncaused by the PDs is disproportionate to the amount of attention it gets in the public consciousness,in government research funding, in medical school education or even in psychiatric residencytraining4And no less important than dealing with the social costs of personality disorders is thepotential value inherent in preventive programs designed to enhance personality resilience andadaptive capacities.

Contributors: Allen Frances, Joel Paris, and Robert Reugg

II. DEFINITIONS

Reification (Verdinglichung) is a process whereby cultural notions are converted into things.Thinghood, in general, is expressed along an ontological continuum which may range from objectswith dense ontology, such as stones, orchids or dogs, to structures and cultural monumentsexhibiting little or none. The objects of psychology are placed somewhere along such continuum.

They are notions and ideas that can be measured, used as causes for behaviour and reasons foraction, as explanatory accounts, and predictive devices, and which can be correlated with proxy

variables representing the brain from which it could be said, they attempt to borrow ontology.The 19thcentury impetus to naturalize the mind attempted to endow psychological notions

with ontology. This entification was encouraged by evolutionary theory. Concepts such as character,self, constitution, identity, temperament, emotion, and personality felt the effects, in that the subtledifferentiating features were disregarded and thrown into a semantic melting pot. By the end of thecentury, personality had taken morsels of meaning from other concepts: it was singular such as theself, enduring like character, and somatic like temperament and constitution5. This madepersonality appear as a candidate for natural kind6, which could then be measured, structured,related to the brain and most importantly affected by disease.

With costly effects, the naturalization of the personality model required that it shed itssemantics, such as its role for more than three millennia as the social representation of individuality(social representations is used here in the manner of Moscovici7). This bowdlerization of meaningthat allowed researchers to search for what Eysenck8 referred to as the biological basis ofpersonality has been called by Graumann9the process of desocialization of the individual.


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Personality is a member of a family of concepts constructed to talk about and shore up theview that society is a collection of singular individuals. Up to the 19th century, these roles wereexercised in the field of religion, morality, the law, and metaphysics. During the 19 th century theconcept of personality and various of its companions were psychologized and naturalized.

What is the concept of personality today?The question is simple to pose, but difficult to answer, despite the fact that as an idea, personality ismany thousands of years old. Historically, the word personality itself derives from the Greek termpersona, originally representing the theatrical mask used by dramatic players. This meaning haschanged through history. As a mask assumed by an actor it suggested a pretense of appearance, thatis, the possession of traits other than those which actually characterized the individual behind themask. In time, the term persona lost its connotation of pretense and illusion, and began to represent,not the mask, but the real person, his/her apparent, explicit, and manifest features. The third andmost recent meaning that the term personality has acquired delves beneath surface impression andturns the spotlight on the inner, less revealed, and hidden psychological qualities of the individual.

Thus, through history the meaning of the term has shifted from external illusion to surface reality,

and finally to opaque or veiled inner traits. It is this third meaning that comes closest tocontemporary use. Personality is seen today as a complex pattern of deeply embedded psychologicalcharacteristics that are largely nonconscious and not easily altered, expressing themselvesautomatically in almost every facet of functioning. Intrinsic and pervasive, these traits emerge from acomplicated matrix of biological dispositions and experiential learnings, and ultimately comprise theindividual's distinctive pattern of perceiving, feeling, thinking, coping, and behaving.

Personality is the patterning of characteristics across the entire matrix of the person. Ratherthan being limited to a single trait, personality regards the total configuration of the personscharacteristics: interpersonal, cognitive, psychodynamic, and biological. Each trait reinforces theothers in perpetuating the stability and behavioural consistency of the total personality structure. Forthe personality disorders, then, causality is literally everywhere. Each domain interacts to influence

the others, and together, they maintain the integrity of the whole structure. In contrast, the causes ofthe Clinical Syndromes are assumed to be localizable. The cause of an adjustment disorder, forexample, lies in a recent change in life circumstances. Here, causes and consequences aredistinguishable, with discrete distinction between the underlying cause and its symptomexpression. Difficulty making an adjustment might result in feelings of depression, for example. Forthe personality disorders, however, the distinction between cause and symptom is lost. Instead,causality issues from every domain of functioning. Each element in the whole structure sustains theothers. This explains why personality disorders are often resistant to psychotherapy.

Personality disorders are not diseases; thus, we must be very careful in our causal usage of theterm disease. To imagine that a disorder, of any kind, could be anything other than a medicalillness is very difficult. The idea that personality constitutes the immunological matrix that

determines our overall psychological fitness is intended to break the long-entrenched habit ofconceiving psychopathology as one or another variant of a disease, that is, some foreign entity orlesion that intrudes insidiously within the person to undermine his or her so-called normal functions.

The archaic notion that these disorders represent external intrusions or internal disease processes isan offshoot of pre-scientific ideas such as demons or spirits that ostensibly possess or cast spellson the person. The role of infectious agents and anatomical lesions in physical medicine hasreawakened this archaic view. While we no longer see demons, many still see PDs as involving somealien or malevolent force which invades and unsettles the patient's otherwise healthy status. This

view is an appealing simplification to the layman, who can attribute his/her irrationalities to someintrusive or upsetting agent. It also has its appeal to the less sophisticated clinician, for it enables himor her to believe that the insidious intruder can be identified, hunted down, and destroyed.

Such naive notions carry little weight among modern-day medical and behavioural scientists.Given our increasing awareness of the complex nature of both health and disease, we now


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recognize, for example, that most physical disorders result from a dynamic and changing interplaybetween individuals' capacities to cope and the environment within which they live. It is the patients'overall constitutional makeup - their vitality, stamina, and immunological system - that serves as asubstrate that inclines them to resist or to succumb to potentially troublesome environmental forces.

To illustrate: infectious viruses and bacteria proliferate within the environment; it is the persons

defences that determine whether or not these microbes will take hold, spread, and, ultimately, beexperienced as illness. Individuals with robust immune activity counteract the usual range ofinfectious microbes with ease, whereas those with weakened immunosuppressive capacities are

vulnerable, fail to handle these intrusions, and quickly succumb. Similarly, structural disorderssuch as coronary artery disease are not merely a consequence of food consumed or life stress butreflect in large measure each individuals metabolic capacity to break down lipoprotein intake; it isthe body's ability to process nutritional excess that is a major determinant of whether arterial diseasedoes or does not occur. Those with balanced enzymatic functions will readily transform and disposeof excess lipids, whereas those with less adequate equipment will cumulate arterial plaques thatgradually develop into disease.

PDs should be conceived as reflecting the same interactive pattern. Here, however, it is not

the immunological defences or enzymatic capacities but the patient's coping skills and adaptiveflexibilities that determine whether or not the person masters or succumbs to his/her psychosocialenvironment. Just as physical ill health is likely to be less a matter of some alien virus than it is adysfunction in the bodys capacity to deal with infectious agents, so too is psychological ill healthlikely to be less a product of some intrusive psychic strain than it is a dysfunction in the personalityscapacity to cope with lifes difficulties. Viewed this way, the structure and characteristics ofpersonality become the foundation for the individuals capacity to function in a mentally healthy orill way.

To restate matters, PDs are not disorders in the usual medical disease sense. Rather, PDs aretheoretical constructs employed to represent varied styles or patterns in which the personalitysystem functions maladaptively in relation to its environment. When the alternative strategies

employed to achieve goals, relate to others, and cope with stress are few in number and rigidlypracticed (adaptive inflexibility), when habitual perceptions, needs, and behaviours perpetuate andintensify pre-existing difficulties (vicious circles), and when the person tends to lack resilience underconditions of stress (tenuous stability), we speak of a clinically maladaptive personality pattern, that is,a PD.

A. Differentiating Normality and Abnormality

Numerous attempts have been made to develop definitive criteria for distinguishing psychologicalnormality from abnormality. Some of these criteria focus on features that characterize the so-callednormal, healthy, even ideal, state of mental health. Others have sought to specify criteria for

concepts such as abnormality or psychopathology. Such distinctions between normality andpathology are largely social constructions or cultural artefacts. While persons may be segregated intogroups according to overt and reproducible criteria, lending such classifications the respectabilityand occasionally even the substance of science, the desire to segregate and the act of segregatingsuch persons is a uniquely social phenomenon. Hence, all definitions of pathology, ailment, malady,sickness, illness, disorder, or derangement are ultimately value-laden and circular. Disorders are whatdoctors treat, and what doctors treat is defined implicitly by social standards which for the most partare assumed and thus exist at a nonconscious level.

Given its social heritage, positive aspects of normality are best exemplified by participation inthose behaviours and customs that are prototypal for one's reference group. Conversely, pathologyor disorder is exemplified by behaviours which are uncommon, irrelevant, or hostile to that

reference group. However uncomfortable one may be with the knowledge that abnormality is largelya social construction, the origins of this construction may at least be acknowledged and dealt with


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heuristically, without reification. Accordingly, normality and pathology must be viewed as relativeconcepts; they represent arbitrary points on a continuum or gradient - no sharp line divides normalfrom pathological behaviour. Among diverse and ostensibly content- and culture-free criteria usedto signify normality are a capacity to function autonomously and competently, a tendency to adjustto ones social milieu effectively and efficiently, a subjective sense of contentment and satisfaction,

and the ability to self-actualize or to fulfil ones potentials throughout the life span into ones lateryears.PDs were noted either by deficits among the preceding or by the presence of characteristics

that actively undermine these capacities. Perhaps these criteria are too Westernized or Eurocentric tobe universal. While the unfolding and rich differentiation of some immanent plan of organismicpotentials would seem to be generic to all development, its ultimate expression is specified by socialand cultural forces. In some Asian cultures, for example, where the individual is expected tosubordinate individual ambitions to group consensus, the capacity to function autonomously mightbe praiseworthy, but the desire to do so is not.

Developmentally, personality pathology results from the same forces as involved in thedevelopment of normal functioning. Important differences in the character, timing, and intensity of

these influences lead some individuals to acquire pathological constraints and others to developmore adaptive traits. When an individual displays an ability to cope with the environment in aflexible manner, and when his or her typical perceptions and behaviours foster increments inpersonal satisfaction, then the person is deemed by the larger reference group to possess a normal orhealthy personality. Conversely, when average or everyday responsibilities are responded toinflexibly or defectively, or when the individuals perceptions and behaviours result in increments inpersonal discomfort or curtail opportunities to learn and to grow, then we may speak as a linguisticcontrivance of a pathological or maladaptive pattern.

Despite the foregoing, it should be noted that the traits which compose a number ofpersonality styles are likely in certain historical periods or cultures, such as contemporary Westernsocieties, to promote healthy functioning (e.g., Histrionic, Compulsive, Narcissistic traits). Similarly,

in this society, there are personality styles and traits that are highly conducive to pathologicalfunctioning (e.g., Avoidant, Dependent, Masochistic). There are other personality patterns (e.g.,Schizotypal, Borderline, Paranoid) which have a very small probability of falling at the normal end ofthe continuum in almost all cultures.

Contributors: G. E. Berrios, Juan J. Lopez-Ibor

III. HISTORICAL REVIEW

The interest in the description of individual differences is very old. In Theophrastus10Characters,written in the 3rd century BC, 32 different types of human beings are described, some of themfamiliar to clinicians nowadays. Among them there are some in which there is a poor control of theirimpulses (shamelessness, loutishness, coarseness) and in others obsessive traits (superstition). Sincethen universal literature is full of archetypal individuals, like the characters of Shakespeare, Molire,Cervantes or Dostoyevsky.

Current conceptions of personality, therefore, are the result of a long and continuing history.Despite the desultory nature of our path to knowledge, there appear to be certain themes andconcepts to which clinicians and theorists return time and again; these are noted as the discussionproceeds in this module.

As noted, perhaps the first explanatory system to specify personality dimensions is likely to

have been the doctrine of bodily humours posited by early Greeks some 25 centuries ago.Interestingly, history appears to have come full circle. The humoural doctrine sought to explain


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personality with reference to alleged body fluids, whereas much of contemporary psychiatry seeksanswers with biochemical and endocrinological hypotheses. In the fourth century B.C. Hippocratesconcluded that all disease stemmed from an excess of or imbalance among four bodily humours:yellow bile, black bile, blood, and phlegm. Humours were the embodiment of earth, water, fire, andair - the declared basic components of the universe according to the philosopher Empedocles.

Hippocrates identified four basic temperaments, the choleric, melancholic, sanguine, andphlegmatic; these corresponded, respectively, to excesses in yellow bile, black bile, blood, andphlegm. Modified by Galen centuries later, the choleric temperament was associated with a tendencytoward irascibility, the sanguine temperament prompted the individual toward optimism, themelancholic temperament was characterized by an inclination toward sadness, and the phlegmatictemperament was conceived as an apathetic disposition. Although the doctrine of humours has beenabandoned, giving way to scientific studies on topics such as neurohormone chemistry, itsterminology and connotations still persist in such contemporary expressions as being sanguineorgoodhumoured.

The writer and physician Juan Huarte de San Juan, in his work Examination of wits for thesciences11 introduced a clinical perspective in the description of individual differences. It was at the

end of the 18th

century in France, coinciding with the birth of modern psychiatry, where thedistinction between immoral behaviour and mental illness appeared. Up to then general hospitals,especially in France, were institutions for all those on the social margins of society, not just for theinsane or the ill. Along the 19thcentury the concept of pathological personality was forged. Pinel in1809 described his manie sans dlire, that is to say, mental illness without symptoms of illness, to

which he later on also referred asfolie raisonnante, that is to say, madness without insanity.The ancients speculated also that body structure was associated with the character of

personality. Whereas the humoural doctrine may be seen as the forerunner of contemporarypsychiatric neurobiology, phrenology and physiognomy may be conceived as forerunners of modernpsychiatric morphology. Physiognomy, first recorded in the writings of Aristotle, sought to identifypersonality characteristics by outward appearances, particularly facial configurations and expressions.

People sought to appraise others throughout history by observing their countenance, the play intheir face, and the cast of their eyes, as well as their postural attitudes and the style of theirmovements. It was not until the late eighteenth century, however, that the first systematic effort wasmade to analyze external morphology and its relation to psychological functions.

Despite its discredited side, phrenology, as practiced by Franz Josef Gall, was an honest andserious attempt to construct a science of personology. Although Gall referred to his studies ofbrain physiology as organology and crainoscopy, the term phrenology, coined by a youngerassociate, came to be its popular designation. The rationale that Gall presented for measuringcontour variations of the skull was not at all illogical given the limited knowledge of eighteenth-century anatomy. In fact, his work signified an important advance over the naive and subjectivestudies of physiognomy of his time in that he sought to employ objective and quantitative methods

to deduce the inner structure of the brain. That these assertions proved invalid should not besurprising when we recognize, as we do today, the exceedingly complex structure of neuroanatomyand its tangential status as a substrate for personality functions. Despite the now transparent

weaknesses of Galls system, he was the first to attempt a reasoned thesis for the view thatpersonality characteristics may correlate with body structure.

A late nineteenth-century French psychologist, T. Ribot12 attempted to formulate charactertypes in a manner analogous to botanical classifications. By varying the intensity level of two traits,those of sensitivity and activity, Ribot sought to construct several major types. Among thepersonalities proposed were: (I) the humble character, noted by excess sensibility and limitedenergy; (2) the contemplative character, marked by keen sensibility and passive behaviour; and (3)the emotional type, combining extreme impressionability and an active disposition. Among other

major categories were the apathetic and the calculative characters.


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Attempts were made in the early twentieth century to identify the constituents oftemperament and determine the ways in which they blend into distinctive patterns. The ideasproposed by several theorists illustrate this line of thinking. Among the first of these was thepsychiatrist E. Hirt, director of a German asylum. Extrapolating from work with institutionalizedcases, Hirt divided temperament in accord with the classical four humours, but, in addition, he

attempted to find their parallels among psychiatric populations. To Hirt, those who possessed anaccentuated phlegmatic temperament were inclined to exhibit a morbid apathy such as seen in casesof dementia praecox; these patients were not only inactive but lacked insight, seemed detached fromthe world, and were too indifferent to complain about their plight. Patients endowed with a sanguinetemperament to an extreme degree were characterized by superficial excitability, enthusiasm, andunreliability, and were therefore typically diagnosed as hysterical types; to Hirt, vanity, a craving forattention, and the seeking of enjoyment served as their primary stimuli for action. The cholerictemperament was found among several subcategories of patients, including suspicious characters

who were forever anticipating treachery and ill-will, and grumbling types who were invariably criticalof others, claiming their personal superiority to all if only they were given a chance. Those of amelancholic disposition were divided into two categories: Those of an active inclination were filled

with an irritable pessimism and bitterness, and those more passively inclined were found amongspeculative and brooding types.Throughout the nineteenth century, German psychiatrists abandoned what they considered to

be the value-laden theories of the French and English alienists of the time and moved toward whatthey judged to be empirical or observational research. Among this group was J.A. Koch whoproposed replacing the label moral insanity with the term psychopathic inferiority, under which heincluded: All mental irregularities whether congenital or acquired which influence a man in hispersonal life and cause him, even in the most favourable cases, to seem not fully in possession ofnormal mental capacity.

Koch used the term psychopathic, a generic label employed to characterize all personalitydiagnoses until recent decades, to signify his belief that a physical basis existed for these character

impairments. Thus, he sated: They always remain psychopathic in that they are caused by organicstates and changes which are beyond the limits of physiological normality. They stem from acongenital or acquired inferiority of brain constitution.

The prime psychiatric nosologist at the turn of the century, Emil Kraepelin, did notsystematize his thinking on PDs until the eighth edition of his major text, in 1913. Until then,Kraepelin paid but scant attention to personality disturbances, concentrating his organizing effortson the two major syndromes of dementia praecox and maniacal depressive insanity. In his efforts totrace the early course of these syndromes, Kraepelin uncovered two premorbid types: thecyclothymic disposition, exhibited in four variants, each inclined to maniacal-depressive insanity;and the autistic temperament, notably disposed to dementia praecox. In addition, Kraepelin wroteon a number of so-called morbid personalities, those whom he judged as tending toward criminality

and other dissolute activities. The four varieties of the cyclothymic disposition were labelled thehypomanic, the depressive, the irascible, and the emotionally unstable.The best-known European classification of disordered personalities was proposed by Kurt

Schneider. Schneider differed from many of his contemporaries, most notably Kretschmer, in thathe did not view personality pathology to be a precursor to other mental disorders but conceived it asa separate group of entities that covaried with them. Ernst Kretschmer was the prime modernconstitutionalist, suggesting a series of inventive propositions that he sought to support empirically.In his early research, Kretschmer categorized individuals in accord with their physical build andattempted to relate morphological differences to schizophrenia and manic-depressive psychosis. Ashis work progressed he extended the presumed relationship of physique, not only to severepathology but also to premorbid personality and to normal temperament.

The best-known and perhaps most fully conceptualized of PDs are those formulated bypsychoanalytic theorists. Their work was crucial to the development of an understanding of the


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causal agents and progressions that typify the background of these disorders. It was Sigmund Freudand his early associates who laid the foundation of the psychoanalytic character typology. Thesecategories were conceived initially as a product of frustrations or indulgences of instinctual orlibidinous drives, especially in conjunction with specific psychosexual stages of maturation. Thesenotions, referred to as oral, anal and genital character types were fully formulated by his younger

associates, Karl Abraham and Wilhelm Reich.Carl G. Jung, another young Freudian disciple and later dissident, was among the seminalthinkers in proposing his distinction between extraversion and introversion.Extraversionrepresentedthe flowing of energy toward the outer world, whereas introversion was a flow inward. Extravertsexplain events from the viewpoint of the environment, seeing things as coming from without. Theintrovert's approach is essentially subjective, drawing from the environment whatever is perceived asnecessary to satisfy inner inclinations.

Faced with the insecurities and inevitable frustrations of life, the neo-Freudian analyst, KarenHorney, identified three broad modes of social relating: moving toward people, moving againstpeople, or moving away from others. Horney formulated three character types to reflect each ofthese three social modes: Moving toward is found in a compliant type; moving against, in an

aggressive type, and moving away, in a detached type. In 1950 Horney reconceptualized hertypology in line with the manner in which individuals solve intrapsychic conflicts. Correspondingroughly to the prior trichotomy, they were termed the self-effacement solution, the expansivesolution, and the solution of neurotic resignation. Although these sets of three do not matchperfectly, they do correspond to the essential themes of Horneys characterology.

Although numerous analytic theorists have continued to contribute to the study of character,the contemporary work of Otto Kernberg deserves special note. Taking steps to develop a newpsychoanalytic characterology, Kernberg constructed a framework for organizing personality typesin terms of their level of severity. Breaking away from a rigid adherence to Freuds psychosexualmodel, Kernberg proposed the dimension of structural organization. Coordinating character types inaccord with severity and structural organization lead Kernberg to speak of higher, intermediate and

lower levels of character pathology; both intermediate and lower levels are referred to asborderline personality organizations.Another contemporary theorist, Lorna Benjamin13, recognized the interplay of cognitive,

affective, and interpersonal dimensions in her effort to articulate the qualities of each PD. Hermodel encompasses elements of the recent work of the cognivists and those of a psychodynamicorientation. Her venue is centred in the interpersonal sphere (although her schematic includesphenomenological and intrapsychic features as well).

Note should be made of another productive personologist who utilized amathematical/factorial approach to construct personality dimensions, namely Raymond Cattell14.His research has led him to identify 16 primary factors, or source traits, which he then arranged insets of bipolar dimensions that would undergird personality types. Other contemporary quantitative

contributors include Peter Tyrer15

and W. John Livesley16

.In a model which seeks to draw on genetic and neurobiologic substrates, Robert Cloninger 17has proposed a complex theory based on the interrelationship of several trait dispositions. Central tohis formula are a series of heritable characteristics or dimensions, notably: novelty seeking, harmavoidance, and reward dependence. Each of these is associated with different neurobiologic systems,respectively dopamaninergic, serotonergic, and noradrenergic. The interaction of these heritabletraits shape the development of personality by influencing learning experiences, processinginformation, mood reactions, and general adaptation.

Another biosocial model using three pairs of evolutionary polarities as a basis is onedeveloped by Theodore Millon18. Here, he derived a PD taxonomy that subsumed the dependent,independent, ambivalent, and detached coping styles with an activity-passivity dimension. This

produced eight theoretically-derived personality types of an innovative character, e.g., avoidant,narcissistic, borderline. Despite their correspondence to the official DSM PDs, these PDs were


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considered to be conceptual and prototypal, seen essentially to represent styles of maladaptive functioningthat stem from different deficiencies, imbalances, or conflicts in the human species capacity torelate to the environments it faces.

Notably, in their recent work, numerous theorists have begun to turn their attention topositive mental health, speaking of personality resilience and adaptive capacities.

Contributors: Juan J. Lopez-Ibor and Erik Simonsen

IV. CLASSIFICATION ALTERNATIVES

Classification is the act of distributing things into classes or groups of the same type. It has beenan important subject in psychiatry since modern ways of examining the subject started in 1900 withthe first edition of the International Classification of Diseases (ICD). Interest has accelerated sincethe publication of the third edition of the DSM in the United States and the eight edition of the

ICD. There have been many changes, not always based on good evidence, so now there are morethan three times as many mental disorders than there were in 1979. When we focus our attention onthe specific area of personality disorders, there has long been controversy. This is due to acombination of limited evidence, cultural variation, definitional uncertainty, variation in theoreticalmodels, and the influence of pressure groups. Despite the many existing problems related toclassifications in the general field of psychiatry, personality characteristics reflect the diversity ofcultural influences. However, there is general agreement that personality disorders are conditions in

which there is abnormal behaviour and attitudes, that these create distress and social dysfunction,and that they cannot be attributed to a temporary or longer term disruption created by the presenceof a mental state disorder. There is also agreement it is only when a persons behaviour patterndeviates markedly from the standards of the individuals culture that the diagnosis of personality

disorder should be entertained.

A. The Current Official Systems

Two classificatory systems of mental disorders are recognized internationally today, namely, theDiagnostic and Statistical Manual of Mental Disorders - 4th Edition-Text Revised (DSM-IV-TR)19 and theInternational Classification of Mental and Behavioural Disorders(ICD-10)20. Personality disorders are givenimportant weight in both classifications. The DSM-IV-TR places them in its separate Axis II (thisclassification comprises five such axes). The personality disorders in the DSM are grouped into threeclusters, based essentially on empirical descriptive similarities; this cluster grouping has not (andmaybe never will be) been satisfactorily validated but its widespread use indicates a frequent wish toreduce the number of categories. Cluster A includes paranoid, schizoid and schizotypal personalitydisorders (the so-called odd or eccentric individuals), Cluster B comprises antisocial, borderline,histrionic and narcissistic PDs (the ostensible dramatic, emotional or erratic individuals), and ClusterC includes avoidant, dependent and obsessive-compulsive PDs (anxious/fearful individuals). A lastcategory, PD not otherwise specified, comprises disorders of personality that do not fulfil thespecific criteria for any of the above individual PDs. An Appendix B includes two more PDs, thosethat need further study, the depressive and the passive-aggressive (negativistic) PDs. Alsonoteworthy are two other PDs included in Appendix A of the DSM-III-R21; these were dropped inthe DSM-IV, the sadistic and the self-defeating personalities, this later type, known better as themasochistic personality, was said to be one of the most frequent PDs found in clinical studies.

The ICD-10 Classification includes a single section covering all personality abnormalities andpersistent behavioural disturbances. This is separated into specific named personality disorders,mixed and other personality disorders, and enduring personality changes. The individual personality


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disorders are paranoid, schizoid, dissocial, emotionally unstable (impulsive and borderline types),histrionic, anxious (avoidant), anankastic and dependent ones. Two more categories are otherspecific PDs and PD, unspecified. The ICD classification is similar to that of DSM-IV, althoughdifferences are noteworthy. For example, the borderline PD of the DSM-IV is subsumed as one ofthe two emotionally unstable disorders in ICD-10, the obsessive-compulsive adjective in DSM-IV is

retained as anankastic in ICD-10, and avoidant personality disorder is only a partial equivalent ofthe ICD-10 anxious personality disorder. Two more disorders included in the official section of theDSM-IV are excluded from ICD-10; schizotypal disorder is a variant within the schizophreniaspectrum of conditions in ICD-10 and narcissistic personality disorder is only mentioned in thesection on other specific PDs in ICD-10, without any specific criteria noted for this diagnosis.

The ICD-10 contains other general categories that refer to PDs that have no counterpart in theDSM-IV, such as mixed disorders and other disorders of adult personality and behaviour.

The official classification systems reflect a variety of personality related issues that are unlikelyto be solved in the near future. First, there is the question of the retention of personality disorderson a different axis (Axis II) from that of clinical syndromes (Axis I) in the DSM-IV. The divisionbetween Axis I and Axis II seems to some to be arbitrary and not justified adequately. A second

persistent problem is the classificatory status of the individual categories of personality disorder.There is great overlap between the criteria for diagnosing personality disorders in both DSM-IV andICD-10 and this seriously compromises their validity as separate disorders. Clear differentiationbetween the disorders is often difficult and many individuals diagnosed with a personality disorderhave several other personality disorders that do not always appear to be fundamentally different. Athird issue is the overlap of some personality disorders with disorders in Axis I. An example is therelationship between avoidant PD and generalized social phobia, both of which address the samegroup of symptoms without a clear distinction between them. Although still included in the

Appendix B of DSM-IV, there seems to be a similar problem between depressive personalitydisorder (Axis II) and dysthymia (Axis I). A fourth question is how many personality disordersdeserve separate description in the two classification systems? It is also uncertain what type of

criteria should constitute the building blocks of personality disorder and how many of them areneeded for each diagnosis. Both classifications rest mainly on historical traditions and committeeconsensus rather than on empirical data or well-constructed theoretical grounds. Many of theassumptions of each classification are implicit or covert and need to be exposed so that diagnosiscan be made consistently and subjected to systematic testing. There are also many questions aboutthe division between normal personality and personality disorders that need answering and

whether it is wise to have a division at all.Another major controversy in the field is the categorical/dimensional/prototypical

controversy, to which we will turn shortly. A further issue is the polythetic criterion lists used incurrent classification systems; these produce considerable intragroup variability such that two people

with the same diagnosed PD may display very different features because they score for different

sections. Finally, as already mentioned, PDs are tied to cultural variables to a much greater extentthan the clinical disorders in Axis I, creating difficulties when diagnosing this kind of disordersacross different cultures, a topic we will also address in a later section.

Given the need for a clear unambiguous official classificatory system for personality disordersand the dissatisfaction with the current two systems, there are likely to be important changes in theclassification of personality disorders in DSM-V and ICD-11, both of which are planned to bepublished in 2011. Perhaps the most important question is how to we improve the clinical utility ofthe classification of personality disorders so that it is recognised to be helpful in decision-making atall levels? The following sections examine the areas in which such changes are likely to be made soas to achieve this goal.


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B. On the Reality of Personality Syndromes

Not only are personality data complex, they can also be approached from a variety of frames ofreference. As previously noted, they can be conceived and grouped behaviourally as complexresponse patterns to environmental stimuli. Biophysically, then can be approached and analyzed assequences of complex neural and chemical activity. Intrapsychically, they can be inferred and

categorized as networks of entrenched unconscious processes that bind anxiety and conflict. Quiteevidently, the complexity and intricacy of personological phenomena not only make it difficult bothto establish clear-cut relationships among phenomena, but to find simple ways in which thesephenomena can be classified or grouped. Should we artificially narrow our perspective to one datalevel to obtain at least a coherency of view? Or should we trudge ahead with formulations whichbridge domains, but threaten to crumble by virtue of their complexity and potentially low internalconsistency?

There is a clear logic to classifying syndromes in medical disorders. Bodily changes wroughtby infectious diseases and structural deteriorations repeatedly display themselves in a reasonablyuniform pattern of signs and symptoms that make sense in terms of how anatomic structures andphysiological processes are altered and dysfunction. Moreover, these biological changes provide a

foundation not only for identifying the etiology and pathogenesis of these disorders, but also foranticipating their course and prognosis. Logic and fact together enable us to construct a rationale toexplain why most medical syndromes express themselves in the signs and symptoms they do, as wellas the sequences through which they unfold.

Can the same be said for classifications of personality disorder? Is there a logic, or evenevidence, for believing that certain forms of clinical expression (e.g. behaviours, cognitions, affects,defence mechanisms) cluster together as do medical syndromes - in other words, that they not onlycovary frequently, but make sense as a coherently organized and reasonably distinctive group ofcharacteristics? Are there theoretical and empirical justifications for believing that the varied featuresof personality display a configurational unity and expressive consistency over time? Will the carefulstudy of individuals reveal congruency among attributes such as overt behaviour, intrapsychic

functioning, and biophysical disposition? Is this coherence and stability of psychological functioninga valid phenomenon - that is, not merely imposed upon observed data by virtue of clinicalexpectation or theoretical bias?

There are reasons to believe that the answer to each of the preceding questions is yes. Statedbriefly and simply, the observations of covariant patterns of signs and symptoms, and traits may betraced to the fact that people possess relatively enduring biophysical dispositions that give aconsistent coloration to their experience, and that the range of experience to which people areexposed throughout their lives is both limited and repetitive22. Given the limiting and shapingcharacter of these biogenic and psychogenic factors, it should not be surprising that individualsdevelop clusters of prepotent and deeply ingrained behaviours, cognitions, and affects that clearlydistinguish them from others of dissimilar backgrounds. Moreover, once a number of the

components of a particular clinical pattern are identified, knowledgeable observers are able to tracethe presence of other, unobserved, but frequently correlated features comprising that pattern.

If we accept the assumption that most people do display a pattern of internally consistentcharacteristics, we are led next to the question of whether groups of patients evidence commonalityin the patterns they display. The notion of personality syndromes rests on the assumption thatthere exist a limited number of such shared covariances - for example, regular groups of diagnosticsigns and symptoms that co-occur frequently and therefore can confidently be used to distinguishcertain classes of patients. For example, why does the possession of characteristic A increase theprobability, appreciably beyond chance, of also possessing characteristics B, C, and so on? Lessabstractly, why do particular behaviours, attitudes, mechanisms, and so on covary in repetitive andrecognizable ways, instead of exhibiting themselves in a more or less haphazard fashion? And even

more concretely, why should, say, behavioural defensiveness, interpersonal provocativeness,cognitive suspicion, affective irascibility, and excessive use of the projection mechanism co-occur in


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the same individual, instead of being uncorrelated and randomly distributed among differentindividuals?

To answer these questions, we believe that temperament and early experience simultaneouslyaffect the development and nature of several emerging psychological structures and functions; thatis, a wide range of behaviours, attitudes, affects and mechanisms can be traced to the same origins,

leading thereby to their frequently observed covariance. Second, once an individual possesses theseinitial characteristics, they set in motion a series of derivative life experiences that shape theacquisition of new psychological attributes causally related to the characteristics that preceded themin the sequential chain. Common origins and successive linkages increase the probability that certainpsychological characteristics will frequently be found to pair with specific others, resulting thereby inrepetitively observed symptom or trait clusters. Hence, the existence of legitimate andunderstandable syndromes of a personality nature. Whether these evolving patterns are lifelong,that is, extend into old age, remains unknown, a question that deserves active empirical study,particularly in light of humankinds increasingly long lives this coming century.

C. Structuring a taxonomy of personality disorders?In addition to asking about the content of personality and how a taxonomy may be established andinvestigated, we need to know how personality data should be organized. What units of analysis arebest for grouping and differentiating clinical personalities? Though a number of formulations arepossible, including the radix and class-quantitative approaches, the answer to this question hastraditionally turned on whether one believes that the person should be embedded in the diagnosticsystem, or whether the diagnostic system should be embedded in the personthe perennialcontroversy between categories, dimensions and prototypes. Each has advantages anddisadvantages23,24.

Categorical Models: Among the advantages of categorical typologies is their ease of use byclinicians who must make relatively rapid diagnoses with large numbers of patients whom they see

briefly. Although clinical attention in these cases is drawn to only the most salient features of thepatient, a broad range of traits that have not been directly observed is often strongly suggested. Infact, the capacity to suggest characteristics beyond those immediately manifest adds special value toan established system of categories. For example, let us assume that an individual is suspected ofbeing histrionic following the observation of behaviours which are seductive and dramatic in relatingto the clinical staff. After observing behaviours associated with only these two traits, what clinician

would not want to inquire whether the person is stimulus seeking, needful of attention,interpersonally capricious, emotionally labile, and so on? In effect, assignment to a particular type orcategory often proves useful by alerting the clinician to a range of unobserved but frequentlycorrelated behaviours. The ability of categories to extend the scope of associated characteristicscontrasts with the tendency of dimensional schemas to fractionate the intrinsic unity of personality

into separate and uncoordinated traits. As such, typologies restore and recompose the unity ofpersonality by integrating seemingly diverse elements into a single syndrome. Moreover, theavailability of well-established syndromes provides a standard reference for clinicians who wouldotherwise be faced with repeated analyses and de novo personality constructions that could not begeneralized from one patient to the next.

Ardent proponents of dimensional classification note a number of disadvantages of thecategorical model. Categories assume the existence of discrete boundaries both between separatepersonality styles and between normality and abnormality, a feature felicitous to the medical model,but not so for personality functioning, which exists on a continuum. Consequently, diagnosticthresholds, far from being coordinated with the definition of PD in a generic sense, are essentiallyarbitrary, with the result that small changes in diagnostic criteria may radically influence prevalence

estimates. Moreover, by being oriented to the presence or absence of a disorder, even groupsrigorously diagnosed by structured interviews may be biased by a substantial subsample that


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possesses subclinical traits for another disorder. To state the problem more generally, assume aresearcher is interested in an Axis I condition: If the Axis I disorder and an Axis II personalitydiagnosis are strongly comorbid, is it better for research purposes to include only those with the

Axis I condition to obtain a pure representation of this disorder, or to let the group be biasedtogether with the Axis II condition on the grounds that this sample is in fact more representative?

Dimensional Models: Dimensional models possess a number of virtues. Most important isthat they combine several clinical features or personality traits into a single profile, which can begrasped and interpreted by experienced clinicians almost in toto. Because of theircomprehensiveness, little information of potential significance is lost; nor is any single trait givenspecial attention, as when only one distinctive characteristic is brought to the foreground in atypology. Further, a trait profile permits the assessment of unusual or atypical cases; in typologies,odd, infrequent, or "mixed" conditions often excluded since they do not fit the prescribedcategories. Given the diversity and idiosyncratic character of many clinical personalities, adimensional system encourages the representation of individuality, rather than forcing patientsinto categories for which they are ill-suited. A final advantage of a dimensional format is that thestrength of traits is gauged quantitatively - each characteristic extends into the normal range; as a

consequence, normality and abnormality are merely arranged as points on a continuum rather thanas distinct and separable phenomena. In contrast to categories, dimensional schemas recognize thetenuous nature of the normal-abnormal distinction. Indeed, continuity is the cardinal feature ofdimensional systems as they are usually articulated.

Unfortunately, while the arguments of those who favour the adoption of dimensional modelscentre mainly around one theme, that the categorical model, because it entails discrete boundariesbetween the various disorders and between normality and abnormality, is simply inappropriate forthe PDs, the kind of discreteness that dimensional systems often bring to personality assessment,discreteness between dimensions, tends to be largely overshadowed by the continuity characteristicof each dimension itself. Many dimensional systems, for example, have been createdmethodologically through factor analytic techniques explicitly designed to extract independent or

orthogonal factors (e.g. the five-factor model). In other words, an individuals standing on any onedimension is in no way related to his or her standing on any other dimension.One can ask, however, as dimensional proponents have of the categorical model, does the

world really work this way? The answer to this question is to be found in the systems conception ofpersonality. The cardinal feature of systems is their functional-structural interdependence. Whatexists in one domain of the system constrains what can comfortably co-exist elsewhere. A child born

with a reactive, choleric temperament, for example, might develop any number of future personalitycharacteristics, but would probably not grow up to become a sanguine diplomat, delicately weighingthis and that to the satisfaction of all sides with great premeditation. Thus, while a system is a systemprecisely because of interrelationship between essential variables, a taxonomy of orthogonaldimensions is orthogonal precisely because it presumes independence among essential variables, an

absence of interrelationships. While the world does not exist in categories, neither can it besupposed to exist in rows and columns25.Other complications and limitations have been noted in the literature, and these should be

recorded also. Some traits possess inherently positive connotations, and so are anchored innormality, while other traits possess inherently negative connotations, and so are anchoredexclusively in the undesirable or clinical realm. An example here would be emotional stability versusemotional vulnerability. Other trait dimensions may be conceived that are psychologicallycurvilinear, such that both extremes have negative implications; an example of this would be foundin an activity dimension such as listlessness versus restlessness.

Additionally, while trait dimensions have a number of desirable properties, there is littleagreement among their proponents concerning either the nature or number of traits necessary to

represent personality adequately. For example, Menninger26

contends that a single dimension willsuffice; Eysenck27asserts that three are needed, whereas Cattell28claims to have identified as many as


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33 and believes there to be many more. Theorists may, in fact, invent dimensions in accord withtheir expectations rather than "discovering" them as if they were intrinsic to nature, merely awaitingscientific detection. Apparently, the number of traits required to assess personality is not determinedby the ability of our research to disclose some inherent truth but rather by our predilections forconceiving and organizing our observations. Describing personality with more than a few such trait

dimensions produces schemas so complex and intricate that they require geometric or algebraicrepresentation. Although there is nothing intrinsically wrong with such quantitative formats, they dopose considerable difficulty both in comprehension and in communication among professionals.Most mental health workers are hesitant about working with complex multivariate statistics, and theconsequent feeling that one is lost in one's own professional discipline is not likely to make suchschemas attractive, no less practical for everyday use.

Apart from matters of convenience and comfort, dimensional profiles are often grouped intocategories before the information they contain can be communicated. Indeed, it is not clear thatdimensional models can free themselves from ultimately embracing the category-like entities theirproponents so much eschew. Paradoxically, as more and more external variables are correlated witha particular profile, the profile itself begins to take on aspects of an integrative hypothesis, effectively

acquiring a construct-like nature. Thus, clinicians and researchers begin to focus, for example, on 4-9and 1-2 profiles, and these groups become an area of interest and investigation. The tendency tosimplify dimensional profiles suggests that even if a dimensional format were universally adopted,researchers might well end up studying populations of profiles rather than persons.

Prototypal Models: Prototypes are a relatively recent diagnostic innovation, one first implicitlyadopted in the DSM. The prototype is neither category nor dimension, but a synthesis of both. Forseveral reasons, prototypal models may become the preferred schema for representing PDs andclinical syndromes. First, most contemporary typologies neither imply, nor were constructed, as all-or-none categories. Most advocates of the dimensional approach to clinical practice choose tooverlook the fact that the word categories has been used very loosely in the DSM. Second, theprototype construct recognizes the explicit heterogeneity of personality disordered patients. Pure

prototypal cases are extremely rare; most patients meet criteria for multiple disorders and may havesubclinical features of other personality styles as well. Indeed, the problems imputed to categoricalmodels largely evaporate if categories are regarded as prototypes. Prototypal constructs do notassume discrete boundaries29and have the advantage that they are already implicit in the diagnosticsystem. A prototype consists of the most common features or properties of members of a categoryand thus describes a theoretical ideal or standard against which real people can be evaluated. All ofthe prototype's properties are assumed to characterize at least some members of the category, but noone property is necessary or sufficient for membership in the category. Therefore, it is possible thatno actual person would match the theoretical prototype perfectly. Instead different people wouldapproximate it to different degrees. The more closely a person approximates the ideal, the moreclosely the person typifies the concept.

Explicit in this description is the use of diagnostic criteria as a heuristic method, not as areified model. The surplus causal meaning associated with latent taxons need not be postulated.Such an approach would seem thoroughly consonant with the atheoretical orientation of the DSM,

which, if taken to its logical conclusion, should be atheoretical not only with regard to the variousschools of psychopathology but structurally as well. Because certain literatures, methodologies, andstructural models appear to cohere tenaciously - for example, empiricism, the lexical approach,factor analysis, and dimensional models - this point cannot be underestimated.

How might prototypes actually be used in clinical contexts? As Horowitz and associates30noted, the resemblance of an individual to the prototype is necessarily a qualitative as well as aquantitative affair. Although categories and dimensions inevitably sacrifice one or the other kind ofinformation, the prototype conserves both. That is, by its heuristic nature, the prototype asks both

how and how much the individual resembles the prototype. Thus, not all persons who havecoronary artery disease (CAD) have the same blockages in their arteries; some have them in the


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left descending main, some in the circumflex, and so on. However, all have CAD. Similarly, not allpersons with metastatic carcinoma are identical in their pathology; the disease of some is relativelylocalized, others are widespread, some are slow growing, others faster, yet all importantly evidencethe same basic disease process.

Will the same variation be true for personality prototypes? There is a logic for asserting that

certain behaviours, cognitions, and moods cluster together as do medical syndromes. As notedpreviously, these characteristics not only covary frequently, but they make sense as a distinctivegroup of clinical traits that evidence configurational unity and expressive consistency. The questionremains, however, are there not variations in these reasonably consistent patterns of clinicalcharacteristics? Each personality prototype will display a cluster of cohesive characteristics, but it isalso clear that each PD will evidence variations in the manner in which its clinical features aremanifested. It is these numerous variations that clinical theorists have termed personality subtypesor prototypal variants31. The fact that patients can profitably be classified into personality prototypesdoes not negate the fact that patients, so categorized, may display a measure of clinical difference as

well, a fact observed quite routinely, as noted previously, with medical diseases. It is argued byprototypal researchers, such as Westen31, that the widely publicized categorical versus dimensional

debate may, in part, be resolved by identifying the numerous prototypal variants that exist amongPDs. According to this research, only a small subset of the basic trait characteristics that have beentheoretically or empirically proposed in the literature are found to combine in clinically relevant

ways. Every conceivable combination of traits does not emerge as personality variants; that is, only afew of the many combinations that are mathematically possible are in fact found to be theoreticallycoherent or clinically evident. Only those few prototypal variants which cohere realistically inactual clinical practices are worth including in a PD taxonomy.

Contributors: Vicente Caballo, Theodore Millon and Drew Westen

V. DEVELOPMENTAL PATHOGENESIS

PDs begin to be diagnosed in adolescence, but usually have precursors in childhood. For example,adults with antisocial disorder usually have a preceding history of conduct disorder, a childhoodcondition that closely resembles the adult diagnosis. In most cases, PDs continue over the course ofadult life. However, certain groups of patients (notably those in the borderline category) have beenshown to improve and a small proportion do attain normal levels of functioning. These observationsunderline the clinical challenge of understanding and treating these populations.

The premise that early experience plays a central role in shaping personality attributes is oneshared by numerous theorists. To say the preceding, however, is not to agree as to which specific

factors during these developing years are critical in generating particular attributes, nor is it to agreethat known formative influences are either necessary or sufficient. Psychoanalytic theorists almostinvariably direct their etiologic attentions to the realm of early childhood experience. Unfortunately,they differ vigorously among themselves as to which aspects of nascent life are crucial todevelopment. Of increasing importance to the study of developmental pathogenesis is the need toresearch the nature of personality disorders in the latter years of life.

Before we proceed, there is reason to ask whether etiologic analysis is even possible inpersonality pathology in light of the complex and variable character of developmental influences.Can this most fundamental of scientific activities be achieved given that we are dealing with aninteractive and sequential chain of causes composed of inherently inexact data of a highlyprobabilisti

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