Personality Disorders in Modern Life

Theodore Millon, Carrie M. Millon, Sarah E. Meagher, Seth D. Grossman, Rowena Ramnath

• Publisher: Wiley
• Year: 2012
• ISBN:
  9781118428818
• Edition: 2
• Topic: Psychology
• Subtopic: Psychopathology
• Index: Psychology

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(TM).

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(TM) 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.

Chapter 1

Personality Disorders: Classical Foundations

Objectives

• What is personality?
• Distinguish among personality, character, and temperament.
• What makes a personality disordered?
• 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?
• Why is personality 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 sort of a person are you? What do you see as distinctive about your 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? Questions such as these are easy to ask, but are 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 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 several decades, the study of personality and its disorders has become central to the study of abnormal psychology. In the course of clinical work, we encounter 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. Although the problems of patients vary, everyone has a personality. Personality disorders occupy a place of diagnostic prominence today and constitute a special area of scientific study. The issues involved are complex, certainly much more sophisticated than the everyday understanding of personality described in the previous questions. This chapter introduces the emergence of this new discipline by analyzing personality and personality disorders by comparing and contrasting the basic assumptions that underlie different approaches to these ideas 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 understanding of personality disorders? Do the assumptions underlying the concept of personality support the use of the term disorder? How can the content of different personality disorders best be described?

One way to investigate the definition of a term is to examine how its meanings and usage have evolved over time. 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 words 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.

Abnormal Behavior and Personality

The concept of personality disorders requires an understanding of their role in the study of abnormal behavior. The Diagnostic and Statistical Manual of Mental Disorders (DSM) 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 two 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.

TABLE 1.1 Brief Description of the Fourteen Personality Disorders of DSM-III, DSM-III-R, and DSM-IV

Schizoid	Apathetic, indifferent, remote, solitary. Neither desires nor need 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.
Depressive1	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.
Sadistic2	Explosively hostile, abrasive, cruel, dogmatic. Liable to sudden outbursts of rage. Feels self-satisfied through dominating, intimidating and humiling 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.
Negativistic1	Resentful, contrary, skeptical, discontented. Resist fulfilling others’ expectations. Deliberately inefficient. Vents anger indirectly by undermining others’ goals. Alternately moody and irritable, then sullen and withdrawn.
Masochistic3	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 suspiciousness. 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. Thinks can read 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 alternatively 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.

BASIC VOCABULARY

Abnormal psychology has its own special vocabulary, or jargon. Many terms used in the discussion of abnormal behavior appear repeatedly 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).

The criteria list for each personality disorder includes 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 criteria, deceitfulness is considered a personality trait, a long-standing pattern of behavior expressed across time and in many different situations. The histrionic criteria 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 often manipulative, reckless, aggressive, irresponsible, exploitive, and lacking in empathy and remorse. When all of these characteristics are taken together, they constitute what is 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.

Real persons, however, seldom are seen 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 diagnosis. Although Charles Manson and Jeffrey Dahmer might both be considered antisocial personalities, for example, their personalities are nevertheless substantially different. Determining exactly what separates individuals such as Dahmer and Manson from the rest of us requires a great deal of biographical information. Each chapter in this text, therefore, focuses on factors important in the development of a personality disorder. For example, a chummy relationship between father and daughter is one of the major pathways in the development of an adult histrionic personality disorder.

Categorical typologies are advantageous because of their ease of use by clinicians who must make relatively rapid diagnoses with large numbers of patients whom they see briefly. Although clinical attention in these cases is drawn to only the most salient features of the patient, a broad range of traits that have not been directly observed is often strongly suggested. Categories assume the existence of discrete boundaries both between separate personality styles and between normality and abnormality, a feature felicitous to the medical model, but not so for personality functioning, which exists on a continuum. The arguments of those who favor the adoption of dimensional models enter mainly around one theme: The categorical model, because it entails discrete boundaries between the various disorders and between normality and abnormality, is simply inappropriate for the personality disorders. Although trait dimensions have a number of desirable properties, there is little agreement among their proponents concerning either the nature or number of traits necessary to represent personality adequately. Theorists may “invent” dimensions in accord with their expectations rather than “discovering” them as if they were intrinsic to nature, merely awaiting scientific detection. Apparently, the number of traits required to assess personality is not determined by the ability of our research to disclose some inherent truth but rather by our predilections for conceiving and organizing our observations. Describing personality with more than a few such trait dimensions produces schemas so complex and intricate that they require geometric or algebraic representation. Although there is nothing intrinsically wrong with such quantitative formats, they pose considerable difficulty both in comprehension and in communication among clinicians.

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