Disorders of Personality

Introducing a DSM / ICD Spectrum from Normal to Abnormal

Theodore Millon

• Publisher: Wiley
• Year: 2011
• ISBN:
  9780470891018
• Edition: 3
• Topic: Psicologia
• Subtopic: Personalità in psicologia

Now in its Third Edition, this book clarifies the distinctions between the vast array of personality disorders and helps clinicians make accurate diagnoses. It has been thoroughly updated to incorporate the changes in the forthcoming DSM-5. Using the classification scheme he pioneered, Dr. Millon guides clinicians through the intricate maze of personality disorders, with special attention to changes in their conceptualization over the last decade. Extensive new research is included, as well as the incorporation of over 50 new illustrative and therapeutically detailed cases. This is every mental health professional's essential volume to fully understanding personality.

Part I

HISTORICAL, THEORETICAL, AND METHODOLOGICAL FOUNDATIONS

Chapter 1: Historical, Modern, and Contemporary Approaches to Personology

Chapter 2: Sources of Personologic and Psychopathologic Development

Chapter 3: Clinical Methods and Instruments of Personalized Assessment

Chapter 4: Logic and Modalities of Personalized Psychotherapy

Chapter 5: Classification Considerations, DSM-5 Prelims, and Proposals for Personology

Chapter 1

Historical, Modern, and Contemporary Approaches to Personology

That the incidence of both mild and severe mental disorders is strikingly high in contemporary society cannot be denied. Perhaps it reflects the strain of life at the turn of the 21st century, or what political leaders and social thinkers have noted as a time of terrorism and economic decline. Whatever the causes, the inescapable facts are that each year Americans spend billions of dollars for psychopharmaceuticals, tens of billions for liquor and aspirin, and purchase enough books promising successful personal adjustment to fill a good-size college library. One out of every seven or eight Americans, at the current rate, will be involved in counseling or therapy for personality and psychosocial difficulties these next years. For every patient who requires hospitalization there will be 20 other personally distressed and troubled Americans who will seek psychotherapy or pharmacotherapy, hence the importance of the study of personality disorders.

Some have argued that books and chapters on any history of a field be written with detachment and objectivity. Others question whether such detachment is even possible, no less desirable. As the great historian of psychiatry, Gregory Zilboorg, has written (1941), detachment suggests a certain lack of feeling, reviewing the events of the past with the cold eye of an unconcerned and unaroused observer. The events of the past in our field of study, however, derive from intense human conditions and the passions they create, emotions that are charged with anxieties, loves, hatreds, ambitions, and failures. To look on our subject's history as if it could be portrayed as a series of dots on a statistical table will miss an essential aspect of its vitality. As Lytton Strachey, the British writer and historian has noted (1931), to obtain joy and enlightenment from a history of a subject's past, one must mobilize and not anesthetize one's feelings. Being amorphously impartial is to miss the very thing that makes the history of a subject real and alive. Facts relating to the past, when collected without art, are simply compilations. And although compilations can be useful, they are no more history than butter, eggs, salt, and herbs are an omelet. The art of history-telling demands intuition, enlightened intelligence, and the ability to feel the facts, and then to absorb and reconstruct their inner character and their continuous and vivid development. As a tree with many branches, personology has been approached with numerous traditions and paradigms: philosophy, humanism, biological chemistry, society and culture, formal psychological experimentation, and so on (Millon, 2004a). Ideas and discoveries in recent decades have come at a breathtaking rate. It is wise, therefore, to look back and review the vast distance we have traveled from early times. Similarly, it is crucial to our aims that we separate major achievements from those of a more modest character while paying homage to the many thinkers and scientists who pioneered contemporary work. Our goal here is more than academic, for there is a need to place contemporary approaches in their historical perspective so as to recognize the wisest paths to follow in the future.

The curious reader can hardly travel across the threshold of the several segments of the field of personology without noting that all is not peace and harmony under its broad-ranging tree. My intent in this chapter is not to justify this or that perspective or approach, but to trace its origins, note its obscurities and inchoate character, and travel along the evolution of its best ideas. Each set of ideas has been arranged to show its place in the unfolding constellation of perspectives that, today, still stand like invincible armies defending their approach to human personality functioning. History need not boast one or another perspective at this time—at least not yet. It should provide a contemplative base for evaluating where we are today.

The reader may justly ask at this point why the author will not propose his own systematic model of personology and psychopathology (Millon, 1969, 1990, 1996) until after he describes numerous divergent schools of thought. Although a single doctrinaire presentation might at first simplify matters, it would have been pedagogically shortsighted for those who are curious about the state of the field or who plan to engage in further explorations of the subject. Readers should be prevented from developing a false sense of harmony; equally important, they must recognize that in so complex a field as the study of personality and psychopathology, different levels of observation, utilizing different clinical and research techniques are not merely possible, but also are useful, if not necessary. Although these different approaches may be united by a common interest in understanding and treating the mind, there is room, as well as a need, for a variety of perspectives.

The broad discipline of personology and psychopathology is composed of and has emerged from numerous traditions (Millon, 2004a, 2010b). Each has followed parallel yet often isolated chronological courses. There is a fundamental communality among them, but marked differences as well; only time will tell whether these diverse orientations will grow in ways that will lead to greater or lesser interactions with one another. As is evident throughout this book, Thomas Kuhn's brilliant, if controversial, concept of “paradigm” characterizes the divergent patterns of thought regarding the subject of the mind and mental science (1962). Kuhn's concept recognizes that an articulated set of assumptions are posited by theorists and investigators concerning the fundamental entities of which a subject is composed; also, it identifies questions that may legitimately be asked about such entities and the techniques that may be employed in seeking answers to relevant questions. Once a paradigm is established it becomes the given groundwork for “puzzle solving,” that is, the rules that scientists and clinicians may employ to further elaborate their subject. Although Kuhn has described how new paradigms replace previous paradigms, he does acknowledge that competing paradigms can coexist, each posing its own set of propositions, rules, and questions that followers may seek to answer. Toward the end of the chapter the author briefly articulates his own innovative paradigm for solving the puzzle of personology. Facets of this evolutionary paradigm are significantly elaborated throughout the text.

Mental health sciences, as we know them, are largely the result of an evolutionary process of haphazard variation and natural selection. Variation is continually produced by the uncoordinated efforts of innumerable individual investigators, and their selection, communication, and critical appraisal by peers and posterity. An inevitable characteristic of this dissemination process is that whenever we survey the state of most fields, and notably that of personality science, we find it, from the standpoint of organization and elegance, nothing less than a sorry mess—witness “the camel” being built by the DSM-5 Personality and Personality Disorders Work Group. Numerous locally grounded ideas, distinct from one another, no less from the noisy background of miscellaneous ideas and data, vie for attention. Approaches to a broad subject domain form along random, if not irrational lines, and persevere long after their purposes and boundaries, perhaps originally useful as guidelines, have hardened into separating blockades. As noted, the author's distillation of these guidelines has generated a novel paradigm that will override these blockades.

It is comforting to know that the discouraging state of affairs just described is not peculiar to the study of personology and psychopathology. It is inevitable that so broad a subject as this would have produced a scattering of diverse viewpoints. Complex problems lend themselves to many approaches, and divisions of labor in so varied a field become not only a matter of choice but also one of necessity. Beneficially, the historical evolution of these divergent approaches has led to a broad spectrum of knowledge about the mind and clinical phenomena. Nevertheless, these random evolutions and developments have distinct disadvantages as well. Scientists preoccupied with only a small segment of the larger field often have little knowledge of others' work. Intent on their narrow approach, they lose sight of perspective, and their respective contributions become scattered and disconnected. As my early mentor and historian of psychology, Gardner Murphy, has noted (1930), until a mental science Darwin or Einstein comes along, readers have no choice but to develop an attitude by which the various branches and traditions of mental study are viewed as an interrelated, and soon-to-be integrated unit.

Despite the desultory nature of our path to our current models to knowledge, there appear to be certain themes and concepts to which clinicians and theorists return time and again; these are noted as the discussion proceeds in this chapter. Commonalities notwithstanding, the theoretical schemas to be summarized here represent different notions concerning which data are important to observe and how they should be organized to best represent personality. Thus, to Kretschmer (1925), body morphology was a significant variable in conceptualizing pathological types; for Cattell (1957, 1965), statistically derived trait dimensions were given preeminence; for Horney (1950), it was the interpersonal orientation developed to resolve unconscious conflicts that received emphasis.

What should be especially heartening is that theorists and classifiers have been convinced that the complexities and intricacies of personality can, in fact, be studied systematically and will, it is hoped, yield to efforts at scientific comprehension. Each theoretical schema is not only a model for arranging thinking about personality and psychopathology but poses significant questions and provides interesting, if not necessarily valid, answers to them. Moreover, these abstract formulations furnish frameworks to organize clinical concepts and to appraise the everyday utility of observations.

It is not the intent of this chapter to enable the reader to master the details of our subject. The purpose is simply that of outlining the diverse theories into which personality and psychopathology have been cast through history. Much is to be gained by reading original or primary sources (Millon, 1967, 2004a), but the aim of this synopsis is to distill the essentials of what theorists have written and to present them as an orientation to the spectra of personality styles, types, and disorders described in later chapters.

The presentation is divided into three time periods: the first, referred to as Historical Antecedents, encompasses theorists whose major works were promulgated from ancient times to World War I; the second, termed Modern Formulations, represents the contributions of those whose key publications were prominent from World War I to World War II; and the third, noted as “Contemporary Proposals,” includes thinkers whose significant writings are to be found from mid-20th-century to the early 21st century (Blashfield, Flanagan, & Raley, 2010).

Historical Antecedents

The history of formal personality characterization can be traced to the early Greeks. A survey of these notions can be found in the detailed reviews published by Allport (1937), Millon (2004a), and Roback (1927). These sources make it unnecessary to record here any but the most central concepts of early “characterologists.” Also worthy of brief mention are those theorists and clinicians who may be considered the forerunners of contemporary ideas.

Ancient Humoral Notions

One of the first explanatory systems to specify personality dimensions is the doctrine of bodily humors posited by early Greeks some 25 centuries ago. History appears to have come full circle. The humoral doctrine sought to explain personality with reference to alleged body fluids, their warmth versus their coolness, their dryness versus their moistness (Siegel, 1968), whereas much of contemporary psychiatry seeks answers with biochemical and endocrinological hypotheses. In the fourth century B.C., Hippocrates concluded that all disease stemmed from an excess of or imbalance among four bodily humors: yellow bile, black bile, blood, and phlegm. Humors were the embodiment of earth, water, fire, and air—the declared basic components of the universe according to the philosopher Empedocles. Hippocrates identified four basic temperaments—the choleric, melancholic, sanguine, and phlegmatic—these corresponded, respectively, to excesses in yellow bile, black bile, blood, and phlegm. Modified and expanded by the imaginative second-century physician, Galen, centuries later (Millon, 2004a) he posited nine temperamental types derived from the four humors. Among them the choleric temperament, associated with a tendency toward irascibility, the sanguine temperament prompted the individual toward optimism, the melancholic temperament, characterized by an inclination toward sadness, and the phlegmatic temperament, conceived as an apathetic disposition.

Similar in some respects to the ideas of Hippocrates and Galen were notions of temperament in China, (Millon, 2004a; Yosida, 1973) proposed some one or two millennia earlier. To them, healthful balances stemmed from energy flows rather than humoral disparities. Also notable were their assertions that temperament was markedly variable, influenced by climate, diet, and seasonal variations. Although the doctrines of humors and energy balances have been abandoned, giving way to scientific studies on modern topics such as neurohormone chemistry, their terminology and connotations still persist in such contemporary expressions as being sanguine or good humored.

Early Physiognomic/Phrenologic Conceptions

The ancients speculated also that body structure was associated with the character of personality. Whereas the humoral doctrine may be seen as the forerunner of contemporary psychiatric neurobiology, phrenology and physiognomy may be conceived as forerunners of modern psychiatric morphology. Physiognomy, first recorded in the writings of Aristotle, seeks to identify personality characteristics by outward appearances, particularly facial configurations and expressions. As late as the late 19th century, writers such as Joseph Simms (1887) sought to appraise others by observing their countenance, the play in their face, and the cast of their eyes, as well as their postural attitudes and the style of their movements.

It was not until the mid-19th century, however, that the first glimmerings of a “scientific” effort were made to analyze external morphology and its relation to psychological functions. Despite its controversial, if not discredited side, phrenology, as practiced by Franz Josef Gall (1835), was an initially honest and serious attempt to construct a science of personology. Although Gall referred to his studies of “brain physiology” as “organology” and “cranioscopy,” the term phrenology, coined by a younger associate, J. G. Spurzheim (1834), came to be its popular designation. The rationale that Gall presented for measuring contour variations of the skull was not at all illogical given the limited knowledge of 18th-century anatomy. In fact, his work signified an important advance over the naive and subjective studies of physiognomy of his time in that he sought to employ objective and quantitative methods to deduce the inner structure of the brain. Seeking to decipher emotional characteristics by their ostensible correlations with the nervous system, he was among the first to claim that a direct relationship existed between mind and body. Contending that the brain was the central organ of thought and emotion, Gall concluded, quite reasonably, that both the intensity and character of thoughts and emotions would correlate with variations in the size and shape of the brain or its encasement, the cranium. Thus, Gall asserted that just as it is logical to assume that persons with large bicep muscles are stronger than people with thin or small ones, so, too, would it be logical to assume that persons possessing large cranial projections would display corresponding psychological characteristics to a greater extent than those who evidence smaller protuberances. That these assertions proved invalid should not be surprising when we recognize, as we do today, the exceedingly complex structure of neuroanatomy and its tangential status as a substrate for personality functions. Despite the now transparent weaknesses of Gall's system, he was the first to attempt a reasoned thesis for the view that personality characteristics may correlate with body structure.

Literary Portrayals

Allport has referred to “character writing” as a minor literary style originating in Athens, probably invented by Aristotle and brought to it...