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).