Lecture 18
Personality Disorders: Controversies and Theory
Lecture Outline
I. Introduction
II. The DSM-III-R
III. Controversies
A. Personality: Fact or Fiction
B. Models of Classification
C. Theory
IV. Psychoanalytic Theory: Borderline Personality Disorder
A. Normal Development
B. What Goes Wrong
C. Borderline Personality Disorder
V. Conclusion
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I. Introduction
As we noted last lecture, the Personality Disorders are perhaps the
most controversial of the diagnostic categories in the DSM-III-R. We
will examine this controversy in further detail today, noting in
particular the problems that arise from the DSM-III's atheoretical
approach.
We will then look at a particular theoretical approach to the
personality disorders (the psychodynamic approach) and examine how this
approach conceptualizes the etiology and nature of one of the
personality disorders: Borderline Personality Disorder.
II. The DSM-III-R
Over 100 changes in the criteria for the Personality Disorders were
made in the revised version of the DSM-III (Peele, 1986). More than any
other diagnostic category, the Personality Disorders as conceptualized
in the DSM-III received the most complaints from scientists. The
complaints were largely about the unreliability and questionable
validity of the DSM-III categories. It was not clear what the
"boundaries" were for each of the disorders. As a result, multiple or
mixed diagnoses were frequent. Much confusion existed regarding
diagnosis (Cloninger, 1987; Widiger & Frances, 1985; Widiger, Trull,
Hurt, et al., 1987; Wong, 1987).
In the DSM-III-R, an attempt has been made to address some of these
problems. The latest research was used in an attempt to clarify and
"tighten-up" the diagnostic criteria, so reliability would improve. But
at the same time, the authors of the revised manual did not want to
sacrifice coverage: It's easy to increase reliability by limiting the
diagnostic criteria to such an extent that it is unquestionable who
falls into the category. (An extreme example: If the diagnosis of
Depression were given if and only if the person has attempted suicide in
the past 12 months: You will have very high reliability if this is your
diagnostic criteria). However, this also means that a lot of people who
should be diagnosed will go undiagnosed - falling between the cracks.
So, the authors of the revised DSM-III were treading a difficult tight-
rope: at the same time attempting to improve reliability without
sacrificing coverage. The ultimate goal of the authors was to provide
diagnostic criteria that would avoid the confusion and mixed diagnoses
so problematic with the DSM-III (Peele, 1986; Morey, 1988).
III. Controversies
Nevertheless, the DSM-III-R still suffers from many of the same
problems faced by the DSM-III: unreliability, mixed diagnoses, overlap
with Axis I disorders. Although the revised manual is an improvement
over its predecessor, the Personality Disorders are still the weakest
part of the DSM diagnostic system. Let us examine some of the reasons
why there is so much debate concerning the Personality Disorders.
A. Personality: Fact or Fiction?
There is a long debate in Psychology over whether or not there
is such a thing as "personality". There is a lot of evidence
(e.g.: Mischel, 1968; Bem & Allen, 1974; Wiggins, 1980) that
people's behaviors (including thoughts, feelings, and so on) are
influenced by the situations they find themselves in, and not some
underlying set of personality traits. On the other side of the
debate, there is a lot of evidence that personality is real and
does play a role in people's lives (Wiggins, 1980; Block, 1971;
Epstein, 1979). Yet, you may say, of course personality is real -
I know I have a personality! I have certain characteristics that
are more or less consistent across situations and over time. If
you want me to describe the kind of person I am (ie, what my
personality is), I will have little difficulty doing so.
Nevertheless, you may in fact be mistaken. Research on people's
memory processes has shown that there are all sorts of mistakes and
biases people make when they recall information about themselves.
One of these biases is the tendency to see consistency and order
even when such consistency and order are absent. We remember
consistency in our lives, but that does not mean there was
consistency and order. We simply believe in personality, and so we
"remember" being consistent in our lives: acting the same way,
feeling the same things, thinking the same thoughts, regardless of
the situations we might be in. But our memories are really
"reconstructions"; and if that is so, then there may be no such
thing as "personality". Who we are is determined by situational
factors.
A provocative argument, indeed. And one with serious
implications for the DSM-III-R Personality Disorder categories. If
personality is actually fiction, then it is no wonder reliability
is so low for the Personality Disorders. How can you hope to
reliably diagnose something that doesn't exist?
We should note that perhaps we can still talk about
Personality Disorders, even if "personality" per se doesn't exist:
PD could be conceptualized as the lack of the usual variability we
see in people's behavior as they move from one situation to
another.
In any event, we are left with the problem of deciding what
information is important in our classification system, and how to
organize that information. We now turn to this issue...
B. Models of Classification
1. The "Classical" Categorical Model
The DSM-III diagnostic system uses a categorical model of
classification. This model conceptualizes the mental
disorders as discrete syndromes. That is, the disorders form
homogeneous syndromes with distinct boundaries. They are
defined by a limited set of symptoms - a certain constellation
of which will warrant the diagnosis. This approach is
consistent with the traditional conception of medical
disorders (Widiger & Frances, 1985; Widiger et al., 1987). We
thus see the influence of an overarching medical model on the
DSM-III.
2. The "Prototypal" Categorical Model
A number of problems arise when this classical approach is
used in the diagnosis of psychological disorders.
- the similarity among patients is exaggerated
- inconsistencies and important idiosyncracies are
ignored
- the focus is on stereotypic features of the patients
- a particular patient's diagnosis may contain symptoms
that do not apply to that patient
An alternative to the classical categorical approach which
attempts to avoid these problems has been suggested by various
writers (see Millon, 1986a).
This model, the "prototypal" model of classification, still
attempts to place people into different categories, but it
does not assume that these categories are discrete syndromes
with well defined boundaries. Rather, categories are "fuzzy"
around their edges. The symptoms that define the category are
features which are correlated; they are imperfectly related to
category membership: the symptoms are often but not
necessarily present.
Examples: Furniture
Bird
...what are the defining features of these classes of
objects? The category becomes fuzzy at its edge. Eg:
penguin as a bird (does not fly, in fact it swims!)
A prototypal approach to classification would allow for
multiple diagnoses. In fact, proponents of this approach
argue that this would be a more realistic approach: "Just as
it is possible for the normal person to exhibit many different
personality traits, it is also possible for a person to have
many different...maladaptive personality traits (Widiger &
Frances, 1985, p.616). Reliability would also be improved:
When diagnosis relies on the classical approach, disagreement
among clinicians regarding the presence or absence of any one
criterion can result in disagreement regarding the presence or
absence of the disorder. With a prototypal approach,
disagreement over single features is less likely to affect
agreement over the presence or absence of the disorder as a
whole (Widiger & Frances, 1985).
3. Dimensional Models
An alternative to categorical approaches to classification has
been suggested by numerous researchers (eg: Cloninger, 1987;
Millon, 1986b). This alternative approach, known as
"dimensional classification", does not attempt to place people
into diagnostic categories. Instead, key characteristics or
dimensions (sometimes seen as dimensions of personality, but
not necessarily) are identified. Often, these are dimensions
upon which all persons can be placed. Diagnosis, then,
becomes not a process of deciding the presence or absence of a
symptom or disorder, but rather, the degree to which a
particular characteristic is present. Instead of making
judgments of "present or not?", the dimensional approach asks
the question "how much?" Different researchers have
identified different dimensions. For example:
neuroticism, psychoticism, introversion-extroversion
(Eysenck & Eysenck, 1985)
novelty seeking, harm avoidance, reward dependence
(Cloninger, 1987)
positive emotionality, negative emotionality, constraint
(Tellegen, 1985)
A categorical system may miss many of the subtleties and
complexities of a person's life. A dimensional approach would
be better able to capture this complexity. The overlap seen
with the DSM-III-R categories would be expected and accounted
for with a dimensional approach (Wong, 1987).
C. Theory
But how do we decide what the defining criteria are?..or
what's prototypical? How do we decide what the dimensions are? To
do this, we need to be guided by some theory (cf: Meehl, 1972).
But the DSM-III is atheoretical. "Since no unifying theoretical
structures served as a frame of reference for deducing the
components of the category (ie: Personality Disorders), the various
kinds of descriptors associated with these components [are]
unsystematically scattered across the eleven identified personality
disorders (Davidson, 1982, quoted in Kiesler, 1986). Perhaps the
problems (unreliabilty, mixed diagnoses, etc) are inevitable (no
matter what classification approach is used) until theory comes to
play an explicit role in the construction of the classification
system. Without theory, the DSM-III categories are constructed
without any guidance - a "shot in the dark". But then...which
theory?? A major goal of the DSM-III was to be useful to people
across various theoretical orientations. Should we instead have
different diagnostic manuals for each theoretical persuasion? Will
this lead us into confusion? No communication across theories...?
How do we balance out the pros and cons of Theoretical Neutrality
vs Theoretical Guidance? We find ourselves on another tight-rope.
IV. Psychoanalytic Theory: Borderline Personality Disorder
In the remainder of today's lecture, we will look at the
theoretical side of the Personality Disorders. One theoretical approach
that we have not examined in any detail in our discussions of the
etiology of psychological disorders is the psychoanalytic approach. We
need to include this in our discussions: Psychoanalysis, although
criticized for being inconsistently supported by research evidence,
remains one of the major theoretical perspectives within psychology.
Important insights into psychopathology may be found in psychoanalytic
theory.
The psychoanalytic approach began with the work of Sigmund Freud
back in the late 1800's and early 1900's. Many theorists have followed
in Freud's footsteps, modifying and extending his original ideas. The
focus of this approach is on internal processes, especially those that
are unconscious, such as anxiety, impulses, conflict and defenses
against these things. The confusion surrounding the DSM-III, the
psychoanalytic approach argues, is due to its focus on purely
descriptive symptomatology.
If the basic concepts of psychoanalytic theory are unfamiliar to
you, make sure you study pages 58 - 67 in your text book. This lecture,
however, will be comprehensible even if you are not familiar with basic
theory.
In psychoanalytic theories (there are many variants), early
experiences are central to personality development. Who we are today is
largely determined by the experiences we had in our first few years of
life. If things were amiss in our early childhood, then we are likely
to have problems in all the rest of our years. Let us look at how a
borderline personality disorder is understood from a psychoanalytic
point of view. We'll be specifically looking at a more recent variant
of the psychoanalytic school: Object Relations theory (Blanck & Blanck,
1974; Gunderson, 1984; Masterson, 1976).
A. Normal Development
Psychoanalytic theories place a lot of emphasis on how "the
self" develops. The infant is born with no sense of self - this
self gradually develops through its interactions with the world.
There are a number of stages a normal child passes through as its
self develops (ages given are approximations). (NB: I use the term
"mother" here because her role is typically emphasized in
psychoanalytic writings. Sometimes "father" is not even mentioned
- a source of further criticism of psychoanalytic theory. This
deficiency is changing, however).
1. Stage of Symbiosis (1-18 months)
In this early stage, the infant and mother form a symbiotic
unit. The mother mediates every perception, action,
satisfaction and frustration that the child has. She also
provides the child with new experiences, propelling him/her
onward. In a sense, the mother is the child's "auxiliary
self". She performs all the functions that the child's self
(or more accurately: "ego" in psychoanalytic terminology) will
someday perform. The child's image of reality is of self &
mother as one unit. Within the first few months, the child
learns to distinguish between good and bad, ie: between
pleasure and pain.
As this stage progresses, the child begins to differentiate
between self and nonself. This differentiation is spurred on
by the child's tentative early explorations into the world.
He/she begins to form images of mother and images of self that
are separate. These images, however, are split in various
ways. Most importantly, the young child has separate images
of "good" mother (eg: the person/object that feeds me right
away) and "bad" mother (the person/object who frustrates me
and doesn't meet my every need immediately), as well as
separate images of the "good" self (the me that feels good and
warm and full) and the "bad" self (the me that is frustrated
and in pain). He or she is not yet able to see the good and
bad in one single person. Instead, the child splits the bad
stuff off, forming a separate image.
2. Stage of Separation and Individuation (18-36 months)
During this stage, the "object splitting" comes to an end.
The child relates to objects (people) as wholes. The "good"
and "bad" coalesce into integrated images of others and an
integrated self-concept. The child internalizes (takes in,
learns...) the functions performed by mother, and now does
them him/herself. In addition, the child learns that objects
do not cease to exist when not present ("object constancy").
He/she no longer needs to feel anxious when mother is absent.
Thus, stable, consistent, and independent sense of self and
images of others are emerging. The child is approaching the
actuality and reality of others and him/herself.
A key subphase in this process of separation-individuation is
known as "rapprochement" (15-22 months). Around this time, as
the child is moving out into the world, he/she also needs to
periodically return to mother for reassurance, approval and
admiration: "emotional refueling" as it were. It's as if the
child were making sure it was ok with mom to be a separate
individual.
B. What goes wrong
According to Object Relations theory, the seeds of borderline
personality disorder are planted during the separation-
individuation stage of development. The person never successfully
passes through this stage. He or she is "fixated" at this early
point in development.
This fixation arises because of the actions of the child's
mother. She has a need for her child to remain symbiotic with her.
This need is rooted in her own arrested development - she has her
own psychological problems. Indeed, she may be borderline herself.
In any event, the child's mother does not provide the
emotional "refueling" the child needs, especially during the
rapprochement subphase. She is threatened by her child's autonomy
- to her it equals losing her child. So, she discourages her
child's independence, and her discouragement takes on a devastating
form: Whenever the child makes a move toward autonomy, she
withdraws her love and support. This is terrifying for the young
child - loss of the most important thing in the world. Indeed, in
the rapprochement phase, the child needs this support and love to
successfully become autonomous. A terrible paradox: To grow, the
child needs mother, but if s/he grows s/he will lose mother.
The result: The child develops Feelings of Abandonment:
1. depression -from the threat of loss
2. rage -at being "held back"
3. fear -of being helpless, and also of being engulfed
4. guilt -over his/her own self-assertion and
individuality
5. passivity and helplessness -the effect of mother's
threat of abandonment
6. inner emptiness and void -a sense of self never fully
develops
C. Borderline Personality Disorder
These feelings of abandonment are intolerable to the child.
So s/he psychologically "defends" against them. That is, the child
keeps them out of full awareness. The main process which
accomplishes this is splitting: The "bad" parts of mother and of
self, and the accompanying abandonment feelings are "split off"
from awareness. But as we have seen, splitting is a primitive
mechanism. The child's over-reliance on it prevents the child from
moving on: a process which requires that s/he integrate the objects
s/he has initially split. This does not occur here.
The child grows up, but remains fixated at this earlier stage
of development. S/he is unable to see people as whole objects.
They are either all "good" or all "bad". S/he is terrified
(unconsciously) of abandonment. S/he carries around all the
feelings of abandonment, and subtly plays them out in his/her
interpersonal relationships: depression, fear, rage...
The symptoms as outlined by the DSM-III fall into place now;
they make a certain amount of "sense" seen from the vantage point
of this theory:
-unstable/intense relationships, alternating between
idealizing and devaluation
-impulsive, irritable, anxious
-intense anger
-marked and persistent identity disturbance
-chronic feelings of emptiness
-frantic efforts to avoid abandonment
V. Conclusion
We have looked at various approaches to classification (classical
and prototypal categorical models and dimensional models), noting the
importance of theory in guiding the development of a classification
system. We then spent some time looking at one theory (psychoanalytic
theory) and how it conceptualizes Borderline Personality Disorder. Of
course, there is the possibility that personality doesn't even exist.
Theory is important in the development of any system of
classification, be it a diagnostic system, a psychological test, or a
structured interview. Indeed, guidance from theories was probably
implicit in the DSM-III-R; the problem is that a) the guidance was not
explicit, and b) the guidance was thus inconsistent (involving various
theories).