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A revision of the leading textbook on personality disorders by renowned expert Theodore Millon

"Personalities are like impressionistic paintings. At a distance, each person is ‘all of a piece’; up close, each is a bewildering complexity of moods, cognitions, and motives."
Theodore Millon

Exploring the continuum from normal personality traits to the diagnosis and treatment of severe cases of personality disorders, Personality Disorders in ...

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Personality Disorders in Modern Life

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Overview

A revision of the leading textbook on personality disorders by renowned expert Theodore Millon

"Personalities are like impressionistic paintings. At a distance, each person is ‘all of a piece’; up close, each is a bewildering complexity of moods, cognitions, and motives."
Theodore Millon

Exploring the continuum from normal personality traits to the diagnosis and treatment of severe cases of personality disorders, Personality Disorders in Modern Life, Second Edition is unique in its coverage of both important historical figures and contemporary theorists in the field. Its content spans all the major disorders–Antisocial, Avoidant, Depressive, Compulsive, Histrionic, Narcissistic, Paranoid, Schizoid, and Borderline–as well as their many subtypes. Attention to detail and in-depth discussion of the subtleties involved in these debilitating personality disorders make this book an ideal companion to the DSM-IV™.

Fully updated with the latest research and theory, this important text features:

  • Discussion of the distinctive clinical features and developmental roots of personality disorders
  • Balanced coverage of the major theoretical perspectives–biological, psychodynamic, interpersonal, cognitive, and evolutionary
  • Individual chapters on all DSM-IV™ personality disorders and their several subtypes and mixtures
  • Case studies throughout the text that bring to life the many faces of these disorders

Including a new assessment section that singles out behavioral indicators considered to have positive predictive power for the disorders, this Second Edition also includes a special focus on developmental, gender, and cultural issues specific to each disorder. A comprehensive reference suitable for today’s practitioners, Personality Disorders in Modern Life, Second Edition features a clear style that also makes it a valuable resource for advanced undergraduate and graduate students. The most thorough book of its kind, this Second Edition is a powerful, practical resource for all trainees and professionals in key mental health fields, such as psychology, social work, and nursing.

The book contains black-and-white illustrations.

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Editorial Reviews

From the Publisher
"William James would certainly consider Personality Disorders in Modern Life a fine tribute to mark the end of the first century of the scientific study of personality disorders. It is an exemplary book to usher in the next century of research and developments in the exciting and ever-changing field of personality disorders." (Contemporary Psychology, 10/01)

"...you should certainly read what Millon has to say about the personality disorders." (Behavioural & Cognitive Psychotherapy, January 2001)

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Product Details

  • ISBN-13: 9781118428818
  • Publisher: Wiley
  • Publication date: 6/12/2012
  • Sold by: Barnes & Noble
  • Format: eBook
  • Edition number: 2
  • Pages: 624
  • Sales rank: 1,096,603
  • File size: 9 MB

Meet the Author

Theodore Millon, PhD, DSc, is one of the world’s leading authorities on personality disorders. Developer of the widely used Millon personality assessment inventories, he has been the editor of the Journal of Personality Disorders, President of the International Society for the Study of Personality Disorders, and a key member of the DSM-III and DSM-IV committees on personality disorders.

Seth Grossman, PsyD, is a codeveloper of several personality inventories, and coauthor of numerous theoretical, research, and clinical papers with Dr. Millon.

Carrie Millon, PhD, is former EAP director of the University of Miami and currently Associate Director of the Institute for Advanced Studies of Personology and Psychopathology (IASPP).

Sarah Meagher, PhD, is a research clinician practicing health psychology in the behavior medicine programs of Kaiser Permanente mental health services in California.

Rowena Ramnath, PsyD, is a research associate at IASPP and specializes in forensic psychology and Internet addiction.

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Table of Contents

CHAPTER1 PERSONALITY DISORDERS: CLASSICAL FOUNDATIONS 1

Abnormal Behavior and Personality 3

Early Perspectives on the Personality Disorders 14

The Biological Perspective 17

The Psychodynamic Perspective 22

Summary 35

CHAPTER2 PERSONALITY DISORDERS: CONTEMPORARY PERSPECTIVES 38

The Interpersonal Perspective 39

The Cognitive Perspective 48

Trait and Factorial Perspectives 54

The Evolutionary-Neurodevelopmental Perspective 57

Summary 72

CHAPTER3 DEVELOPMENT OF PERSONALITY DISORDERS 74

On the Interactive Nature of Developmental Pathogenesis 77

Pathogenic Biological Factors 78

Pathogenic Experiential History 88

Sources of Pathogenic Learning 90

Continuity of Early Learnings 101

Sociocultural Influences 112

Summary 116

CHAPTER4 ASSESSMENT AND THERAPY OF THE PERSONALITY DISORDERS 117

The Assessment of Personality 118

Psychotherapy of the Personality Disorders 134

Summary 147

CHAPTER5 THE ANTISOCIAL PERSONALITY 150

From Normality to Abnormality 155

Variations of the Antisocial Personality 158

Early Historical Forerunners 161

The Biological Perspective 162

The Psychodynamic Perspective 166

The Interpersonal Perspective 168

The Cognitive Perspective 172

The Evolutionary-Neurodevelopmental Perspective 175

Therapy 182

Summary 184

CHAPTER6 THE AVOIDANT PERSONALITY 187

From Normality to Abnormality 191

Variations of the Avoidant Personality 193

Early Historical Forerunners 198

The Biological Perspective 198

The Psychodynamic Perspective 201

The Interpersonal Perspective 203

The Cognitive Perspective 206

The Evolutionary-Neurodevelopmental Perspective 210

Therapy 217

Summary 220

CHAPTER7 THE OBSESSIVE-COMPULSIVE PERSONALITY 223

From Normality to Abnormality 227

Variations of the Compulsive Personality 229

Early Historical Forerunners 235

The Psychodynamic Perspective 236

The Interpersonal Perspective 240

The Cognitive Perspective 244

The Evolutionary-Neurodevelopmental Perspective 247

Therapy 255

Summary 257

CHAPTER8 THE DEPENDENT PERSONALITY 259

From Normality to Abnormality 263

Variations of the Dependent Personality 265

Early Historical Forerunners 268

The Psychodynamic Perspective 270

The Interpersonal Perspective 273

The Cognitive Perspective 275

The Evolutionary-Neurodevelopmental Perspective 278

Therapy 284

Summary 289

CHAPTER9 THE HISTRIONIC PERSONALITY 292

From Normality to Abnormality 295

Variations of the Histrionic Personality 297

Early Historical Forerunners 301

The Biological Perspective 302

The Psychodynamic Perspective 304

The Interpersonal Perspective 311

The Cognitive Perspective 315

The Evolutionary-Neurodevelopmental Perspective 318

Therapy 324

Summary 327

CHAPTER 10 THE NARCISSISTIC PERSONALITY 330

From Normality to Abnormality 333

Variations of the Narcissistic Personality 337

Early Historical Forerunners 342

The Biological Perspective 343

The Psychodynamic Perspective 343

The Interpersonal Perspective 349

The Cognitive Perspective 355

The Evolutionary-Neurodevelopmental Perspective 358

Therapy 366

Summary 369

CHAPTER 11 THE SCHIZOID PERSONALITY 371

From Normality to Abnormality 376

Variations of the Schizoid Personality 377

The Biological Perspective 380

The Psychodynamic Perspective 383

The Interpersonal Perspective 386

The Cognitive Perspective 390

The Evolutionary-Neurodevelopmental Perspective 392

Therapy 398

Summary 401

CHAPTER 12 THE SCHIZOTYPAL PERSONALITY 403

From Normality to Abnormality 408

Variations of the Schizotypal Personality 409

Early Historical Forerunners 412

The Biological Perspective 414

The Psychodynamic Perspective 416

The Interpersonal Perspective 419

The Cognitive Perspective 423

The Evolutionary-Neurodevelopmental Perspective 425

Therapy 430

Summary 433

CHAPTER 13 THE PARANOID PERSONALITY 435

From Normality to Abnormality 439

Variations of the Paranoid Personality 442

Early Historical Forerunners 445

The Biological Perspective 448

The Psychodynamic Perspective 449

The Interpersonal Perspective 455

The Cognitive Perspective 458

The Evolutionary-Neurodevelopmental Perspective 463

Therapy 471

Summary 475

CHAPTER 14 THE BORDERLINE PERSONALITY 477

From Normality to Abnormality 481

Variations of the Borderline Personality 482

The Biological Perspective 488

The Psychodynamic Perspective 490

The Interpersonal Perspective 495

The Cognitive Perspective 502

The Evolutionary-Neurodevelopmental Perspective 505

Therapy 511

Summary 516

CHAPTER 15 PERSONALITY DISORDERS FROM THE APPENDICES OF DSM-III-R AND DSM-IV 519

The Self-Defeating (Masochistic) Personality 520

The Sadistic Personality 530

The Depressive Personality 539

The Negativistic (Passive-Aggressive) Personality 548

Summary 558

References 561

Author Index 583

Subject Index 593

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First Chapter

Chapter 1
Personality Disorders: Current Concepts and Classical Foundations

Note: Some of the Figures and/or Tables mentioned in this sample chapter do not appear on the Web.

Objectives
  • What is personality?
  • Distinguish among personality, character, and temperament.
  • What is the DSM?
  • Make a list of terms important in the study of personality and its disorders.
  • Explain the DSM's multiaxial model. What are the reasons for having a multiaxial classification system?
  • Explain why personality is analogous to the body's immune system.
  • What are the three criteria that distinguish normal from abnormal functioning?
  • Why is eclecticism perforce a scientific norm in the social sciences?
  • Explain how ideas progress in the social sciences.
  • What are the different components of the biological perspective?
  • Describe Freud's topographical and structural models of the mind.
  • What is the function of defense mechanisms? How do they work?
  • Describe the stages of psychosexual development.
  • What are character disorders?
  • Explain the significance of object relations theory.
  • Explain Kernberg's use of the term structural organization.

What are you like as a person? What is your distinctive personality? How well do you know yourself? Are there aspects of your personality of which you are unaware? Do others know you as you know yourself? What are the best and worst things about your personality? These questions are easy to ask, but often difficult to answer. Yet, they go directly to the essence of what we are as human beings. Personality is that which makes us what we are, and also that which makes us different from others. People who are especially different, for example, are said to have "personality" or be "quite a character." Other people have "no personality at all." Depending on how someone affects us, he or she may be viewed as having a "good personality" or a "bad personality."

In the past two decades, the study of personality and its disorders has become central to the study of abnormal psychology. In the course of clinical work, one encounters subjects with vastly different pathologies. Some are in the midst of a depressive episode, and some must cope with the lasting effects of traumas far beyond the range of normal human experience. Some are grossly out of contact with reality, and some have only minor "problems in living" rather than clinical disorders. But although the problems vary, everyone has a personality. Today, however, the personality disorders occupy a place of diagnostic prominence and constitute their own area of scientific study. The issues involved are complex, certainly much more sophisticated than the everyday understanding of personality described in the questions above. This chapter introduces the emergence of this new discipline by analyzing the constructs of personality and personality disorders, by comparing and contrasting the basic assumptions that underlie approaches to these constructs, and by presenting the fundamentals of the classical perspectives on personality, which are essential to the understanding of the clinical chapters that follow. The questions are: What is personality? How does our definition of personality inform our definition of personality disorder? Do the assumptions underlying the concept of personality support the use of the term disorder? How can the content of different personality constructs best be described?

One way to investigate the definition of a term is to examine how its meanings and usage have evolved over time. Historically, the word personality is derived from the Latin term persona, originally representing the theatrical mask used by ancient dramatic players. As a mask assumed by an actor, persona suggests a pretense of appearance, that is, the possession of traits other than those that actually characterize the individual behind the mask. In time, the term persona lost its connotation of pretense and illusion and began to represent not the mask, but the real person's observable or explicit features. The third and final meaning personality has acquired delves "beneath" surface impression to turn the spotlight on the inner, less often 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. This last meaning comes closest to contemporary use. Today, personality is seen as a complex pattern of deeply embedded psychological characteristics that are expressed automatically in almost every area of psychological functioning. That is, personality is viewed as the patterning of characteristics across the entire matrix of the person.

Personality is often confused with two related terms, character and temperament. Although all three have similar meanings in casual usage, character refers to characteristics acquired during our upbringing and connotes a degree of conformity to virtuous social standards. Temperament, in contrast, refers not to the forces of socialization, but to a basic biological disposition toward certain behaviors. One person may be said to be of "good character," whereas another person may have an "irritable temperament." Character thus represents the crystallized influence of nurture, and temperament represents the physically coded influence of nature.

Understanding the personality disorders requires an understanding of their role in the study of abnormal behavior. The Diagnostic and Statistical Manual of Mental Disorders, called the DSM for short, is considered the bible of mental disorders by psychologists and psychiatrists. The first official edition, published in 1952, was heavily influenced by previous systems established by the Army and the Veterans Administration to assist in understanding the mental health problems of World War II servicemen. In time, the DSM evolved beyond its original military purpose, becoming the standard or compendium for all of abnormal behavior. Now in its fourth edition, the DSM-IV is widely considered the official classification system or taxonomy for use by mental health professionals. It describes all mental disorders widely believed to exist, as well as a variety of others provisionally put forward for further research. Twelve personality disorders are included in DSM-IV, 10 of which are officially accepted, and 2 of which are provisional. In addition, this text briefly discusses 2 others that appeared in the revised third edition of the DSM. Although deleted from the latest edition, their diagnostic labels remain in widespread clinical use. Table 1.1 gives brief descriptions of these 14 personality disorders, an overview to the later chapters of this book.

BASIC VOCABULARY

Every field of study has its own special vocabulary, or jargon. Many terms used in the discussion of abnormal behavior appear over and over again in this book. Learn them now, for you will see them again and again. Diagnostic criteria are the defining characteristics used by clinicians to classify individuals within a clinical category. Essentially, diagnostic criteria constitute a checklist of features that must be present before a diagnosis can be made. Each disorder has its own unique list. Some lists are short, others are longer. For example, seven criteria are used to diagnose the antisocial personality. One of these is "deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure" (DSM-IV, 1994, p. 650). Eight criteria are used to diagnose the histrionic personality. One of the most interesting is "interaction with others is often characterized by inappropriate sexually seductive or provocative behavior" (p. 657).

In general, criteria for the personality disorders list either seven, eight, or nine items, each of which details some characteristic trait, attitude, or behavior strongly related to that particular disorder. In the antisocial criterion listed above, deceitfulness is considered a personality trait, a long-standing pattern of behavior expressed across time and in many different situations. The histrionic criterion listed above can also be considered as tapping the personality trait of seductiveness, because histrionics are known for inappropriately sexualizing their communications. Where many such personality traits typically occur together, they may be said to constitute a personality disorder. Antisocials, for example, are much more than just deceitful; they are also manipulative, reckless, aggressive, irresponsible, explositive, and lacking in empathy and remorse. When all of these characteristics are taken together, they constitute what is a called a personality prototype, a psychological ideal found only rarely in nature. The disorder is the prototype, put forward in terms of its purest expression.

In contrast, real persons seldom present as "pure types." The DSM does not require that subjects possess each and every characteristic of a personality disorder before a diagnosis can be made. Typically, some majority of criteria will suffice. For example, five of eight criteria are required for a diagnosis of histrionic personality disorder, and five of nine are required for a diagnosis of narcissistic personality disorder. Many different combinations of diagnostic criteria are possible, a fact that recognizes that no two people are exactly alike, even when both share the same personality disorder diagnoses. Although Charles Manson and Jeffrey Dahlmer might both be considered antisocial personalities, for example, their personalities are nevertheless substantially different. Determining exactly what separates individuals like Dahlmer and Manson from the rest of us requires a great deal of biographical information. For that reason, each chapter in this text focuses on factors important in the development of a personality disorder. For example, a special relationship between father and daughter is one of the major pathways in the development of an adult histrionic personality disorder. TABLE 1.1 Brief Descriptions of the 14 Personality Disorders of DSM-III, DSM-III-R, and DSM-IV Schizoid Apathetic, indifferent, remote, solitary. Neither desires nor needs human attachments. Minimal awareness of feelings of self or others. Few drives or ambitions, if any. Avoidant Hesitant, self-conscious, embarrassed, anxious. Tense in social situations due to fear of rejection. Plagued by constant performance anxiety. Sees self as inept, inferior, or unappealing. Feels alone and empty. Depressive 1 Somber, discouraged, pessimistic, brooding, fatalistic. Presents self as vulnerable and abandoned. Feels valueless, guilty, and impotent. Judges self as worthy only of criticism and contempt. Dependent Helpless, incompetent, submissive, immature. Withdraws from adult responsibilities. Sees self as weak or fragile. Seeks constant reassurance from stronger figures. Histrionic Dramatic, seductive, shallow, stimulus-seeking, vain. Overreacts to minor events. Exhibitionistic as a means of securing attention and favors. Sees self as attractive and charming. Narcissistic Egotistical, arrogant, grandiose, insouciant. Preoccupied with fantasies of success, beauty, or achievement. Sees self as admirable and superior, and therefore entitled to special treatment. Antisocial Impulsive, irresponsible, deviant, unruly. Acts without due consideration. Meets social obligations only when self-serving. Disrespects societal customs, rules, and standards. Sees self as free and independent. Sadistic 2 Explosively hostile, abrasive, cruel, dogmatic. Liable to sudden outbursts of rage. Feels self-satisfied through dominating, intimidating, and humiliating others. Is opinionated and close-minded. Compulsive Restrained, conscientious, respectful, rigid. Maintains a rule-bound lifestyle. Adheres closely to social conventions. Sees the world in terms of regulations and hierarchies. Sees self as devoted, reliable, efficient, and productive. Negativistic 1 Resentful, contrary, skeptical, discontented. Resists fulfilling others' expectations. Deliberately inefficient. Vents anger indirectly by undermining others' goals. Alternately moody and irritable, then sullen and withdrawn. Masochistic 3 Deferential, pleasure-phobic, servile, blameful, self-effacing. Encourages others to take advantage. Deliberately defeats own achievements. Seeks condemning or mistreatful partners. Paranoid Guarded, defensive, distrustful, and suspicious. Hypervigilant to the motives of others to undermine or do harm. Always seeking confirmatory evidence of hidden schemes. Feels righteous but persecuted. Schizotypal Eccentric, self-estranged, bizarre, absent. Exhibits peculiar mannerisms and behaviors. Reads thoughts of others. Preoccupied with odd daydreams and beliefs. Blurs line between reality and fantasy. Borderline Unpredictable, manipulative, unstable. Frantically fears abandonment and isolation. Experiences rapidly fluctuating moods. Shifts rapidly between loving and hating. Sees self and others alternately as all-good and all-bad.

1 Listed as a provisional disorder in DSM-IV.
2 From the appendix of DSM-III-R.
3 Called Self-Defeating in DSM-III-R appendix.

THE MULTIAXIAL MODEL

The mental disorders in the DSM are not listed one after another. Instead, they are grouped in terms of the multiaxial model. Multiaxial literally means multiple axes. Each axis represents a different kind or source of information. Later, we will concentrate on exactly what these sources are; right now, we just want to explain their purpose. The multiaxial model exists because some means is required whereby the various symptoms and personality characteristics of a given patient can be brought together to paint a picture that reflects the functioning of the whole person. For example, depression in a narcissistic personality is different from depression in a dependent personality. Because narcissists consider themselves superior to everyone else, they usually become depressed when confronted with objective evidence of failure or inadequacy too profound to ignore. Their usually puffed-up self-esteem deflates, leaving feelings of depression in its wake. In contrast, dependent personalities seek powerful others to take care of them, instrumental surrogates who confront a cruel world. Here, depression usually follows the loss of a significant caretaker. The point of the multiaxial model is that each patient is more than the sum of his or her diagnoses: both are depressed, but for very different reasons. In each case, what differentiates them is not their surface symptoms, but rather the meaning of their symptoms in the context of their underlying personalities. By considering symptoms in relation to deeper characteristics, an understanding of the person is gained that transcends either symptoms or traits considered separately. To say that someone is a depressed narcissist, for example, conveys much more than does the label of depression or narcissism alone.

The multiaxial model is divided into five separate axes (see Figure 1.1), each of which gets at a different source or level of influence in human behavior. The first axis, Axis I clinical syndromes, consists of the classical mental disorders that have preoccupied clinical psychology and psychiatry for most of the history of these disciplines. Axis I is structured hierarchically. Each family of disorders branches into still finer distinctions, which compose actual diagnoses. For example, the anxiety disorders include obsessive-compulsive disorder, posttraumatic stress disorder, and generalized anxiety disorder. The mood disorders include depression and bipolar disorder. Other branches recognize sexual disorders, eating disorders, substance abuse disorders, and so on. Finally, each disorder is broken down in diagnostic criteria, a list of symptoms that must typically be present for the diagnosis to be given. The second axis, the Axis II personality disorders, is the subject of this text.

The third axis, Axis III, consists of any physical or medical conditions relevant to understanding the individual patient. Some influences are dramatic, and others are more subtle. Examples of dramatic influences include head injury, the effects of drug abuse or prescribed medications, known genetic syndromes, and any other disease of the nervous, respiratory, digestive, or genitourinary system, brain structure, or other bodily system that impacts psychological functioning. Examples of subtle influence include temperament as the pattern of activity and emotionality to which an individual is genetically disposed, as well as constitutional and hormonal patterns. Essentially, Axis III recognizes that the body is not just the vessel of the soul. Instead, we are all integrated physical and psychological beings. To use a computer metaphor, software always requires hardware, and, depending on the hardware, different software functions may be either enhanced or disabled, or just run in a different way. Some individuals have a central processing unit that keeps crunching busily, for example, whereas others run hot and have a great-looking case, but not much more. Physical factors always impact psychological functioning, if only because the body is the physical matrix from which mind emerges. Anyone who has had a lobotomy undoubtedly knows this already, but probably doesn't much care.

Axis IV consists of all psychosocial and environmental factors relevant to psychological functioning. Included are problems related to the family or primary support group, such as the death of a family member, marital separation or divorce, sexual or physical abuse, family conflict, or inappropriate or inadequate discipline at home. Also included are problems in the social environments outside the family. Educational problems include poor reading skills, lack of sufficient instruction, and conflict with teachers. Occupational problems include threats to employment, actual job loss, and conflict with authority figures and coworkers. Finally, Axis IV includes such miscellaneous issues as general economic and legal problems, for example, a pending criminal trial.

Essentially, Axis IV recognizes that each person exists and functions in a variety of contexts and, in turn, that these contexts often have profound effects on the individual. For example, if a narcissistic person is fired from employment, odds are that the firing has something to do with the person's intolerable attitude of superiority. Narcissists are above it all, to the point of not bowing to the boss. Some even view themselves as being above the law, as if the rules of ordinary living could not possibly apply to them. By putting all the pieces together– current symptoms, personality characteristics, and psychosocial stressors– a complex, but logical, picture of the total person is obtained. When considered in relation to specific biographical details, the result is an understanding that links the developmental past with the pathological present to explain how particular personality characteristics and current symptoms were formed, how they are perpetuated, and how they might be treated. This complex integration of all available information is known as the case conceptualization.

In contrast to the other axes, Axis V contains no specific content of its own. Once the case has been conceptualized, the next question is the level of severity: How pathological is this total picture? To make this determination, problems across all other axes are collapsed into a global rating of level of psychological, social, and occupational functioning, called the GAF, or Global Assessment of Functioning Scale, which ranges from 0 to 100. Ratings may be made at any particular moment in time, perhaps admission to the hospital emergency room, at intake, or at discharge. Alternatively, ratings can sum up functioning across entire periods of time, perhaps the past week or the past year. Limitations due to physical handicaps are excluded. In general, Axis V functions as an overall index of psychological health and pathology. Such measurements are often useful in tracking total progress over time.

Although you could just memorize the five axes of the multiaxial model, it is much better to understand the purpose for which the model was constructed, why it exists as it does. The most fundamental reason is that the model increases clinical understanding by ensuring that all possible inputs to the psychopathology of the given subject receive attention. If you went to the doctor for a physical, you would want him or her to check your lungs, heart, kidneys, stomach, and all other major organs and systems. A doctor who pronounced you healthy after taking only your blood pressure would not be much of a doctor at all.

The same is true of the mental disorders. Psychopathology is much more complex, but nothing of importance should be neglected. Each of the axes in the multiaxial model corresponds to a different "level of organization," so that each axis contextualizes the one immediately below it, changing its meaning and altering its significance. Axis I is the presenting problem, the reason the patient is currently being held in psychiatric emergency or sits chatting with a psychotherapist. In turn, Axis II, the personality disorders, provides both a substrate and context for understanding the symptoms of Axis I. As a substrate, personality inclines us toward the development of certain clinical disorders rather than others. For example, avoidant personalities typically shun contact with others, even though intimacy, approval, and self-esteem are what they most desperately seek. In contrast, narcissistic personalities, who are frequently indulged as children, grow up with a sense of superior self-worth that others often see as prideful and grandiose. Of the two, the avoidant is much more likely to develop a fear of public speaking, and the narcissist is much more likely to be fired from a job for being arrogant to everyone. The kinds of problems that a particular individual might develop can, in many cases, be predicted once his or her personality characteristics are known. In turn, personality rides on top of biology and rests within the psychosocial environment. We are both physical and social beings. When problems seem to be driven principally by personality factors, we speak of maladaptive personality traits or personality disorders. When difficulties concern primarily environmental or social factors, an Axis I adjustment disorder may be diagnosed, or Axis IV problems in living may be noted. Personality is the level of organization in which these influences are synthesized (see Figure 1.2).

The multiaxial model draws attention to all relevant factors that feed into and perpetuate particular symptoms, and it also guides our understanding of how psychopathology develops. In most cases, the interaction of psychosocial stressors and personality characteristics leads to the expression of psychological symptoms. In other words, Axis II and Axis IV interact to produce Axis I (see Figure 1.3). When personality includes many adaptive traits and relatively few maladaptive ones, the capacity to cope with such psychosocial calamities as death and divorce is increased. However, when personality includes many maladaptive traits and few adaptive ones, even minor stressors may precipitate an Axis I disorder.

In this sense, personality may be seen as the psychological equivalent of the body's immune system. Each of us lives in an environment of potentially infectious bacteria, and the strength of our defenses determines whether these microbes take hold, spread, and ultimately are experienced as illness. Robust immune activity easily counteracts most infectious organisms, whereas weakened immune activity leads to illness. Psychopathology should be conceived as reflecting the same interactive pattern. Here, however, it is not our immunological defenses, but our overall personality pattern– that is, coping skills and adaptive flexibilities– that determine whether we respond constructively or succumb to the psychosocial environment. Viewed this way, the structure and characteristics of personality become the foundation for the individual's capacity to function in a mentally healthy or ill way. Every personality style is thus also a coping style, and personality becomes a cardinal organizing principle through which psychopathology should be understood.

A MISCONCEPTION: PERSONALITY AND THE MEDICAL MODEL

By presenting the personality disorders as entities that can be diagnosed, the DSM encourages the view that they are discrete medical diseases. They are not. The causal assumptions underlying Axis I and Axis II are simply different. Personality is the patterning of characteristics across the entire matrix of the person. Rather than being limited to a single trait, personality instead regards the total configuration of the person's characteristics: interpersonal, cognitive, psychodynamic, and biological. Each trait reinforces the others in perpetuating the stability and behavioral consistency of the total personality structure (see Figure 1.4). For the 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 of the Axis I clinical syndromes are assumed to be localizable. The cause of an adjustment disorder, for example, lies in a recent change in life circumstances that requires considerable getting used to. Here, causes and consequences are distinguishable, with discrete distinction between the underlying "disease" and its symptom expression. Difficulty making an adjustment might result in feelings of depression, for example. For the personality disorders, however, the distinction between disease and symptom is lost. Instead, causality issues from every domain of functioning. Each element in the whole structure sustains the others. This explains why personality disorders are notoriously resistant to psychotherapy.

Because personality disorders are not diseases, we must be very careful in our casual usage of the term. To imagine that a disorder, of any kind, could be anything other than a medical illness is very difficult. The idea that personality constitutes the immunological matrix that determines our overall psychological fitness is intended to break the longen-trenched habit of conceiving syndromes of psychopathology as one or another variant of a disease, that is, as some "foreign" entity or lesion that intrudes insidiously within the person to undermine his or her so-called normal functions. The archaic notion that all mental disorders represent external intrusions or internal disease processes is an off-shoot of prescientific ideas, such as demons or spirits that possess or hex the person. The role of infectious agents and anatomical lesions in physical medicine has reawakened this view. Demons are almost ancient history, but personality disorders are still seen as involving some external entity that invades and unsettles an otherwise healthy status. Although we are forced to use such terminology by linguistic habit, it is impossible for anyone to "have" a personality disorder. Rather, it is the total matrix of the person that constitutes the potential for psychological adaptation or illness.

NORMALITY VS. PATHOLOGY

Normality and abnormality cannot be distinguished on a completely objective basis. All such distinctions, including the diagnostic categories of the DSM-IV, are in part social constructions and cultural artifacts. Although persons may be segregated into groups according to explicit criteria, ostensibly lending such classifications the respectability of science, the desire to segregate and the act of segregating persons into diagnostic groups is uniquely social. All definitions of pathology, ailment, malady, sickness, illness, or disorder are ultimately value-laden and circular (Feinstein, 1977). Disorders are what doctors treat, and what doctors treat is defined by implicit social standards. Given its social basis, normality is probably best defined as conformity to the behaviors and customs typical for one's reference group or culture. Pathology would then be defined by behaviors that are uncommon, irrelevant, or alien to one's reference group. Not surprisingly, American writers have often thought of normality as the ability to function independently and competently to obtain a personal sense of contentment and satisfaction. Other cultures may have other standards; in Asian societies, for example, individualism is not valued as highly as respect for group norms.

Even within a reference group, normality and pathology usually reside on a continuum. One slowly fades into the other. Because personality disorders are composed of maladaptive traits, there are two ways that personality pathology becomes more severe when moving along the continuum from health to pathology. First, single traits can become more intense in their expression; assertiveness can give way to aggression, for example, or deference can give way to masochism. Second, the number of maladaptive traits attributed to the given subject may increase. By comparing the statements given in Table 1.2 for a subset of compulsive traits, we can easily see how normality gradually gives way to personality disorder.

THE MISUNDERSTOOD STUDENT Jenna, a first-year graduate student in psychology, was required to write up her impressions of a videotaped therapy session featuring a beginning therapist and a female Asian student referred by her instructor for excessive shyness. Eventually, Jenna noticed that regardless of what the therapist said, the student always seemed to agree. At the end of the session, the therapist was interviewed and asked for his impressions. The therapist reinforced the instructor's opinion about the student's shyness, and felt change would be fast, as the student offered little resistance. As Jenna's instructor pointed out, this conclusion was incorrect. In fact, the much younger female student was prevented from disagreeing with the much older male therapist because of cultural norms. Once the student was empowered to disagree, it was discovered that conventions appropriate to her reference group largely accounted for her behavior with her instructor, not long-standing personality traits. Accordingly, therapy was refocused on adjustments to the expectations of American culture, not on personality change.

Keeping the above cautiously in mind, personality disorders do seem to be characterized by three pathological characteristics (Millon, 1969). The first follows directly from the conception that personality is the psychological analogue of the body's immune system: Personality disorders tend to exhibit a tenuous stability, or lack of resilience, under conditions of stress. The coping strategies of most individuals are diverse and flexible. When one strategy or behavior isn't working, normal persons shift to something else. Personality disorder subjects, however, tend to practice the same strategies over and over again with only minor variations. As a result, they always seem to make matters worse. Consequently, the level of stress keeps increasing, amplifying their vulnerability, creating crisis situations, and producing increasingly distorted perceptions of social reality.

TABLE 1.2 The Compulsive Personality, from Adaptive to Severely Disordered
Adaptive Subclinical Disordered Severely Disordered
Perfectionistic "I take pride in what "I feel I have to work on things until I get them right." "I can't stop working on something until it's perfect, even if it already satisfies what I need it for." "Because nothing is ever good enough, I never finish anything."
Hard-working "I believe in the work ethic." "I rarely take time off for leisure or family." "It drives me crazy if something is unfinished. I have never taken a vacation." "I panic if I leave the office with something left undone. I work so late that I usually end up sleeping there."
Playful "I like to consider my choices before I act on something." "I have to analyze all the alternatives before I make up my mind." "I try to consider so many eventualities that it becomes very difficult to make a decision." "I get so lost in trying to anticipate all the possibilities and details that I put things off and never commit to anything."
Morally scrupulous "I like to do the right thing." "I am sometimes intolerant of people whose moral standards are less than my own." "I am disgusted by the moral laxity and indulgence I see in 99% of humanity." "I think anyone who deviates from the straight and narrow should be punished swiftly for their sins."
Conscientious "I like to take my time and do things right." "Sometimes I think others will disapprove of me if they find even one small mistake." "I find it hard to stop working until I know others will be satisfied with the job I've done." "I check and re-check my work until I'm absolutely sure that no one can find a mistake in what I've done."
Emotionally constricted "I rarely get excited about anything." "I don't believe in expressing much emotion." "There are only a few things I enjoy, and even with those, I can't let myself go." "I have never found any use for emotion. I have never felt any enjoyment from life."

The second characteristic overlaps somewhat with the first: Personality disordered subjects are adaptively inflexible. Normal personality functioning entails role flexibility, knowing when to take the initiative and change the environment, and knowing when to adapt to what the environment offers. Normal persons exhibit flexibility in their interactions, such that their initiatives or reactions are proportional and appropriate to what circumstances require. When constraints on behavior come from the situation, the behavior of normal individuals tends to converge, regardless of personality. If the boss wants something done a particular way, most people will follow directions. Such situations are highly scripted. Almost everyone knows what to do and behaves in nearly the same way.

In contrast, the alternative strategies and behaviors of personality disordered subjects are few in number and rigidly imposed on conditions for which they are poorly suited. Personality disordered subjects implicitly drive or control interpersonal situations through the intensity and rigidity of their traits. In effect, the personality disordered person provides the most powerful constrains on the course of the interaction. Because they cannot be flexible, the environment must become even more so. When the environment cannot be arranged to suit the person, a crisis ensues. Opportunities for learning new and more adaptive strategies are thereby even further reduced, and life becomes that much less enjoyable.

The third characteristic of personality disordered subjects is a consequence of the second. Because the subjects fail to change, the pathological themes that dominate their life tend to repeat over and over and over again as vicious circles. Pathological personalities are themselves pathogenic. In effect, life becomes a bad one-act play that repeats over and over. They waste opportunities for improvement, provoke new problems, and constantly create situations that replay their failures, often with only minor variations on a few related, self-defeating themes.

THE COMPULSIVE ENTREPRENEUR Eager to learn about the characteristics of the different personality disorders, Jenna asked her clinical supervisor for materials that might bring the different personalities vividly to life. She received an audiotape of a husband-and-wife interview, provided by consent of the subjects. During the session, the wife bitterly complained that her husband, married once previously, spent almost no time with the family. Asked why his first wife had divorced him, the man stated solemnly that she was incapable of taking life seriously, and refused to help while he toiled hour after hour checking and rechecking the operational details of their new business. Further probing revealed that although both women acknowledged his ability to stay focused on task, both also complained that the marriage had no intimacy, spontaneity, or romance. As additional data came to light, the husband was diagnosed as an obsessive-compulsive personality. His rigid work ethic and unending earnestness created almost identical problems across two relationships.

The Evolution of Scientific Ideas

The history of every science may be said to include a prescientific "natural history" phase, where the main questions are What are the essential phenomena of the field? and How can we know them? Ideally, as more and more data are gathered through increasingly sophisticated methodologies, common sense begins to give way to theoretical accounts that not only integrate and unify disparate observations, but also actively suggest directions for future research. The existence of black holes, for example, is predicted by the theory of relativity, and the accumulated evidence of several decades now suggests that one or more black holes exist at the center of every galaxy. Of course, no one will ever smell, taste, touch, hear, or see an actual black hole. Because even light cannot escape their gravitational power, they must remain forever hidden from observation. Instead, scientists must infer the existence of black holes from the predictions of relativity and from their observable effects on surrounding space-time. Technological advances have since allowed many other predictions of relativity to be tested.

With this brief example, the function of theory in science becomes clear. Theories represent the world to us in some way that accounts for existing observations, but nevertheless also goes beyond direct experience, a characteristic known as surplus meaning. Theories embrace the available evidence, but allow us to make novel predictions precisely because they exceed the evidence. Thus, the mathematics of relativity may be used to predict exactly what would happen if you fell into a black hole, though you would never return to report about it.

In the natural sciences, chemistry and physics for example, theory and experimentation are equally important. Sometimes in the history of science, as with the theory of relativity, theory outpaces the capacity of science to make observations. Black holes, for example, were a known mathematical consequence of relativity long before scientists began to figure out ways to observe their effects. Alternatively, new technologies may make possible observations that are more detailed, more precise, and more abundant than ever before, challenging existing theories to the point that entire fields are sent into chaos. The ready availability of new observations allows testing to progress unfettered, quickening the pace of theory formation in turn. And so, the science matures. The yield of the Hubble space telescope, for example, is so vast that cosmologists cannot yet assimilate everything their new tool allows. Because there are usually multiple competing theories for any given phenomenon, determining which account is correct depends on the construction of a paradigm experiment, one designed to produce results consistent with one theory but inconsistent with the other. In this way, research tends to close in on the truth, whittling down the number of possible theories through experimentation over time.

The social sciences, however, are fundamentally different. Whereas investigation in the natural sciences eventually comes to closure through the interplay of theory and research, the social sciences are fundamentally open. Here, advancement occurs when some new and interesting point of view suddenly surges to the center of scientific interest. Far from overturning established paradigms, the new perspective now exists alongside its predecessors, allowing the subject matter of the field to be studied from an additional angle. A perspective is, by definition, just one way of looking at things. Accordingly, paradigm experiments are either not possible or not necessary, because it is understood that no single perspective is able to contain the whole field. Tolerance thus becomes a scientific value, and eclecticism a scientific norm. In personality, the dominant perspectives are psychodynamic, biological, interpersonal, and cognitive. Other, more marginal conceptions could also be included, perhaps existential or cultural. Some offer only a particular set of concepts or principles, and others generate entire systems of personality constructs, often far different from those of the DSM. Hopefully, the most important ways of looking at the field are already known, though it is always possible that alternative conceptions remain undiscovered. The chapters in this text that discuss the specific personality disorders address these different perspectives: the cognitive, the psychodynamic, the biological, and the interpersonal views of the antisocial personality, for example.

The open nature of the social sciences has further important consequences for how they are presented for study. The history of physics as a science is interesting, but only incidental to the study of its subject matter. Universal laws are universal laws. If Einstein had never been born, the equations that describe the relationship between energy and matter, space and time, would still be the same. We may disagree about politics and religion, but we all live in the same physical universe, and the mathematics describing that universe constitute one Truth about its nature.

In the social sciences, however, different perspectives on the field are discovered in no necessary order. Later perspectives tend to be put forth as reactions to preceding ones. The social sciences have what philosophers might call a contingent structure: had Freud never been born, the history and content of psychology would be very different. In fact, primacy is perhaps the single most important reason why Freud has been so influential. Freud was simply first. When psychoanalysis was becoming established, the only truly competing perspective was biological. In time, psychoanalysis became so dominant it was synonymous with the study of abnormal behavior. Because the cognitive and interpersonal perspectives had not yet been founded, it took some time to discover that psychoanalysis is really just one part of psychopathology, rather than the whole science. Later thinkers studied Freud's work to draw important contrasts with their own points of view, so that today, the father of psychoanalysis is one of the most famous and most refuted figure in history. And naturally, in studying Freud, these important thinkers were also influenced by him, in effect becoming psychoanalysts, at least somewhat, in order to become something more.

In any field, perspectives seldom emerge fully formed. Instead, novel ideas coalesce slowly, so that only after a period of time does their presence as a new point of view become apparent. When this occurs, many individuals formerly seen as belonging to the old school are now seen as transitional figures, difficult to classify. Harry Stack Sullivan, about whom you will be reading more later, reacted so strongly against psychoanalysis that he is regarded as the father of the interpersonal perspective. Nevertheless, many of Sullivan's notions were anticipated by Alfred Adler, who also reacted against Freud. Yet, Adler is regarded as psychodynamic, and Sullivan is regarded as interpersonal. Even so, contemporary interpersonal theory has advanced so far that Sullivan sometimes looks analytic in contrast.

Understanding the open nature of social sciences and how they evolve may seem tangential, but in fact, it is fundamental to understanding personality and its disorders. Each perspective contributes different parts to personality, but personality is not just about parts. Instead, personality is the patterning of characteristics across the entire matrix of the individual. Whatever the parts may be, personality is about how they intermesh and work together. Occasionally, you may hear someone say that personality is really just biological, or really just cognitive, or really just psychodynamic. Do not believe them. The explicit purpose of a perspective is to expose different aspects of a single phenomenon for study and understanding. A single element cannot be made to stand for the whole.

By definition, each perspective is but a partial view of an intrinsic totality. And by definition, personality is the integration of these perspectives, the overall pattern or gestalt. Each point of view belongs to the study of personality, but personality itself is more than the sum of its parts. In the next two sections, we trace the history and importance of two competing approaches to personality, the biological and the psycholdynamic. Among other things, these perspectives have given the field important units of analysis– temperament and character, respectively– that have sometimes sought to replace personality itself as the proper focus of clinical study.

The Biological Perspective

Axis III of the DSM recognizes an important truth about human nature: We are all biological creatures, the result of five billion years of chemical evolution here on planet Earth. In the course of everyday life, we do not ordinarily think about the link between mind and body. Especially when young, our physical matrix usually hums along so smoothly that its functions are completely transparent. Subjectively, our existence seems more like that of a soul captured or held within a body, not that of a self that emerges from a complex physical organization of neurons communicating chemically across synapses. So strong is the illusion that philosophers have debated for centuries whether the universe is ultimately composed of mind or matter or both. To us, our minds seem self-contained, and our will free. Because our choices always seem to be our own, we cannot imagine that our bodies are anything more than vessels. No wonder, then, that many religions maintain that each of us has an immortal soul that escapes upon the body's demise. From the standpoint of science, however, humans are social, psychological, and biological beings. As such, our will is neither totally determined nor totally free, but constrained by influences that cut across every level of organization in nature.

Biological influences on personality may be thought of as being either proximal or distal, meaning nearby or far away. Distal influences originate within our genetic code and often concern inherited characteristics transmitted as part of the evolutionary history of our species. Many such characteristics are sociobiological. These exist because genetic recombination could not exist in the absence of sexuality. As a prerequisite for evolution, we are gendered beings who seek to maximize the representation of our own genes in the gene pool. For the most part, the influence is subtle, but even among human beings, males tend to be more aggressive, dominant, and territorial, and females tend to be more caring, nurturant, and social. Such tendencies are only weakly expressed among normals, but some personality disorders do caricature their sex-role stereotype, notably the antisocial and narcissistic personalities among males and the dependent and histrionic personalities among females.

Other biological influences in personality focus on proximal causes, influences that exist because we are complex biological systems. When the structures that underlie behavior differ, behavior itself is affected. Two such concepts important to personality are temperament and constitution.

TEMPERAMENT

Just as everyone has a personality, everyone has characteristic patterns of living and behaving that to a great extent are imposed by biology. Each child enters the world with a distinctive pattern of dispositions and sensitivities. Mothers know that infants differ from the moment they are born, and perceptive parents notice differences between successive children. Some infants have a regular cycle of hunger, elimination, and sleep, whereas others vary unpredictably. Some twist fitfully in their sleep; others lie peacefully awake in hectic surroundings. Many of these differences persist into adulthood. Some people wake up slowly, and others are wide awake almost as soon as their eyes open.

The word temperament came into the English language in the Middle Ages to reflect the biological soil from which personality develops. Temperament is thus an underlying biological potential for behavior, seen most clearly in the predominant mood or emotionality of individuals and in the intensity of their activity cycles. Although Buss and Plomin (1984, p. 84) refer to it as consisting of "inherited personality traits present in early childhood," we might argue that temperament is the sum total of inherited biological influences on personality that show continuity across the life span. A case can certainly be made that temperament is more important than other domains of personality and more pervasive in its influence. Because our physical matrix exists before other domains of personality emerge, biologically built-in behavioral tendencies preempt and exclude other possible pathways of development that might take hold. Thus, although an irritable, demanding infant may mature into a diplomat famous for calmly understanding the issues on all sides, the odds are stacked against it. Similarly, a child whose personal tempo is slower than average is unlikely to develop a histrionic style, and an unusually agreeable infant is unlikely to develop an antisocial personality. Thus, biology does not determine our adult personality, but it does constrain development, channeling it down certain pathways rather than others, in interaction with social and family factors.

GENDER BIAS IN THE DIAGNOSIS OF PERSONALITY DISORDERS
Do certain personality disorders favor men and others favor women? The answer may depend on where you look. Because more women than men seek treatment for mental disorders, there are usually more women among the patients in mental health centers. Conversely, because more men than women are veterans, one would expect more male patients at Veterans Administration hospitals.
Nevertheless, certain personality disorders do seem weighted toward a particular gender. For some researchers (Kaplan, 1983; Pantony & Caplan, 1991), these discrepancies in diagnostic frequency, particularly in the larger number of females diagnosed borderline, dependent, and histrionic, are inherently sexist. However, although the
DSM-IV agrees that these three are more frequently diagnosed in women, it also states that the paranoid, schizoid, schizotypal, antisocial, narcissistic, and obsessive-compulsive are more frequently diagnosed in men. If there is a bias, then, it would appear to go against the males.
One problem that creates bias is that certain diagnostic criteria seem to refer to both normalcy and pathology. Most people would argue that the histrionic criterion "consistently uses physical appearance to draw attention to self," for example, is exceptionally ambiguous in a society where a pleasing physical appearance is an expected part of the female gender role. Accordingly, where subjects have several traits of the histrionic personality, it is possible that clinicians might simply assume that this ambiguous criterion is met. Widiger (1998) argues that the more unstructured the interview situation, the more likely it is that clinicians will rely on sex stereotypic bias when diagnosing.
Even where diagnostic criteria are not ambiguous, it may nevertheless prove difficult to apply them equally across the sexes. The criteria for the dependent personality, for example, seems to emphasize as pathological female types of dependency, but fails to include masculine types of dependency. For example, Walker (1994, p. 36) argues that "men who rely on others to maintain their homes and take care of their children are ... expressing personality-disordered dependency." Were this criterion added, many more men would certainly be diagnosed dependent.
Future DSMs must profit from the above considerations if diagnostic criteria are to be devised that can replace implicit sex-stereotypic conceptions to be valid for both genders.

The doctrine of bodily humors posited by the early Greeks some 25 centuries ago was one of the first systems used to explain differences in personality. In the fourth century B. C., Hippocrates concluded that all disease stems from an excess of or imbalance among four bodily humors: yellow bile, black bile, blood, and phlegm. These humors were the embodiment of earth, water, fire, and air, the declared basic elements of the universe according to the philosopher Empedocles. Hippocrates identified four basic corresponding temperaments: choleric, melancholic, sanguine, and phlegmatic. Centuries later, Galen would associate each temperament with a particular personality trait; the choleric temperament was associated with irascibility, the sanguine temperament with optimism, the melancholic temperament with sadness, and the phlegmatic temperament with apathy. Although the doctrine of humors has been abandoned, giving way to the study of neurochemistry as its contemporary analogue, the old view still persists in such contemporary expressions as being sanguine or good-humored.

CONSTITUTION

Constitution refers to the total plan or philosophy upon which something is constructed. The foremost early exponent of this approach was Ernst Kretschmer (1926), who developed a classification system based on three main body types– thin, muscular, and obese— each of which was associated with certain personality traits and psychopathologies. According to Kretschmer, the obese were disposed toward the development of manic-depressive illness, and the thin toward the development of schizophrenia. Kretschmer also believed that his types were associated with the expression of normal traits. Thin types were believed to be introverted, timid, and lacking in personal warmth, a less extreme version of the negative symptoms exhibited by withdrawn schizophrenics. Obese persons were conceived as gregarious, friendly, and interpersonally dependent, a less extreme version of the moody and socially excitable manic-depressive.

Kretschmer's work was continued by Sheldon (1942), who saw similarities between the three body types and the three basic layers of tissue that compose the embryo: ectoderm, mesoderm, and endoderm. The endoderm develops into the soft parts of the body, the mesoderm eventually forms the muscles and skeleton, and the ectoderm forms the nervous system. Each embryonic layer corresponds to a particular body type and is associated with the expression of certain normal-range personality characteristics. Accordingly, endomorphs, who tend toward obesity, were believed to be lovers of comfort and to be socially warm and goodwilled. Mesomorphs, who usually resemble athletes, were believed to be competitive, energetic, assertive, and bold. And finally, ectomorphs, who tend toward thinness, were believed to be introversive and restrained but also mentally intense and restless. Although interesting, the idea of body types is no longer influential in personality theory. Rather than study the total organization of the body, researchers have begun to examine the role of individual anatomical structures in detail, many of which lie in the human brain.

NEUROBIOLOGICAL MODELS

Cloninger (1986, 1987b) proposed an elegant theory based on the interrelationship of three genetic-neurobiologic trait dispositions, each of which is associated with a particular neurotransmitter system. Specifically, novelty seeking is associated with low basal activity in the dopaminergic system, harm avoidance with high activity in the serotonergic system, and reward dependence with low basal noradrenergic system activity. Novelty seeking is hypothesized to dispose the individual toward exhilaration or excitement in response to novel stimuli, which leads to the pursuit of potential rewards as well as an active avoidance of both monotony and punishment. Harm avoidance reflects a disposition to respond strongly to aversive stimuli, leading the individual to inhibit behaviors to avoid punishment, novelty, and frustrations. Reward dependence is seen as a tendency to respond to signals of reward, verbal signals of social approval, for example, and to resist extinction of behaviors previously associated with rewards or relief from punishment. These three dimensions form the axes of a cube whose corners represent various personality constructs (see Figure 1.5). Thus, antisocial personalities, who are often seen as fearless and sensation-seeking, are seen as low in harm avoidance and high in novelty seeking, whereas the imperturbable schizoid is seen as low across all dimensions of the model. Interestingly, the personality disorders generated by Cloninger's model correspond only loosely to those in the DSM-IV. A number of personality disorders do not appear in the model at all.

Another model, proposed by Siever and Davis (1991), is a psychobiological model consisting of four dimensions— cognitive/ perceptual organization, impulsivity/ aggression, affective instability, and anxiety/ inhibition— each of which has both Axis I and Axis II manifestations. Thus, cognitive/ perceptual organization appears on Axis I in the form of schizophrenia, and on Axis II especially as the schizotypal personality disorder but also the paranoid and the schizoid. All exhibit a disorganization of thought, dealt with by social isolation, social detachment, and guardedness. Impulsivity/ aggression appears on Axis I in the form of impulse disorders, and on Axis II particularly as the borderline and antisocial personalities. Borderlines are prone to sudden outbursts of anger and suicide attempts, and antisocials are unable to inhibit impulsive urges to violate social standards, for example, stealing and lying. Affective instability, a tendency toward rapid shifts of emotion, is manifested in the affective disorders on Axis I, and in the borderline, and possibly histrionic, on Axis II. Anxiety/ inhibition, associated with social avoidance, compulsivity, and sensitivity to the possibility of danger and punishment, is manifested in the anxiety disorders on Axis I, and particularly in the avoidant personality on Axis II, but also in the compulsive and dependent.

HEREDITY

The most distal influence in personality is genetics. Researchers explore the influence of genes on behavior by searching for the presence of similar psychopathologies in siblings and relatives of an afflicted subject, by studying patterns of transmission across generations of the extended family, and by comparing the correlation of scores obtained on personality tests between sets of fraternal twins and identical twins reared together and apart. Other esoteric methodologies are also available, including structural equation modeling (Derlega, Winstead, & Jones, 1991) and Multiple Abstract Variance Analysis (Cattell, 1982). A comparison of correlations for identical twins reared together and apart shows that both are approximately equal, running at about .50 across a variety of personality traits (Bouchard, Lykken, McGue, Segal, & Tellegan, 1990). Even measures of religious interests, attitudes, and values have been shown to be highly influenced by genetic factors (Waller, Kojetin, Bouchard, Lykken, et al., 1990).

Studies of the heritability of the personality disorders have been less definite. Trait researchers can avail themselves of large samples of normal subjects, but the sample sizes generated by personality disorders are comparatively small and highly pathological in comparison to normal samples, which can distort correlational statistics. Moreover, because personality disorders exist as overlapping composites of personality traits, genetic environmental interactions are much more complex than for single traits alone. In a review of the evidence, Thapar and McGuffin (1993) argue that the evidence for heritability is most strong for antisocial and schizotypal personality disorders. In another review, Nigg and Goldsmith (1994) suggest that the paranoid and schizoid personality disorders may be linked genetically with schizophrenia. Another popular genetic hypothesis is that the wild emotional swings of the borderline personality are evidence of its association with the affective disorders, which include depression and manic-depression.

Livesley, Jang, Jackson, and Vernon (1993) sought to examine the heritability of 18 dimensions associated with personality disorder pathology, as assessed by the Dimensional Assessment of Personality Pathology (Livesley, Jackson, & Schroeder, 1992). They found that the dimensions of anxiousness, callousness, cognitive distortion, compulsivity, identity problems, oppositionality, rejection, restricted expression, social avoidance, stimulus seeking, and suspiciousness all have heritabilities of between 40 and 60%. Because these are all facets of one or more personality disorders, their study provides indirect support that at least certain problematic traits are indeed heritable to a degree. For example, callousness is often thought of in association with the antisocial, sadistic, and narcissistic personalities, and stimulus seeking is associated with the histrionic and antisocial personalities. Cognitive distortion is associated with the schizotypal; suspiciousness is obviously associated with the paranoid. Social avoidance would be associated with the avoidant personality; oppositionality would likely be associated with the negativistic personality. Other associations could also be drawn.

The Psychodynamic Perspective

Of all the major perspectives on personality, the psychoanalytic is perhaps the most conceptually rich and yet the most widely misunderstood (Gay, 1988). Sigmund Freud, the father of psychoanalysis, was born in 1856. As the oldest child of an adoring mother whose belief in her son's destiny never flagged, Freud knew he would be famous. Naturally attracted to science and influenced by Darwin, he settled on a medical career and spent a period of time involved in pure research. Eventually, practical necessity intervened, and Freud began a more applied course, specializing in neurology and psychiatry. In 1885, he traveled to France and witnessed Jean Charcot cure a case of hysterical paralysis using hypnosis. Because the psychiatric treatments of the times were highly ineffective, Freud was impressed and began to experiment with the technique on his own, eventually developing the foundational ideas of psychoanalysis.

THE TOPOGRAPHIC MODEL

By the early 1890s, Freud and his friend Josef Breuer, a respected physician and original scientist in his own right, had begun to explore the use of hypnosis together. Breuer had already discovered that when subjects with hysterical symptoms talked about their problems during a hypnotic state, they often experienced a feeling of catharsis, or emotional release. Eventually, the two formed the theory that hysterical symptoms resulted from early sexual molestation, leaving memories so distressing that they were intentionally forgotten and could only be fully remembered under hypnosis. Eventually, Freud discovered that when these memories were completely recalled to consciousness in an emotional release, the symptoms disappeared. This became Freud's first theory of neuroses, the idea that behind every neurotic conflict lies a forgotten childhood trauma. Such memories are said to be repressed. Motivated to forget what it knows, the mind defends against the painful experiences by actively excluding them from conscious awareness. The past cannot be rewritten, but its impact can be contained. In fact, massive repression is one of the major coping strategies used by the histrionic personality, the contemporary parallel to the turn-of-the-century hysterical syndromes through which the basic principles of psychoanalysis were discovered.

Eventually, Freud elaborated his insights into what is known as the topographic model, the idea that the mind has an organization or architecture that overflows consciousness and can be described in terms of different levels or compartments. At the foundation lies the unconscious, a mysterious realm consisting of everything that we cannot become aware of by simple reflection alone. According to classical psychoanalytic theory, the unconscious is the only part of the mind that exists at birth. Just above the unconscious lies the preconscious, which consists of everything that can be summoned to consciousness on command, for example, your phone number. And finally, there is the part of the mind that forms our waking lives, which we call conscious awareness. According to Freud, the desire to bring satisfaction to our unconscious instincts continues to be the main motivator in human behavior throughout the life span. By declaring the unconscious and its drives to be the origin and center of psychological existence, Freud effected a Copernican revolution against the Enlightenment rationalism that dominated the times. Behavior was not fundamentally rational, it was irrational. Just as the earth is not the center of the universe, conscious awareness is but a backwater that conceals the main currents of mental life. For this reason, the idea of making the unconscious conscious, the goal Freud and Breuer had in mind with hypnosis, is a major goal of many contemporary psychotherapies.

THE STRUCTURAL MODEL

Despite his original enthusiasm for hypnosis, in time, Freud developed additional techniques that allowed him to map the contents of the unconscious, such as free association. In doing so, he discovered an additional organizing principle, the structural model of id, ego, and superego. The id consists of the basic survival instincts and the two dominant drives of personality: sex and aggression. At birth, infant behavior is motivated by the desire for immediate instinctual gratification, which Freud referred to as the pleasure principle: I want what I want, and I want it now! In a way, the id is like a dictator that knows only how to assert its own desires over and over again, something that makes the world a very frustrating place.

To relieve this frustration and ensure greater adaptability in the organism, a second part of the personality, the ego, develops to mediate between the demands of the id and the constraints of external reality. Whereas the id is fundamentally irrational, the ego is fundamentally rational and planful, operating on the reality principle. To be effective, the ego must perform such sophisticated intellectual activities as risk-benefit and means-ends analysis, projecting the consequences of various courses of action into the future, judging the range of possible outcomes and their respective cost and reward, all the while modifying plans and embracing alternatives as necessary.

Not every course of action that the ego might imagine is acceptable, however. Eventually, a third part of the personality emerges that internalizes the social values of caretakers, the superego. The process by which the superego forms is called introjection, which literally means "a putting inside." The superego consists of two parts, the conscience and the ego ideal: what you shouldn't do, and what you should do and should become. The conscience is concerned with the morality principle, the right and wrong of behavior. In contrast, the ego ideal pulls each of us toward the realization of our unique human potentials. Breaking moral codes results in feelings of guilt; satisfying the ego ideal results in feelings of pride and self-respect.

For Freud, personality is seen as a war of attrition fought by three generals. As the executive branch of the personality, the ego must balance and mediate between constraints on all sides. On the one hand, the id, upwelling from below, is always percolating, yearning for gratification. On the other hand, the prohibitions of the superego prevent its desires from being directly satisfied. For this reason, the psychoanalytic perspective is often regarded as intrinsically pessimistic: human beings are said to exist in a state of perpetual conflict between the needs and constraints of various parts of the personality. We can endure, but we cannot escape.

Many of the personality disorders are in exactly this situation. Avoidant personalities, for example, deeply desire close connectedness to others, but also feel a sense of shame about themselves so profound that very few such relationships are actually possible. Instead, avoidants retreat into a shell where they can at least be alone with their humiliating defects and deficiencies. Compulsive and negativistic personalities wrestle with issues related to the obedience versus defiance of authority. Compulsives express this conflict passively by overconforming to internalized superego demands; on the surface, they appear normal and in control, but beneath, they are taut, anxious, and ever circumspect of their own conduct. In contrast, the negativistic personality, formerly called the passive-aggressive, expresses conflict actively by vacillating between loyalty and insubordinate sabotage. Knowing the outcomes that others seek, they work subtly within the system to bring the plans of others to ruin, or at least cause them great frustration. Only a subset of the antisocial personality, the psychopath, escapes conflict Given their stunted superego development, psychopaths have no need to evaluate their actions according to some standard of right or wrong; instead, their ego is free to select any pathway to gratification that seems realistically possible, even if it includes deceitfulness, misconduct, or irreparable damage to the lives of others. Accordingly, they pause only when self-conscious of the raw punishment society might inflict on them because of their transgressions.

DEFENSE MECHANISMS

Because the ego is constantly trying to satisfy the impulsive demands of the id while honoring the constraints of reality and the moral constraints of the superego, awareness is always vulnerable to feelings of anxiety. On the one hand, id instincts are like barbarians at the gate, always threatening to break through ego controls and saturate behavior with raw animal forces. Awareness of this possibility produces what Freud referred to as neurotic anxiety. On the other hand, the superego demands perfection, threatening to flood awareness with guilt whenever the satisfaction of id demands is not sufficiently disguised, which Freud referred to as moral anxiety. One is a sinner, the other a saint. Finally, threats from the external world can produce reality anxiety. If you hear on the radio that the stock market has just crashed, your concern about your investments is realistic. Whatever the source, anxiety is a signal to ego that some form of corrective action must be taken to reinforce its controls.

24 PERSONALITY DISORDERS: CURRENT CONCEPTS AND CLASSICAL FOUNDATIONS FOCUS ON HISTORY: CARL JUNG Although Jung is among the seminal thinkers in personality, his contributions have rarely been applied in the personality disorders. Once Freud's primary disciple, Jung broke from Freud, insisting that there is more to mental life than sex. Most students are acquainted with his distinction between extroversion and introversion. Extroverts explain events from the viewpoint of the environment. They see the focus of life as being driven by events outside themselves and fix their attention firmly on the external world. In contrast, introverts are essentially subjective, drawing from the environment that which satisfies their own inner dispositions. Because, for most of us, the external world is primarily social, extroversion is also associated with sociability, whereas introversion is associated with turning inward, away from the interpersonal world. Among the contemporary personality disorders the histrionic is notoriously gregarious, an important facet of the larger extroversion construct. In contrast, the schizoid personality is almost completely asocial. Finally, the avoidant personality, who desires social relationships yet recoils from engaging others for fear of humiliation, can be seen as conflicted on these dimensions.
Interacting with his famous extroversion-introversion polarity, Jung proposed that thinking-feeling and sensing-intuiting form four additional psychological modes of adaptation or functioning. Thinking refers to logical and directed thought, a tendency to approach situations in a cool, detached, and rational fashion; feeling refers to a tendency to value one's own subjective, emotional appraisals over any rational process. Because feelings very often have multiple contradictory aspects that are deeply felt and have to be figured out, this mode need not refer to impulsive emotionality. Sensation refers to stimuli experienced immediately by the senses. As an orientation, it refers to a tendency to be oriented to the events of the present moment, without reinterpretation or inference. Intuition is the analogue of sensation in the internal world. Like sensation, its products are given immediately to consciousness, without awareness of any intermediate process. As an orientation, it refers to a tendency to go with one's hunches, global appraisals that come from within but whose source or justification is not immediately clear.
Although these additional dimensions do not translate directly into contemporary Axis II constructs, certain personality disorders nevertheless seem stuck in one of Jung's four modes. Compulsive personalities, for example, are famous for a "paralysis of analysis," a heroic effort to get all of life into a rational mode, though mainly because they fear making a mistake and being condemned for it. Histrionic and antisocial personalities are famously sensation seeking, so much so that they fail to anticipate the consequences of their actions in favor of momentary pleasures. Because Jung is now mainly a historical figure, the study of the thinking-feeling and sensing-intuiting polarities in connection with pathological personality has not yet come to fruition.

But how does the ego protect itself from being overwhelmed? In time, Freud and his disciples discovered the defense mechanisms. Through his studies of hysteria, Freud had already been led to the existence of the unconscious and the discovery that guilt can be transformed into a symptom. He found, for example, that uncontrollable aggressive urges might lead to a hysterical paralysis in the hand that might be used to strike someone. Although the goal is always the same— to protect the sanctity of awareness by reducing the level of perceived anxiety or threat— different defense mechanisms work in radically different ways. Some seem simple. Denial, for example, is a straightforward effort to ignore unpleasant realities. Repression is similar, but is intended to keep unpleasant thoughts from ever reaching conscious awareness. If repression is successful, there is nothing to deny. Histrionics, for example, use repression to keep their world sweet and simple; they simply cannot be bothered with the deep existential riddles of human existence, nor do they wish to confront their own hypersexual manipulation of others.

In contrast to denial and repression, other defense mechanisms seem more complex or convoluted. Rationalization, for example, is often used to justify a particular action after the fact. In effect, ego looks at both its own behavior and the situation as it might be perceived by others and asks, How can what I've done be made to seem reasonable? This defenseis a favorite of narcissists, whose self-centeredness often leads them to act without thinking through in advance the consequences for others, or how their own actions might be viewed. Other defense mechanisms seem convoluted. In projection, for example, unacceptable motives are transferred from the self and attributed to others. Paranoids use projection to rid themselves of guilt about their own aggressive impulses; by attributing such threats to others, it is the paranoid who becomes the persecuted, endangered, sympathetic victim. A more complete list of defense mechanisms is given in Table 1.3.

Although many psychodynamic ideas have withered over time— penis envy, for example— the defense mechanisms constitute an enduring heritage that continues to inform contemporary theories of the personality disorders. Early analysts were interested in what psychodynamic jargon calls the "vicissitudes of instincts," that is, their transformation by the ego and eventual expression in behavior, often as symptoms. Gradually, however, thinkers became interested more in the various ways the ego defends itself from anxiety, as well as its own inherent capacities. Whereas Freud held that the ego developed from out of the id and therefore was dependent on its supply of libidinal energy, these ego psychologists asserted that the study of the id was only a first phase in the study of the total personality. They believed the ego possessed its own autonomous capacities, completely independent of the id. Naturally, the ego's method of defending itself against other agencies within the personality was a central focus of the thought.

Today, the defense mechanisms are viewed as so important that they constitute an Axis proposed for further study, to be considered for inclusion in DSM-V, still some years in the future. Although every individual uses a variety of defenses, each personality disorder seems to prefer a particular subset of defenses over the others (Millon, 1990). These can be used to construct a defensive profile that illustrates how that personality disorder protects itself from internal and external sources of anxiety, stress, and challenge. The compulsive personality, for example, must cope with intense aggressive urges created by parents who were excessively controlling and demanding of perfection. Using reaction formation, the compulsive transforms these urges into their opposite. By overconforming to internalized superego strictures, compulsives seem highly controlled and self-contained, though they are often boiling with rebellion underneath. Their need to stifle upwelling aggressive forces is so profound that they often make excessive use of another mechanism: isolation of affect. By stripping the emotions from ideas, the compulsive creates a mental working environment sterilized against the disorganizing influence of uncomfortable affects, while an awareness of the intellectual aspects of the ideas remains. Then the compulsive can get down to business.

PERSONALITY DISORDERS: CURRENT CONCEPTS AND CLASSICAL FOUNDATIONS TABLE 1.3 Common Defense Mechanisms
Defense Definition Example
Acting Out Conflicts are translated into action, with little or no intervening reflection. A student disrupts class because she is angry over an unfair grade.
Denial Refusal to acknowledge some painful external or subjective reality obvious to others. A woman refuses to acknowledge a pregnancy, despite positive test results.
Devaluation Attributing unrealistic negative qualities to self or others, as a means of punishing the self or reducing the impact of the devalued item. The formerly admired professor who gives you a D on your term paper is suddenly criticized as a terrible teacher.
Displacement Conflicts are displaced from a threatening object onto a less threatening one. A student who hates his history professor sets the textbook on fire.
Dissociation Conflict is dealt with by disrupting the integration of consciousness, memory, or perception of the internal and external world. After breaking up with a lover, a suicidal student is suddenly unable to recall the periods of time during which they were together.
Fantasy Avoidance of conflict by creating imaginary situations that satisfy drives or desires. A student from a troubled home daydreams about going to college to become a famous psychologist.
Idealization Attributing unrealistic positive qualities to self or others. A student worried about intellectual ability begins to idolize a tutor.
Isolation of Affect Conflict is defused by separating ideas from affects thus retaining an awareness of intellectual or factual aspects but losing touch with threatening emotions. A biology student sacrifices a laboratory animal, without worrying about its right to existence, quality of life, or emotional state.
Omnipotence An image of oneself as incredibly powerful, intelligent or superior is created to overcome threatening eventualities or feelings. A student facing a difficult final exam asserts that there is nothing about the material that he doesn't know.
Projection Unacceptable emotions or personal qualities are disowned by attributing them to others. A student attributes his own anger to the professor, and thereby comes to see himself as a persecuted victim.
Projective Identification Unpleasant feelings and reactions are not only projected onto others, but also retained in awareness and viewed as a reaction to the recipient's behavior. A student attributes her own anger to the professor but sees her response as a justifiable reaction to persecution.
Rationalization An explanation for behavior is constructed after the fact to justify one's actions in the eyes of self or others. A professor who unknowingly creates an impossible exam asserts the necessity of shocking students back to serious study.
Reaction Formation Unacceptable thoughts or impulses are contained by adopting a position that expresses the direct opposite. A student who hates some group of persons writes an article protesting their unfair treatment by the university.
Repression Forbidden thoughts and wishes are withheld from conscious awareness. A student's jealous desire to murder a rival is denied access to conscious awareness.
Splitting Opposite qualities of a single object are held apart, left in deliberately unintegrated opposition, resulting in cycles of idealization and devaluation as either extreme is projected onto self and others. A student vacillates between worship and contempt for a professor, sometimes seeing her as intelligent and powerful and himself as ignorant and weak, and then switching roles, depending on their interactions.
Sublimation Unacceptable emotions are defused by being channeled into socially acceptable behavior. A professor who feels a secret disgust for teaching instead works ever more diligently to earn the teaching award. Undoing Attempts to rid oneself of guilt through behavior that compensates the injured party actually or symbolically. A professor who designs a test that is too difficult creates an excess of easy extra-credit assignments.
PSYCHOSEXUAL STAGES

According to Freud, personality develops through a series of five psychosexual stages; four of the five involve erogenous zones that provide sexual gratification. For Freud, the term sexual was not limited to genital stimulation, but instead referred to any pleasurable feeling. Over the course of normal maturation, each psychosexual stage naturally gives way to the next, presenting the individual with a sequence of maturational challenges. First is the oral stage, which runs from birth to about 2 years. Here, the mouth, lips, and tongue are the primary focus; pleasure is received through oral activity such as nursing at the mother's breast, thumb sucking, and later, through biting and swallowing. Next is the anal stage, which runs from about age 2 to 3. Pleasurable gratification occurs through defecation, the voiding of feces. Unlike the oral stage, however, the anal stage moves the child into a confrontation with caretakers, who now demand that anal activities be delayed until they can be performed in the proper place, the bathroom. Third is the phallic stage, at age 3 to 6, during which the focus of sexual gratification moves to the penis or clitoris. Also at this point, children begin to experience libidinal desires for the opposite-sex parent and compete for attention with the same-sex parent, the famous Oedipal complex. Although Freud's idea of penis envy is now dismissed, it is nevertheless true that a special relationship with the opposite-sex parents important in the development of several personality disorders. The narcissistic personality, for example, is often an only or first-born male indulged by the mother for being special or gifted; similarly, the histrionic personality enjoys a special relationship a doting father who reinforces behaviors that are cute and pretty. During ages 6 to 12, sexuality subsides in the latency stage, only to flair again in the genital stage, which begins at puberty. Whereas before, the goal was to maximize sexual pleasure from one's own body, the goal here is to invest sexual energy in relationship with others, through which mature love becomes possible.

CHARACTER DISORDERS

Derived from the Greek word for "engraving," the term character was used originally to signify distinctive features that served as the "mark" of a person. In contemporary colloquial usage, character refers to our civilized animal nature, as reflected in the adoption of the habit systems, customs, and manners of prevailing society, taught especially during early childhood.

In the psychodynamic perspective, character has a technical meaning, referring to the way in which the ego habitually satisfies the demands of id, superego, and environment (Fenichel, 1945). Because the study of personality begins with the psychodynamic study of character, many of the personality disorders have direct characterological counterparts. The oral character, for example, closely parallels the dependent personality, and the anal character closely parallels the compulsive. A more complete list of personality disorders and their characterological antecedents is represented Table 1.4. As later analytic writers such as Shapiro (1965) became interested in the relationship among character, defense, interpersonal conduct, and cognitive style, the relationship between character and personality has grown even stronger.

The foundations of analytic characterology were set forth by Karl Abraham (1927a, 1927b, 1927c) in accord with Freud's psychosexual stages of development, detailed above. Freud believed that either indulgence or deprivation could result in the fixation of libidinal energy during a stage, thus coloring all subsequent development. For example oral period is differentiated into an oral-sucking phase and an oral-biting phase. An overly indulgent sucking stage yields an oral-dependent type, imperturbably optimistic naïvely self-assured, happy-go-lucky and emotionally immature. Serious matters not affect this type. In contrast, an ungratified sucking period yields excessive dependency and gullibility, as deprived children learn to "swallow" anything just to ensure that they receive something. Frustrations at the oral-biting stage yield aggressive oral tendencies such as sarcasm and verbal hostility in adulthood. These "oral-sadistic characters" are inclined to pessimistic distrust, cantankerousness, and petulance.

In the anal stage, children learn autonomy and control. Their increasing cognitive abilities allow them to comprehend parental expectancies, with the option of either pleasing or spoiling parental desires. "Anal characters" take quite different attitudes toward authority depending on whether resolution occurs during the anal-expulsive or anal-retentive period. The anal-expulsive period is associated with tendencies toward suspiciousness, extreme conceit and ambitiousness, self-assertion, disorderliness negativism. Difficulties that emerge in the late anal, or anal-retentive, phase are usually associated with frugality, obstinacy, and orderliness, a hair-splitting meticulousness, and rigid devotion to societal rules and regulations. Such characteristics obviously reminiscent of the compulsive personality.

With the writings of Wilhelm Reich in 1933, the concept of character was expanded. Reich held that the neurotic solution of psychosexual conflicts was accomplished through a total restructuring of the defensive style, ultimately crystallizing into a "total formation" called "character armor." The emergence of specific pathological symptoms assumed secondary importance. Symptoms were thus to be understood in the context of this defensive configuration, similar to the contemporary multiaxial model, which holds that symptoms must be understood in the context of the total personality. Reich also extended Abraham's characterology to the phallic and genital stages of development the phallic stage, frustration may lead to a striving for leadership, a need to stand out in a group, and poor reactions to even minor defeats. Such "phallic narcissistic characters" were depicted as vain, brash, arrogant, self-confident, vigorous, cold, reserved, and defensively aggressive.

OBJECT RELATIONS

The development of the psychodynamic perspective can be divided into three stages. Classical psychoanalysis was almost exclusively an id psychology, emphasizing the role of instincts in creating psychological symptoms, the various psychosexual stages of development environmental conflicts that could occur during these stages, the fixation of id energy in the concerns of a particular stage, and the id's role in the emergence of character Freud created and perpetuated his id psychology through several key assumptions. Not only did the ego and superego develop from out of the id, they were forced to rely on basic instinctual drives as their only energy source. The ego and superego were derivative and dependent structures in the study and treatment of psychopathology, whereas the id was central. Understanding a particular mental disorder, then, meant understanding how that disorder served the expression of the basic sexual and aggressive drives in the context of the realistic constraints of the ego and the moral and idealized constraints of the superego. In contemporary terms, Freud was focused on Axis I: his interests were with psychological symptoms, their origin, and their development.

Eventually, however, opponents of Freud's "sexual psychology" shifted their interest from the id to the ego. These new thinkers discovered new forces in personality, so that the entire field began to be described as psychodynamic rather than psychoanalytic. Jung, for example, developed numerous, highly original ideas, including the collective unconscious, synchronicity, and the trait dimension of introversion-extroversion. Adler focused on social influences and on compensations against inferiority feelings. Later thinkers went so far as to assert that the ego is fundamentally an adaptational structure and, as such, is necessarily endowed with its own innate potentials prepared over the course of human evolution. Some of these are simple perceptual abilities present at birth; others are adaptive capacities, including reasoning and cognitive abilities (Hartmann, 1958). The ability to break complex tasks into subtasks, for example, may be necessary to satisfy the sexual drive, but it is difficult to understand how this capacity might derive from sexuality itself. Moreover, because the ego is concerned with coordinating psychological needs with the realities of the external world, ego psychologist naturally became more interpersonal. One important theorist was Karen Horne of the constructs derived from her theory bear a surprising resemblance to the contemporary personality disorders.

The final stage in the development of the psychodynamic perspective is called object relations. The name seems cryptic at first, but its origin is easily understood as a throw-back to the sexual reductionism of classical analysis. Every instinct has an aim and an object: the aim is always the satisfaction of instinctual desires; the object is something in the outside world through which this aim can be achieved. For Freud, the id instincts formed the basis of human nature. Other aspects of the personality, such as the ego and the superego, and persons in the outside world were valuable, or real, to the id only in-so-far they brought with them satisfaction. Accordingly, id psychology cannot be a psychology of human relatedness. Others are just the furniture of mental life, objects whose presence promises instinctual satisfaction, not other beings knowable apart from their capacity for drive reduction.

In contrast, modern object relations theory is simultaneously cognitive and interpersonal phasizing first that the outside world is known through mental representations internal working models (Bowlby, 1969/ 1982), and second that the content of these models is interpersonal, being developed largely during early childhood from experience caretakers and significant others, prior even to the development of self-awareness. In effect, object relations are to the individual what paradigms are to scientific theories: for the most part, they exist as unconscious mental structures that organize experience but are only partially accessible to conscious reflection. As the most recent phase in the development of psychodynamic theory, object relations might be called a superego psychology, as it is explictly concerned with introjects, aspects and images of others internalized in the course of development. However, it is more broadly concerned with how the mental representations of self and others influence on-going behavior in the present, not just with condemnation and the morality principle. The foremost object relations thinker in the personality disorders is Kernberg (1967, 1984, 1996). Kernberg advocates classifying various personalities, some from the DSM and some from the psychoanalytic tradition, in terms of three levels of "structural organization"— psychotic, borderline, and neurotic— which actually represent degrees of organization or cohesiveness in the personality (see Figure 1.6). Normals possess a cohesive, integrated sense of self that psychoanalysts term ego identity. Simply put, most of us know who we are, and our sense of self remains constant over time and situation. We know our likes and dislikes, are conscious of certain core values, and know how we are similar to others and yet different from them as well. Individuals with a well-integrated ego identity are said to possess ego strength, the ability to remain integrated the face of pressure or stress. In addition, normal persons also possess a mature and internalized social or moral value system, the superego, which includes such features as personal responsibility and appropriate self-criticism.

In contrast, the neurotic level is characterized by a well-developed ego identity, complicated "unconscious guilt feelings reflected in specific pathological patterns interaction relation to sexual intimacy" (Kernberg, 1996, p. 121). In other words, neurotic personalities are worried about sexual matters, a concern that leaks into their interpersonal relationships, creating feelings of guilt that affect behavior. The character types described by Kernberg vary somewhat from those of the DSM-IV. The neurotic level includes the depressive-masochistic, obsessive-compulsive, and hysterical personalities depressive-masochistic character, for example, derives primarily from reaction mation, that is, the tendency to do the opposite of unconscious wishes. Thus, the tendency is to deprive or sabotage oneself, rather than indulge what would otherwise be pleasurable or satisfying. In contrast, the hysterical personality is more obviously sexual, exhibiting a superficial provocativeness but with underlying sexual inhibition. Both the masochistic-depressive and hysterical reflect more integrated levels of more primitive character structures. The hysterical personality, for example, exists at the neurotic level, but is also related to the so-called infantile personality, which tends to be more demanding compulsive, and aggressive. The two are said to exist on a spectrum, a term commonly used to express the relationship between higher-functioning and lower-functioning character types.

The borderline level of personality functioning exists between the neuroses and the psychoses. Superficially, personalities at the borderline level are often similar to neuroticst are not as integrated. Like neurotics, they are in contact with reality, but nevertheless sometimes dissociate or experience psychotic episodes. Moreover, they tend to rely on primitive defense mechanisms, not those of mature adults. According to Kernberg, all individuals at the borderline level exhibit what is called split object-representation, which accounts for much of their behavior. Normal persons realize that very few people or situations are either all good or all bad; instead, most are somewhere in the middle, with both good and bad aspects. The good and bad can be held in mind simultaneously, creating a picture that is complex but realistic. Personalities the borderline level, however, see persons and situations as either all-good or all-bad; people are either angels or devils. Such persons invariably exhibit severe difficulties their interpersonal relationships, particularly intimate relationships, and exhibit various degrees of sexual pathology. You can imagine what your friends would think of you if you suddenly switched from worshipping them to hating them and back again, and again. All the psychoanalytic character types, according to Kernberg, derive from the basic borderline and schizoid personalities, end points of a continuum of extroversion-introversion. The relationships are complex and technically unimportant at the current time. Many are reviewed in subsequent chapters.

The psychotic level of personality organization need not be described in detail, for nearly everything we think of as personality is lost in this case. Rather than integration and organization, we find only broken, random pieces, with little or no sense of an integrated. Instead of distinction, there is often fusion between self and other or even between self and physical environment. The psychotic level is particularly characterize intense and inappropriate aggression. There are no personality disorders described in the DSM-IV that typically function at the psychotic level.

FOCUS ON HISTORY: WHATEVER HAPPENED TO BEHAVIORISM?

The duality between empiricism and rationalism has a long history in philosophy and psychology. Empiricism is most often identified with the English philosophers John Locke and David Hume. Locke emphasized the role of direct experience in knowledge, believing that knowledge must be built up from collections of sensations. Locke's position name known as associationism. Here, learning is seen as occurring through a small collection of processes that associate one sensation with another. Empiricism found a counterpoint in the rationalism of continental philosophers, notably the Dutch philosopher Spinoza, the French philosopher Descartes, and the German philosopher Leibniz. In contrast, the empiricists held that innate ideas could not exist. Locke, for example, maintained that the mind was a tabula rasa, or blank slate, on which experience writes. Eventually, however, the elements of learning were recast in the language of stimulus response. The foundations of behaviorism are perhaps more associated with J. B. Watson than with any other psychologist, though Watson was preceded by other important in the history of learning theory, notably Thorndike and Pavlov. Although a variety of learning theories eventually developed, behaviorism as a formal dogma is most associated with the views of B. F. Skinner.

According to Skinner's strict behaviorism, it is unnecessary to posit the existence of unobservable emotional states or cognitive expectancies to account for behavior and its pathologies. Hypothetical inner states are discarded and explanations are formulated solely in terms of external sources of stimulation and reinforcement. Thus, all disorders become the simple product of environmentally based reinforcing experiences. These shape the behavioral repertoire of the individual, and differences between adaptive and maladaptive behaviors can be traced entirely to differences in the reinforcement patterns to which individuals are exposed. Inner states, such as traits or schemata, are regarded as throwbacks to primitive animism. Instead, the understanding of a behavior can be completely when the contextual factors in which the event is embedded are illuminated. The logic is relatively simple: If there are no innate ideas, then sensation or stimuli are by definition all that exists. Because sensation originates in the environment, the environment ultimately control all behavior, however complex. The mind becomes an empty vessel, or tabula rasa, that contains only what the environment puts there. All behavior said to be under stimulus control. For this reason, the relationship between personality and behaviorism has been mainly antagonistic, and understandably so, as behavioral psychology exclusively focuses on observable surface behavior rather than on inferred entities, such as personality traits, cognitive schemata, instinctual drives, or interpersonal positions, all essential units in the study of personality.

By the mid-1980s, a number of crucial reinterpretations of traditional assessment had been made that allowed clinically applied behavioral approaches to become successively broader and more moderate. Most notably, the diagnoses of Axis I, regarded in psychiatry substantive disease entities, were reinterpreted with the behavioral paradigm as inductive maries, labels that bind together a body of observations for the purpose of clinical communication. For example, whereas depression refers to a genuine pathology in the person for a traditional clinician, a behavioral clinician sees only its operational criteria and their label, not a disease. As a result, behavioral assessment and traditional assessment could thus speak the same tongue, while retaining their respective identities and distinctions. This allowed behavioral therapists to rationalize their use of diagnostic concepts without being untrue to their behavioral core. Likewise, as the cognitive revolution underway in earnest in the late 1960s and early 1970s, behavioral psychologists began seeking ways to generalize their own perspective to bring cognition under the behavioral umbrella. In time, cognitive activity was reinterpreted as covert behavior. Finally, the organism itself began to be seen a source of reinforcement and punishment, with affective mechanisms being viewed as the means through which reinforcement occurs. Contemporary behavioral assessment, then, is no longer focused merely on surface behavior instead, behavioral assessment is now seen as involving three "response systems," namely the verbal-cognitive mode, the affective-physiological mode, and the overt-motor response system, a scheme originated by Lang (1968).

Recently however, behavioral theorists have gone far toward rediscovering personality. The relationship among responses across the three response systems, for example, has been extensively studied (see Voeltz & Evans, 1982, for a review). Behavioral psychologists talk about the organization of behavior, an idea that draws on the conception that the individual person is more than a sum of parts, even where those parts are only behavioral units. An especially seminal thinker, Staats (1986) has developed a more system approach to personality that broadens the behavioral tradition. In what he terms "paradigmatic behaviorism," Staats has sought a "third-generation behaviorism" that adds a developmental dimension, arguing that the learning of "basic behavioral repertoire begins at birth and proceeds hierarchically, with each new repertoire providing the foundation for successively more complex forms of learning. Thus, some repertoires must be learned before others. For example, both fine motor movements and the alphabet must be learned before cursive writing can develop. Staats holds that repertoires are learned in the language-cognitive, emotional-motivational, and sensorimotor response systems, and that these systems are interdependent and only pedagogically distinct. personality thus becomes the total complex hierarchical structure of repertoires and reflects the individual's unique learning history. Different repertoires mediate different responses that individual differences simply reflect different learning histories. Thus, the concept of a behavioral repertoire is simultaneously both overt and idiographic, making acceptable from both behavioral and personality perspectives, and capable of spanning normality and abnormality.

Summary

In the last two decades, the study of personality and its disorders has become central to the study of abnormal psychology. Chapter 1 introduces the emergence of this new discipline analyzing the constructs of personality and personality disorders, by comparing contrasting the basic assumptions that underlie approaches to these constructs, and by presenting the fundamentals of the classical perspectives on personality, which are essential to the understanding of the clinical chapters that follow. Historically, the word personality is derived from the Latin term persona, originally representing the theatrical mask used by ancient dramatic players. Today, personality is seen as a complextern of deeply embedded psychological characteristics that are expressed automatically almost every area of psychological functioning. That is, personality is viewed as the patterning of characteristics across the entire matrix of the person. personality is often confused with two related terms, character and temperament. Characterers to characteristics acquired during our upbringing and connotes a degree of conformity to virtuous social standards. Temperament, in contrast, refers not to the forces of socialization, but to a basic biological disposition toward certain behaviors.

Understanding personality disorders requires an understanding of their role in the study of abnormal behavior. Diagnostic criteria are the defining characteristics used by clinicians to classify individuals within a clinical category. Each disorder has its own unique list. In general, the list of criteria for the personality disorders run either seven, eight, or nine items, each of which details some characteristic trait, attitude, or behavior strongly related to that particular disorder. A personality trait is a long-standing pattern of behavior expressed across time and in many different situations. Where many such personality traits typically occur together, they may be said to constitute a personality disorder. When all of these characteristics are taken together, they constitute what is a called a personality prototype.

The mental disorders in the DSM are not listed one after another. Instead, they are grouped in terms of the multiaxial model. Each axis represents a different kind or source of information. The multiaxial model exists because some means is required whereby the various symptoms and personality characteristics of a given patient can be brought together to paint a picture that reflects the functioning of the whole person. The multiaxial model is divided into five separate axes each of which gets at a different source or level of influence in human behavior. Axis II, the personality disorders, provide both a substrate and context for understanding the symptoms of Axis I. Every personality style is also a coping style, and personality is a cardinal organizing principle through which psychopathology should be understood.

Normality and abnormality cannot be distinguished on a completely objective basis. Normality and pathology usually reside on a continuum. Personality disorders do seem to be characterized by three pathological characteristics. First, personality disorders tend to exhibit a tenuous stability, or lack of resilience, under conditions of stress. Second personality disordered subjects are adaptively inflexible. Disordered personalities create vicious cycles by repeating their pathology over and over.

In personality, the dominant perspectives are psychodynamic, biological, interpersonal cognitive. Biological influences on personality may be thought of as being either proximal or distal. Distal influences originate within our genetic code and often concern inherited characteristics transmitted as part of the evolutionary history of our own species. Other biological influences in personality focus on proximal causes, influences exist because we are complex biological systems. When the structures that underlie behavior differ, behavior itself is affected. Two such concepts important to personality are constitution and temperament.

The word temperament came into the English language in the Middle Ages to reflect the biological soil from which personality develops. Temperament is an underlying biological for behavior, seen most clearly in the predominant mood or emotional individual and in the intensity of their activity cycles. As such, it refers to the sum total of inherited biological influences on personality that show continuity across the lifespan. Since our physical matrix exists before other domains of personality biologically built-in behavioral tendencies preempt and exclude other possible pathways of development that might take hold. Constitution refers to the total plan or philosophy upon which something is constructed. The foremost early exponent of the constitutional approach was Ernst Kretschmer, who developed a classification system based on three main body types— thin, muscular, and obese— each of which was associated with certain personality traits and psychopathologies.

More recently, neurobiological models have been proposed by Cloninger and Siever. Cloninger's model is based on the interrelationship of three genetic-neurobiologic trait dispositions, each of which is associated with a particular neurotransmitter system: dopaminergic, serotonergic, noradrenergic. Each is hypothesized to dispose the individual toward a different type of behavioral tendency. Another model has been proposed by Siever and Davis. These authors suggest a psychobiological model consisting of four dimensions— cognitive/ perceptual organization, impulsivity/ aggression instability, and anxiety/ inhibition— each of which has both Axis I and Axis II manifestations.

The most distal influence in personality is genetics. Researchers explore the influences on behavior by searching for the presence of similar psychopathologies in siblings and relatives of an afflicted subject, by studying patterns of transmission across generations of the extended family, and by comparing the correlation of scores obtained on personality tests between sets of fraternal twins and identical twins reared together and apart. The evidence for a genetic influence on personality is strongest for antisocial and schizotypal personality disorders. Other evidence suggests the paranoid and schizoid personality disorders may be linked genetically with schizophrenia. A popular genetic hypothesis is that the wild emotional swings of the borderline personality are evidence of its association with the affective disorders, which include depression and manic-depression.

Of all the major perspectives on personality, the psychoanalytic is perhaps the most conceptually rich. Sigmund Freud, the father of psychoanalysis, was born in 1856. Freud's first theory of neuroses emerged from his work with hypnosis and referred to the idea that behind every neurotic conflict lies a forgotten childhood trauma. The memories of that trauma are said to be repressed. Motivated to forget what it knows, the mind defends against the painful experiences by actively excluding them from conscious awareness. Eventually, Freud elaborated his insights into the topographic model, the idea that the mind has an organization or architecture that overflows consciousness and can be described in terms of different levels or compartments: the unconscious, the preconscious, and conscious awareness. Later, Freud developed a structural model of the mind constitute the id, consisting of the basic survival instincts and drives; the ego, which develop sediate between the demands of the id and the constraints of external reality; and the superego, which represents the internalized social values of caretakers. The id works on the basis of the pleasure principle, whereas the ego works on the reality principle>Breaking moral codes results in feelings of guilt, while satisfying the ego ideal results feelings of pride and self-respect. For Freud, personality is seen as a war of attrition fought by three generals. As the executive branch of the personality, the ego must balance and mediate between constraints on all sides. On the one hand, the id, up-welling from below, is always percolating, yearning for gratification. On the other hand, the prohibitions of the superego prevent its desires from being directly satisfied.

The workings of the id, ego, and superego produce different types of anxiety which is a signal to the ego that something must be done. In time, Freud and his disciples discovered the defense mechanisms. Although every individual uses a variety of defenses, each personality disorder seems to prefer a particular subset of defense over the others. These can be used to construct a defensive profile that illustrates how that personality disorder protects from internal and external sources of anxiety, stress, and challenge. According to Freud, personality develops through a series of five psychosexual stages. Over the course of normal maturation, each psychosexual stage naturally gives way to the next, presenting the individual with a sequence of maturational challenges. In the psychodynamic perspective, character has a technical meaning, referring to the way in which the ego habitually satisfies the demands of the id, superego, and environment. Since the study of personality begins with the psychodynamic study of character, many of the personality disorders have direct characterological counterparts. As later analytic writers became interested in the relationship between character, defense, interpersonal conduct, and cognitive style, the relationship between character and personality has grown even stronger.

The final stage in the development of the psychodynamic perspective is called objections. Every instinct has an aim and an object. The aim is always the satisfaction desires. The object is something in the outside world through which this aim can be achieved. For Freud, the id instincts formed the basis of human nature. In contrast, modern object relations theory is simultaneously cognitive and interpersonal emphasizing first that the outside world is known through mental representations or internal working models and second that the contents of these models are interpersonal, being developed largely during early childhood from experiences with caretakers and significant others, prior even to the development of self-awareness. The foremost object relations thinker in the personality disorders is Kernberg who advocates classifying various personalities, some from the DSM and some from the psychoanalytic tradition, in terms of three levels of "structural organization"— psychotic borderline, and neurotic— which actually represent degrees of organization or cohesiveness in the personality.

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