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
      
                     -------------------------------------------
      
      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).