Adult Psychopathology, Second Edition

A Social Work Perspective

Francis J. Turner

• Publisher: Free Press
• Year: 1999
• eBook ISBN: 9781439137239
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

The most comprehensive textbook for students in advanced social work and mental health courses is now completely revised and updated for a new generation
When Adult Psychopathology: A Social Work Perspective was first published in 1984, this pioneering text was the first to conceptualize and organize theory and practice about the treatment of the mentally ill within their families and communities from a social work perspective. Now, in response to new developments in theory and research, as well as changes in service delivery within the field, the second edition contains updated and accessible information on how mental illnesses develop and how they can be treated within a social work framework that recognizes the importance of family, economics, and culture as well as biochemical and psychodynamic factors. Each chapter is written by the leading social work authority on that subject and includes practical, in-depth discussion of state-of-the-art technologies, treatments, and research. The book encompasses the broad spectrum of topics that social workers need to understand, including personality, adjustment, schizophrenia, suicide, anxiety states, phobias, neurological disorders, psychosexual disorders, drug and alcohol addiction, eating disorders, and others. Adult Psychopathology, Second Edition is essential for both M.S.W. and Ph.D. social work students and, as the authoritative, unequaled reference book, will aid clinicians in making more precise diagnoses in their daily work.

PERSONALITY DISORDERS

Mary E. Woods

The terms personality disorder and character disorder (sometimes used interchangeably) have been plagued with trouble. Over the years, for clinicians and theoreticians alike, the multifarious personality disorders have created even greater confusion and controversy than many other diagnostic designations. Definitions, classifications, and theories about their etiology and dynamics have been extremely divergent. To add to the problem, in recent times there has been a tendency to equate the personality disorder and the borderline disorder. As this chapter will clarify, the borderline personality is only one of several subcategories of the personality disorders.

Certainly, clinical diagnoses in general have the value of designating a cluster of features—traits, behaviors, thought and feeling patterns—characteristically found together, so that each individual is not viewed as totally different from all others, in spite of his uniqueness. When correctly applied, the diagnosis of a mental disorder conveys certain information about a particular client that may not be immediately apparent. However, such diagnoses are—as we all know—replete with ambiguity and hazard and, at best, are inadequate for understanding the complicated emotional and situational dilemmas to which clients seek solutions (Blanck & Blanck, 1974, 1979; Goldstein, 1990; Millon, 1996; Woods & Hollis, 1990). The assessment of a client cannot be complete without taking into account inner strengths and external resources; a full diagnosis cannot be made without appraising family and social forces, as well as environmental conditions. Fundamental social work values—such as our commitment to understand clients from social systems perspectives and to respect the dignity and individuality of each person—can be affronted by the superficial use of psychiatric classifications.

Moreover, there are three reasons for particular concern about the label personality disorder:

1. More than many others, this diagnosis has often been used to describe the total person (e.g., “He’s an obsessive-compulsive” or “She’s a schizoid”). Of course, a person is not a common cold; even if it is serious, a cold is only something a person has or suffers from; the diagnosis tells us precious little about the individual except that he or she is sick and probably will be uncomfortable for several days. Nevertheless, it is not uncommon to hear, “I have a caseload full of personality disorders,” implying a homogeneous group of people rather than a heterogeneous assortment of disorders. Just as one cannot be a neurotic conflict, one cannot be a personality disorder.

2. A person pegged as having (or being!) a personality disorder is often viewed—either subtly or bluntly—in pejorative terms. It is true that in recent years clients with such disorders are looked upon less disparagingly than they once were, but how often we still hear, “Oh, for the good old days when we saw mostly neurotics!” This attitude stems from a widespread, but as yet empirically unsupported, assumption that patients with personality disorders are peculiarly resistant to change.

3. The clinical diagnosis of a personality disorder—perhaps even more than other diagnoses—focuses on pathological traits, behaviors, thoughts, and feelings. In spite of social work’s ongoing commitment to a “strengths perspective” (Cowger, 1994; Weick, et al., 1989; Weick & Saleeby, 1995), for the most part diagnostic thinkers have failed to develop a sytematic means for assessing positive personality characteristics that bear upon the way individuals handle themselves and approach life’s opportunities and challenges. Ego psychology has been most influential in helping us develop some tools to assess particular ego functions (Bellak, et al., 1973; Goldstein, 1995; Woods & Hollis, 1990), but in spite of various efforts, we are not very far advanced toward achieving a common system that describes the essence of the “mature” or “healthy” personality.

In this chapter, I examine personality disorders according to the psychosocial framework, which incorporates several theoretical approaches, including psychoanalytic, ego psychology, object relations, and systems theories, among others. Because this model is an open system of thought, it has been able to incorporate and integrate concepts from many fields, including psychology, sociology, anthropology, and education, among others (for further elaboration see Hollis, 1970; Turner, 1978; Woods & Hollis, 1990; Woods & Robinson, 1996).

PERSONALITY DISORDERS AND DIAGNOSIS

Classifications of Personalities and Disorders

From ancient times to the present, there have been innumerable and diverse attempts to describe and classify personality types, as well as personality disturbances. (The reader is referred to Millon [1996], who has written an outstandingly useful, scholarly, comprehensive volume on disorders of personality, in which he includes a historical review of major personality theories.) Aside from the diagnostic and research value of a taxonomy, it has long been thought important for mental health professionals to have a common language with which to communicate with one another, in order to reduce the risks of ambiguity and misunderstanding.

For the most part, in recent decades psychosocial workers have relied upon two classifications to organize information about personality pathology.

The first classification was developed by psychoanalysts. Surprisingly, perhaps, theories about character or personality were not of major interest to psychoanalytic or psychodynamic thinkers until the 1930s and 1940s. In 1908 however, Sigmund Freud (1953) did develop an idea that connected certain traits—such as orderliness and obstinacy—with an anally oriented instinctual life. In the 1930s, Wilhelm Reich (1949) and others elaborated on Freud’s early identification of the anal character, and went on to classify personality disorders according to the level of psychosexual development at which libidinal energy seemed to be fixated. Thus, it was believed, when a child fails to master the tasks of one developmental phase, he is unable to move on easily or completely to the next; energies are still invested in the earlier phase and the child continues to seek satisfactions related to that phase. As the child with the fixation moves into adulthood—still trying to gratify early needs in a repetitive and frustrating manner—dysfunctional traits and patterns develop and produce a personality disorder. Particularly until the 1960s, psychosocial workers tended to use this model for the classification of oral, anal, and the less well defined urethral and phallic disorders. (For further discussion see Fenichel, 1945; Millon, 1996; Stanton, 1978.)

This system addressed etiological and psychodynamic issues but, particularly before the advent of ego psychology, was seriously limited, in that the value of the ego was underemphasized because it was viewed as dependent on the overbearing power of the id—the instinctual (sexual and aggressive) energies. The extent of the ego’s capacity to make changes—to creatively adapt to realities, to problem-solve, to resolve conflict—was therefore virtually unrecognized. In large measure, the individual was seen as passively shaped by past events, unconscious forces, or environmental assaults. The significance of family and social dynamics was minimized. Ego psychologists (for example, Anna Freud, 1946; Hartmann, 1958; Rapaport, 1958) revised psychoanalytic thinking by viewing the ego as having relative autonomy from the id. Thus, reactivity to inner impulses and inner demands could be modified by the ego; through the ego an individual’s rational and adaptive capacities could be harnessed to develop self-understanding and creative strategies for coping with life circumstances. Ego psychologists recognized the importance of environmental and interpersonal factors. Psychosocial theory and clinical social work practice were greatly enhanced by the realization that the ego could be worked with directly in treatment and was a powerful resource for change; people no longer were viewed as being at the mercy of the id or unconscious forces. By inference at least, and often in practice, workers could be more optimistic in assisting personality-disordered clients, among others. Erikson’s (1950) typology of the eight stages of man was also greeted enthusiastically by many social workers because social and cultural considerations influenced his thinking.

This approach to classifying personality (or character) pathologies, based on fixation of drives, which was spearheaded by psychoanalysts, is still considered relevant to some clinicians, but has been overshadowed by another system:

The second classification system separates personality disorders on the basis of clinical syndromes, such as schizoid, dependent, or obsessive-compulsive. All five editions of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1952, 1968, 1980, 1987, 1994) have followed this approach, although each edition introduced changes in specific syndromes and categories. It is important to point out that, by design, DSM takes an atheoretical and descriptive approach to clinical diagnosis, thereby making the manual useful to researchers and to clinicians across a broad range of theoretical orientations. Theories, considered essential to the psychosocial approach, about etiology of personality disorders—hereditary and biopsychosocial influences of all kinds—are deliberately not addressed in DSM. Actually, Millon (1996) has greatly elaborated on the DSM descriptive approach. He has expanded the list of personality disorders, discusses subtypes of particular disorders, includes discussions of theoretical antecedents to the specific subcategories, hypothesizes about biogenic factors and experiential histories of those with particular disorders, and gives recognition to family and social dynamics. His book is recommended as a companion to DSM for those seeking a rich, informative, detailed study of personality disorders. Nevertheless, in spite of its shortcomings, DSM-IV is the most commonly used reference today, and for that reason the discussions that follow will be built upon its outline of subcategories.

Descriptive Definitions of Personality Disorders

Personality disorders have been defined in various ways over the years. Space does not permit discussion of most of the definitions (for more detail see Cameron, 1963; Jackel, 1975; Millon, 1996; Stanton, 1978). Some related terms (such as neurotic character and character neurosis) were ambiguous and have been discarded. Included here are only those descriptions that serve the purpose of this chapter. These definitions apply to the entire range of specific personality disorders.

Jackel (1975) said that personality disorders are manifested “primarily in the person’s characteristic modes of response and behavior.” Discussing the history of psychoanalytic thinking on the matter, he wrote: “It became evident that patients could react unconsciously with repetitive patterned responses that pushed them into characteristic difficulties. These patterned responses had a marked bearing on choice of career, choice of mate, marital adjustment, and many other aspects of social conduct” (Jackel, 1975, p. 287).

Millon (1996) contrasted the healthy and the unhealthy personality:

When an individual displays an ability to cope with the environment in a flexible manner, and when his or her typical perceptions and behaviors foster increments in personal satisfaction, then the person is deemed by the larger reference group to possess a normal or healthy personality. Conversely, when average or everyday responsibilities are responded to inflexibly or defectively, or when the individual’s perceptions and behavior result in increments in personal discomfort or curtail opportunities to learn and to grow, then we may speak … of a pathological or maladaptive pattern. (p. 13)

Millon puts normality and pathology on a continuum, asserting that there is no sharp division between them, but he has identified three behavioral characteristics that distinguish pathological from normal personalities:

1. Tenuous stability: the individual with pathological personality patterns is distinguished by fragility and lack of resilience under stress; recurrent failures ultimately lead to less control and a distorted view of reality
2. Adaptive inflexibility: the individual with pathological personality patterns has few strategies for adapting to, or coping with, stress, and these are practiced rigidly
3. Vicious circles: the maladaptive patterns themselves and the many constraints personality-disordered individuals bring to their social milieu “generate and perpetuate extant dilemmas, provoke new predicaments, and set into motion self-defeating sequences with others, which cause their already established difficulties not only to persist, but to be aggravated further” (p. 15).

An important distinction should be made between maladaptive personality traits and symptoms. Simply put, maladaptive traits usually have existed over the course of an individual’s life and have significantly affected important aspects of functioning. Whether or not the person objects to or complains about a maladaptive trait, it is nevertheless seen as an integral part of the personality. A symptom, on the other hand, may be episodic or appear abruptly; it often has a beginning and an end, as many physical symptoms do. Without treatment, a symptom may last a long time or recur, but, in contrast to a trait, it is not viewed by the clinician or experienced by the suffering individual as part of the fabric of the personality. According to DSM-IV:

Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts. Only when personality traits are inflexible and maladaptive and cause significant functional impairment or subjective distress do they constitute Personality Disorders. The essential feature of a Personality Disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture and is manifested in at least two of the following areas: cognition, affectivity, interpersonal functioning, or impulse control …. This enduring pattern is inflexible and pervasive across a broad range of personal and social situations and leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. The pattern is stable and of long duration, and its onset can be traced back to adolescence or early adulthood … and is not better accounted for as a manifestation or consequence of another mental disorder … and is not due to the direct physiological effects of a substance … or a general medical condition, (p. 630)

Needless to say, a person with maladaptive traits of a personality disorder can simultaneously manifest signs or symptoms associated with other disorders described by DSM-IV (Axis 1)—such as some form of depression, anxiety, or phobia, among many others. Depending on the nature or type of the personality disorder, the experience and reactions to these symptoms will differ. For example, posttraumatic stress disorder will undoubtedly be experienced differently by a person with a histrionic disorder than by one with a schizoid disorder. More often than not, people with personality disorders go into therapy for symptom relief rather than for personality change. Some symptoms spring from the fears and frustrations intrinsic to maladaptive patterns; some others derive from specific recent events, such as interpersonal experiences or environmental assaults. In any case, once symptoms are reduced, those who want to may then move on to explore maladaptive patterns.

Subcategories of Personality Disorders: Diagnostic Characteristics

For the reason already explained, the DSM-IV subcategories of personality disorders will be employed in this chapter, but the explanations will include matters not addressed in the manual. Because they will be discussed elsewhere in the book, the border line personality (see Chapter 17), the antisocial personality (see Chapter 18), and the paranoid personality (see Chapter 20) will not be covered here as such; from time to time they will be referred to, however, because of frequent overlapping of personality styles and traits. The depressive and passive-aggressive personality disorders are not now part of the DSM classification, pending further research; they can be subsumed under the catchall category “personality disorder not otherwise specified,” which is not discussed in this chapter.

Social workers familiar with personality disorders and their diagnoses know that in many cases diagnoses do overlap, or criteria of two or more disorders coexist in the assessment of one individual. It is also true that there are vast differences in the quality and intensity of maladaptive patterns; thus, two individuals accurately diagnosed as having the same disorder may present themselves very differently. The concept of a continuum between “normal” and “disordered” personalities should always be kept in mind. And, as we have said, the full extent of a person’s condition cannot be usefully evaluated without taking into account personality strengths—qualities that are outside the realm of the diagnoses, such as values, talents, physical attributes, etc.—as well as external resources and opportunities. Finally, even clinicians who have worked extensively with clients with these disorders and are well versed in DSM-IV nosology can have divergent judgments about which label best fits the person in question. Nevertheless, the organization of a single system has been useful; decision making and communication with colleagues are far easier now than when we had to grapple with multiple very diverse classifications that lacked correlation.

An important note of caution: Personality styles must always be assessed in the context of the individual’s cultural background and reference group, including the socioeconomic conditions under which the person has lived. Behaviors—emotional, cognitive, and adaptive patterns common in one ethnic or geographical community—may appea...

Table of contents

• Cover page
• Title Page
• CONTENTS
• ACKNOWLEDGMENTS
• ABOUT THE CONTRIBUTORS
• INTRODUCTION
• A TRANSDISCIPLINARY VIEW OF MENTAL DISORDER
• CASE MANAGEMENT AS A STRATEGY OF SOCIAL WORK INTERVENTION WITH THE MENTALLY ILL
• THE BIOLOGICAL BASES OF PSYCHOPATHOLOGY
• PSYCHOPHARMACOLOGY AND CLINICAL SOCIAL WORK
• SOCIAL WORK AND THE DSM
• NEUROLOGICAL DISORDERS
• SENESCENCE
• ALZHEIMER’S DISEASE PATIENT AND FAMILY VICTIMIZED
• PSYCHOPHYSIOLOGIC DISORDERS
• DEVELOPMENTAL DISABILITIES IN AGING PERSONS
• SCHIZOPHRENIC DISORDERS
• AFFECTIVE DISORDERS
• ANXIETY DISORDERS
• ADJUSTMENT DISORDERS
• PERSONALITY DISORDERS
• BORDERLINE PERSONALITY DISORDER
• ANTISOCIAL PERSONALITY DISORDERS
• DISSOCIATIVE IDENTITY DISORDER
• PARANOID DISORDERS
• PHOBIC DISORDERS
• EATING DISORDERS AND SOCIAL WORK
• PSYCHOSEXUAL DISORDERS
• ALCOHOL DEPENDENCE
• DRUG ADDICTION A BPSI MODEL
• POST TRAUMATIC STRESS DISORDER CONCEPTUALIZED AS A PROBLEM IN THE PERSON ENVIRONMENT SYSTEM
• SUICIDE
• INDEX