DIAGNOSIS AND TREATMENT OF PERSONALITY DISORDERS J o h n M. O l d h a m , M.D.
This article touches on four current areas of controversy in the field of the personality disorders-definition, etiology, assessment, and treatment. There is a tremendous amount of disability, personal distress, and public health expense as a result of the personality disorders. We are seeing steady progress in each of these areas. The implications of this progress are enormous, and the interest in this area is widespread, net just among psychiatric health professionals or among patients and their families and friends, but also among the public at large.
T h e S e p t e m b e r 1987 i s s u e of t h e H a r v a r d M e n t a l H e a l t h Letter(1) w a s d e v o t e d to t h e f i r s t of a t w o - p a r t s e r i e s on p e r s o n a l i t y disorders. It b e g a n as follows: ~'The s t u d y of p e r s o n a l i t y is in s o m e w a y s t h e m o s t f a s c i n a t i n g a s p e c t of p s y c h o l o g y , b e c a u s e it conc e r n s w h a t is m o s t h u m a n a b o u t us. B u t it is a s u b j e c t h i g h l y r e s i s t a n t to s y s t e m a t i c d e s c r i p t i o n a n d e x p l a n a t i o n . T h e d e f i n i t i o n of p e r s o n a l i t y , t h e c l a s s i f i c a t i o n of p e r s o n a l i t y t r a i t s or t y p e s , e v e n the distinction between healthy and disordered personalities have b e e n e l u s i v e . H o w p e r s o n a l i t y is f o r m e d r e m a i n s a m y s t e r y . T h e r e is l i t t l e a g r e e m e n t a b o u t t h e b e s t w a y s to t r e a t p e r s o n a l i t y disorders, or e v e n a b o u t w h e n t r e a t m e n t is possible. T h i s is p r o b a b l y John M. Oldham, M.D., is affiliated wi£h the Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY, and the New York State Psychiatric Institute. Address reprint requests to Dr. Oldham, New York State Psychiatric Institute, Box 4, 722 West 168th Street, New York, NY 10032. PSYCHIATRIC QUARTERLY, Vol. 63, No. 4, Winter 1992 0033-2720/92/1200-0413506.50/0 © 1992 Human Sciences Press, Inc.
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the area of psychology in which experimental research and clinical experience have least modified or deepened the intuitive insights of art, history, literature, and common sense. It is still uncertain whether scientific accounts of personality and its pathology can provide a satisfactory intellectual order and a guide for helping people with their problems." Some of the controversies alluded to in this quote will be outlined below, and it is difficult not to agree with many aspects of this point of view. But I believe that substantive beginnings have now been made in diagnosing personality disorders, which will lead to new knowledge about epidemiology, etiology, and treatment of these disorders. And I also t h i n k that the implications of Axis II pathology go well beyond their impact as discrete disorders; for example, as we become even better able to study these conditions, we may learn about their contributions to the diagnostic heterogeneity and the variability of treatment response of Axis I conditions. DSM-III, for the first time, established criteria by which to diagnose the personality disorders, a decision which has been generally welcomed by the psychiatric research community, though not without its critics, especially from psychiatric psychoanalytic clinicians. Debate about DSM-III's diagnostic system is only one of several areas of controversy in the field of personality disorder; these can be organized in the following categories: 1. 2. 3. 4.
Definition, or construct validity, of the disorders themselves Etiology of the disorders Assessment methodologies Treatment
I will briefly address each category in turn, starting with issues of definition.
DEFINITION
The words we use merit a brief comment, since the words personality, temperament, and character have been used interchangeably. Generally, a consensus has evolved to describe personality as a combination of temperament and character; temperament referring to constitutional and genetic factors and character referring
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to the personality attributes produced by experience and life events. Psychologists have been in the business of studying personality types for decades, but notions of personality types have been around since the Greeks. Not just that people are different, but that there are a limited number of persistent major categories of personality in which people fit, that have important implications. We are all familiar with the four types of temperament-sanguine, melancholic, choleric, and phlegmatic-proposed by Hippocrates in the 5th century B.C. Each of these types of temperament was presumed to be based on a predominant type of body ~'humor." Although the categories are different, the principles of this system are remarkably similar to a system proposed by Robert Cloninger in the June, 1987, issue of the Archives of General Psychiatry(2), where he proposed three major personality dimensions, each linked to a brain system with its principal monoamine neuromodulator. These categories are novelty seeking, harm avoidance, and reward dependence, based on dopamine-modulated behavioral activation, serotonin-modulated behavioral inhibition, and norepinephrine-modulated behavioral maintenance, respectively. The names have changed, and the science supporting these current proposals is substantial, but the principles are ancient. In spite of increasingly sophisticated models of personality types, such as Cloninger's, considerable controversy exists concerning the relationship between personality type, however classified, and personality disorder. Most of the more widely utilized pre-DSM-HI instruments for personality assessment, such as the Minnesota Multiphasic Personality Inventory(3), represent dimensional systems to study variations in personality traits in normal populations. Thomas Widiger and Allen Frances(4) have reviewed these and other contributions of psychology to this field, and they have argued persuasively in favor of a dimensional model of personality functioning. In contrast, DSM-III and DSM-III-R utilize a categorical approach, more typical of medical systems of classifying various types of pathology. Whether one prefers the categorical or the dimensional method of classifying personality, however, there is not good agreement whether personality pathology should be categorized with the same terms used to describe normal personality. Put another way, it is not clear whether a personality disorder represents the maladaptive result of too big a dose of a particular
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set of traits that otherwise might be called normal. Is ~the pathological" quantitatively or qualitatively different from ~the normal?" And in cases where Axis I and Axis II disorders are similar, is there a continuum? For example, does the successful obsessional businessman, due to too much 'Tactor x," develop an obsessivecompulsive personality disorder, and then, due to more "factor x," or ~factor y," develop obsessive-compulsive disorder itself?. Current research has not provided definitive answers for these questions, but this issue illustrates the way Axis I illness complicates attempts to define Axis II disorders. Does it make sense, to mention another example, to consider chronic schizophrenics, i.e., the subgroup of schizophrenics who are most chronically ill and unresponsive to treatment, on Axis II at all? A pervasive and chronic illness, surely, affects one's personality in a major way. It's not that chronic schizophrenics have no personality-type o r disord e r - o t h e r than their illness, but do the DSM-III-R categories apply to such populations? These and other questions of descriptive classification will, hopefully, be steadily clarified as the new assessment instruments are utilized more extensively. If we put aside this complicated issue of the relationship of personality type to disorder and focus on the personality disorders themselves, and if we agree to use DSM-III's categorical system, there are other areas of controversy under the broad heading of definition of the disorders. I will mention three: criteria format, disorder overlap and selection, and the role of theory. DSM-III-R adopted a uniform polythetic format for Axis II criteria sets, which represents an important correction of a problem in DSM-III. As Widiger and Frances pointed out, if two clinicians, using monothetic criteria, disagree on the presence or absence of a given criterion, they cannot agree on the presence of the disorder itself, and, as a result, reliability decreases(4). I have pointed out that prevalence rates of disorders so classified also decrease(5). In our pilot study of 60 cases(6), the Personality Disorder Examination (PDE) diagnoses adequate numbers of cases to analyze interrater reliability in 5 of the 11 DSM-III disorders; all 5 disorders (antisocial, borderline, compulsive, histrionic, and schizotypal) involved prototypic or polythetic criteria. In contrast, 5 (avoidant, dependent, narcissistic, passive-aggressive, and schizoid) of the 6 personality disorders that had base rates too low to analyze involved monothetic criteria sets. Thus, the format clearly affects the research find-
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ings, and this change in DSM-III-R has been an important one. Future research should clarify if a prototypic model for the disorders would be preferable. The second ongoing debate relates both to the degree of overlap among the disorders, and to whether DSM-III has included the most clinically meaningful disorders. Categories such as avoidant, dependent, and passive-aggressive disorders are viewed by some as pervasive generic traits rather t h a n discrete disorders. Other disorders may have been left out, and some Axis I disorders might more appropriately be classified on Axis II, such as dysthymic disorder or Briquet's syndrome. Certainly those of us who followed or were involved in the debate about masochistic personality disorder, which became self-defeating personality disorder, which split into self-defeating and sadistic personality disorders, were impressed by the complications seriously posed by such attempts at definition. "Psychopolitics" is a word that has been applied to this aspect of the process, and it is no simple matter to consider the fate of what we, the authors of the official terms, decide, when, for example, our patients get into the judicial system. Thirdly, there are skeptics who doubt whether personality types or disorders can be meaningfully classified into categories at all. Certainly, from a psychoanalytic point of view, attempts to classify personality disorders on the basis of atheoretical measurable or observable behavior alone inevitably disregard the complexity of unconsciously motivated behavior. And many clinicians have pointed out that DSM-III certainly is not theory-free, in spite of its goal to be so. As a psychoanalyst I am thoroughly convinced of the importance of the dynamic unconscious, but I believe that clinical research must begin with the least level of inference possible. In my opinion the approach taken by DSM-III and DSM-III-R, in spite of its shortcomings, has been a most progressive step in the right direction. I suspect that the criteria will change and that a number of the disorders may collapse into each other as the categories are re-defined based on research findings. The argument, however, t h a t some disorders should not be included in the diagnostic manual because there are no research data to validate their existence has always seemed a spurious one to me. We would certainly not suggest that there be no category called "headache," just because there may not be enough data. Clinicians know it exists because their patients tell them so, and their patients, suffering from this
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malady, need help. Likewise, our patients seek our help for disabling personality disorders, and our best clinical descriptions should be the starting place for our research. The data will follow, and will then help us subtype, refine, and clarify our diagnoses, leading to a better capacity to study etiology and treatment.
ETIOLOGY Uncertainty inevitably surrounds the etiology of personality disorders, even among those who agree on their descriptive definitions, since knowledge of etiology of all major psychopathology is still too limited. Yet we are in a time of exciting advancement in that knowledge. There has been an increasingly clear consensus that most types of psychopathology have both genetic and environmental origins, in varying percentages. Whereas several decades ago psychoanalysts were interested mainly in the psychogenic aspects of character pathology, more recently interest has been renewed in the role of genetic and constitutional factors in the etiology of the personality disorders. The specific DSM-III disorders most clearly linked to genetic defects may be schizotypal and antisocial personality disorders, but others have been suggested, such as borderline disorder as a variant of either affective disorders or impulsive disorders. Building on the New York Longitudinal Study, Thomas and Chess addressed many of these critical questions. As they put it, '~The beginnings of the scientific study of human psychological development and its pathological deviations were fashioned nearly a century ago by the creative seminal work of Sigmund Freud and Ivan Pavlov. They came to the study of h u m a n behavior from two different backgrounds-Freud as the neurologist and clinician, and Pavlov as a research physiologist. Their methods and conclusions were different, but both contributed basic creative insights into the dynamics of human psychological development. Both emphasized the process of the interaction of the biological and environmental in the formation of behavior patterns. Both traced the effects of life experience in transforming simple patterns into more complex ones. Both provided methods for the study of human psychological functioning which proved to be enormously productive in their hands and for succeeding generations of investigators.
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In a deep sense, we are all ~Freudians' and 'Pavlovians.'" This quote, from Thomas and Chess's recent volume entitled, "The Dynamic of Psychological Development"(7), clearly emphasizes the importance of both the biological contributions to behavior patterns, and the adaptational process to life events as they unfold. Their earlier work, '~Temperament and Development"(8) established unequivocally the persistence of stable behavior patterns identifiable early in infancy. The contributions they have made to this area are consistent with numerous converging findings from other infant observation work, from longitudinal studies extending throughout the life cycle, and from expanding data from animal researchers, demonstrating the profound but variable impact of environmental events on animals with genetically different behavior patterns. One critical emerging finding is not just that behavior is molded by genes and the environment, but that there is a remarkable plasticity to the brain. Even in primates, as Suomi(9) has reported, social ~therapy" can reverse behavioral abnormalities produced by social isolation. Many authors have emphasized these areas of importance, including Cooper(10), Kandel(ll), Pardes(12), and Reiser(13).
ASSESSMENT
Assuming one accepts a categorical diagnostic system such as that in DSM-III-R, there are still complicated issues related to standardized assessment methods. These fall mainly into three areas: state/trait issues, cross-sectional versus longitudinal issues, and information retrieval issues. The state/trait issue was alluded to above, in connection with the question of validity of personality disorders in patients with pervasive and chronic Axis I conditions. That question aside, it has been suggested that certain illnesses such as depression affect personality assessment(14). Depressed patients, even if asked to describe what they are like when not depressed, may not accurately do so but, instead, may describe themselves in ways heavily colored by their depressive mood; later evaluation, when they are no longer depressed, can give strikingly different pictures. Other disorders are likely to have similar effects. At the New York State Psychiatric Institute, we have done test-retest evaluations utilizing the PDE, at three-month inter-
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vals, on normal-weight bulimics. After three months of treatment, bulimic patients had significantly reduced numbers of personality disorders, compared to their presentation at the time of admission, well beyond that attributable to test-retest unreliability(15). Numerous other Axis I conditions, yet to be studied, may distort Axis II assessment. Parenthetically, it might be added, there may also be distorting effects of a major Axis I illness on the assessment of other Axis I conditions, yet methods like the Schedule for Affective Disorders and Schizophrenia (SADS)(16) have been used for years with the assumption that patients, for example, who are depressed, do not distort or overreport other Axis I psychopathology. A related issue is the cross-sectional versus longitudinal question. Even if no illness exists on Axis I, it is questionable whether in a single interview one can get an accurate portrait of a person's personality. Many experienced clinicians argue that only getting to know a patient over time can lead to a truly informed assessment. Spitzer has suggested the LEAD standard(17), referring to Longitudinal Evaluation by an expert utilizing All Data. We have reported pilot work comparing semi-structured interviews with this type of LEAD evaluation(18) on a long-term inpatient unit. Our preliminary data suggest that there is considerable unevenness in comparing evaluation methods, so that the semistructured interviews correlate quite well with the clinical evaluation for some disorders, but not well for others. A final assessment problem is that of information retrieval. By this I mean the difficulty posed by the existence of unconscious defense mechanisms which make information unavailable to the patient, and by the reluctance of patients to admit socially unacceptable behavior. Some investigators have suggested that an anonymous self-report instrument might allow patients to acknowledge certain behaviors, thoughts, or feelings t h a t they might otherwise hesitate to reveal(19), but such an approach has all the serious limitations of a self-report method. Our research group, in constructing the PDE, incorporated questions such as "Has anyone ever told y o u . . . ?" or "Has anyone ever accused you of... ?" in the hope that such information might be retrieved. Stangl, Pfohl, and their group from Iowa(20), when developing the Structured Interview for DSM-III Personality Disorders (SIDP), incorporated a requirement that information be obtained from a family member or significant other in addition to the patient. Although such an
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approach has appeal, it has its own complications, such as unavailability of, or psychopathology in, the family members themselves. The relative merits of these various approaches should become clearer as more studies emerge.
TREATMENT
The last of the four major areas of controversy that I will briefly discuss is treatment of the personality disorders. It is here that the aura of pessimism that characterized the quotation from the Harvard Mental Health Letter is most mirrored in the literature. In many ways, this sense of uncertainty is not surprising. In their chapter on "Treatment of Personality Disorders" in Volume 5 of the APA Annual Review, Liebowitz, Stone, and Turkat(21) point out that ~'few systematic studies exist to guide clinicians attempting to help troubled, and troubling, personality~disordered patients." Why so few systematic studies exist is a result of several factors, not the least of which is that, until recently, no standardized method of diagnosing the disorders existed. We are well on our way to overcoming this problem, as described above. A second, more perplexing problem, is the difficulty inherent in attempts to study long-term psychotherapy. In Smith, Glass, and Miller's metastatistical analysis, entitled "The Benefits of Psychotherapy"(22), they studied 475 controlled psychotherapy studies reported in the literature. The average duration of therapy for all 475 studies was 15.75 hours. Their conclusion, that psychotherapy is beneficial, is one supported by many converging lines of psychotherapy r e s e a r c h - a g a i n , however, usually studies of brief psychotherapy. The reason for this skew is apparent, due to the methodological complexity produced by increasing numbers of variables, the longer the treatment lasts. An unfortunate illusion has been created by this problem, however, since all too often one hears the conclusion that brief therapy has been proven more beneficial t h a n other forms of psychotherapy. It is just that we do not have good data about long-term psychotherapy, and we do about brief therapy. If there is a clinical tradition, in fact, it is t h a t personality disorders have been viewed as indications for long-term, psychodynamically-oriented psychotherapy or psychoanalysis. Auchin-
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closs and Michels(23) stated: '~Today it is generally accepted that character disorders, not neurotic symptoms, are the primary indication for analysis. Other therapies are often more effective and usually more efficient in treating symptoms. Psychoanalysis is indicated when the patient suffers from persistent maladaptive character traits or when the recurrence and stability of the symptoms suggest t h a t they are embedded in underlying character pathology t h a t cannot be disregarded in the treatment. In other words, psychoanalysis (as a technique) and character analysis have become synonymous." This view, t h a t the absence of major symptoms determines the choice of long-term treatment, must not be taken too literally. Gunderson and Pollack(24), discussing the therapeutic implications of the Axis I-Axis II division, said that '~it is often assumed t h a t Axis I disorders are best treated pharmacologically and that Axis II disorders are best treated psychotherapeutically." They urged that such an assumption entailed risks of insufficient or inappropriate treatment for many types of p a t i e n t s - f o r example, schizophrenics who need much more than just medication, and patients with personality disorders who need not just psychotherapy, but also medication. They cite Klerman and Weissman's work(25), which ~should have set a more balanced stage by showing the additive effects of pharmacotherapy and psychotherapy." Until more treatment studies provide more definitive data, clinical wisdom remains our best treatment guide, one which should continue to guide us as new research findings emerge.
CONCLUSIONS I have touched on four current areas of controversy in the field of the personality disorders-definition, etiology, assessment, and treatment. We are seeing steady progress in each of these areas. The implications of this progress are enormous, and the interest in this area is widespread, not just among psychiatric health professionals or among patients and their families and friends, but also among the public at large. In spite of overwhelmingly important need to continue and further research in major areas such as schizophrenia and the affective disorders, there is also a tremendous amount of disability,
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personal distress, and public health expense as a result of the personality disorders. I hope I am correct in believing that not only is this being increasingly appreciated, but that significant advances are well under way.
REFERENCES 1. The Harvard Medical School Mental Health Letter, vot. 4 number 3:1-4, 1987. 2. Cloninger CR: A systematic method for clinical description and classification of personality variants. Archives of General Psychiatry 44:573-588, 1987. 3. Morey L, Waugh M, Blashfield R: MMPI scales for DSM-III personality disorders: their derivation and correlates. Journal Personality Assessment 49:245-251, 1985. 4. Widiger T, Francis A: The DSM-III personality disorders. Archives of General Psychiatry 42:615-623, 1985. 5. Oldham JM: DSM-III personality disorders: assessment problems. Journal of Personality Disorders 1(3):241-247, 1987. 6. Loranger A, Susman V, Oldham J, et ah The personality disorder examination: a preliminary report. Journal of Personality Disorders 1:1-13, 1987. 7. Thomas A, Chess S: The Dynamic of Psychological Development. New York, Brunner/ Mazel, 1980. 8. Thomas A, Chess S: Temperament and Development. New York, Brunner/Mazel, 1977. 9. Suomi S: Response styles in monkeys: experimental effects, in Biologic Response Styles: Clinical Implications. Edited by Klar H, Siever LJ. Washington, American Psychiatric Press, 1985. 10. Cooper AM: Will neurobiology influence psychoanalysis? American Journal of Psychiatry 142:1395-1402, 1985. 11. Kandel ER: From metapsychology to molecular biology: explorations into the nature of anxiety. American Journal of Psychiatry 140:1277-1294, 1983. 12. Pardes H: Neuroscience and psychiatry: marriage or coexistence? American Journal of Psychiatry 143:1205-1212, 1986. 13. Reiser M: Toward a Convergence of Psychoanalysis and Neurobiology. New York. Basic Books, 1984 14. Hirschfeld R, Klerman G, Clayton P, et ah Assessing personality: effects of the depressive state on trait measurement. American Journal of Psychiatry 140:695-699, 1983. 15. Ames-Frankel J, Devlin MJ, Walsh BT, et al: Personality disorder diagnoses in patients with bulimia nervosa: clinical correlates and changes with treatment. Journal of Clinical Psychiatry (53:90-96, 1992). 16. Spitzer RL, Endicott J: Schedule for Affective Disorders and Schizophrenia (SADS) (3rd ed.) New York: Biometrics Research, New York State Psychiatric Institute, 1978-79. 17. Spitzer RL: Psychiatric diagnosis: are clinicians still necessary? Comprehensive Psychiatry 24:399-411, 1983. 18. Skodol AE, Rosnick L, Kellman, et al: Validating structured DSM-III-R personality disorder assessments with longitudinal data. American Journal of Psychiatry 145:1297-1299, 1988. 19. Oldham JM, Clarkin J, Appelbaum A, et ah Identity, defenses, and reality-testing in borderlines, in The Borderline: Current Empirical Research. Edited by McGlashan T. Washington, American Psychiatric Press, Inc., 1985. 20. Stangl D, Pfohl B, Zimmerman M, et al: A structured interview for the DSM-HI personality disorders. Archives of General Psychiatry 42:591-596, 1985. 21. Liebowitz M, Stone M, Turkat DA: Treatment of personality disorders, in Psychiatry Update. Edited by Francis A, Hales R. Washington, APA Annual Review Vol. 5, 1986.
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22. Smith ML, Glass GV, Miller T: The Benefits of Psychotherapy. Baltimore. Johns Hopkins University Press, 1980. 23. Auchincloss J, Michels R: Psychoanalytic theory of character, in Personality Disorders. Edited by Frosch J. Washington, American Psychiatric Press, 1983. 24. Gunderson JG, Pollock WS: Conceptual risks of the Axis I-II division, in Biological Response Styles: Clinical Implications. Edited by Klar H, Siever L. Washington, American Psychiatric Press, 82-95, 1985. 25. Klerman GI, DiMascio A, Weissman MM, et al: Treatment of depression by drugs and psychotherapy. American Journal of Psychiatry 131:186-191, 1974.
This article touches on four current areas of controversy in the field of the personality disorders-definition, etiology, assessment, and treatment. There is a tremendous amount of disability, personal distress, and public health expense as a result of the personality disorders. We are seeing steady progress in each of these areas. The implications of this progress are enormous, and the interest in this area is widespread, net just among psychiatric health professionals or among patients and their families and friends, but also among the public at large.
T h e S e p t e m b e r 1987 i s s u e of t h e H a r v a r d M e n t a l H e a l t h Letter(1) w a s d e v o t e d to t h e f i r s t of a t w o - p a r t s e r i e s on p e r s o n a l i t y disorders. It b e g a n as follows: ~'The s t u d y of p e r s o n a l i t y is in s o m e w a y s t h e m o s t f a s c i n a t i n g a s p e c t of p s y c h o l o g y , b e c a u s e it conc e r n s w h a t is m o s t h u m a n a b o u t us. B u t it is a s u b j e c t h i g h l y r e s i s t a n t to s y s t e m a t i c d e s c r i p t i o n a n d e x p l a n a t i o n . T h e d e f i n i t i o n of p e r s o n a l i t y , t h e c l a s s i f i c a t i o n of p e r s o n a l i t y t r a i t s or t y p e s , e v e n the distinction between healthy and disordered personalities have b e e n e l u s i v e . H o w p e r s o n a l i t y is f o r m e d r e m a i n s a m y s t e r y . T h e r e is l i t t l e a g r e e m e n t a b o u t t h e b e s t w a y s to t r e a t p e r s o n a l i t y disorders, or e v e n a b o u t w h e n t r e a t m e n t is possible. T h i s is p r o b a b l y John M. Oldham, M.D., is affiliated wi£h the Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY, and the New York State Psychiatric Institute. Address reprint requests to Dr. Oldham, New York State Psychiatric Institute, Box 4, 722 West 168th Street, New York, NY 10032. PSYCHIATRIC QUARTERLY, Vol. 63, No. 4, Winter 1992 0033-2720/92/1200-0413506.50/0 © 1992 Human Sciences Press, Inc.
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the area of psychology in which experimental research and clinical experience have least modified or deepened the intuitive insights of art, history, literature, and common sense. It is still uncertain whether scientific accounts of personality and its pathology can provide a satisfactory intellectual order and a guide for helping people with their problems." Some of the controversies alluded to in this quote will be outlined below, and it is difficult not to agree with many aspects of this point of view. But I believe that substantive beginnings have now been made in diagnosing personality disorders, which will lead to new knowledge about epidemiology, etiology, and treatment of these disorders. And I also t h i n k that the implications of Axis II pathology go well beyond their impact as discrete disorders; for example, as we become even better able to study these conditions, we may learn about their contributions to the diagnostic heterogeneity and the variability of treatment response of Axis I conditions. DSM-III, for the first time, established criteria by which to diagnose the personality disorders, a decision which has been generally welcomed by the psychiatric research community, though not without its critics, especially from psychiatric psychoanalytic clinicians. Debate about DSM-III's diagnostic system is only one of several areas of controversy in the field of personality disorder; these can be organized in the following categories: 1. 2. 3. 4.
Definition, or construct validity, of the disorders themselves Etiology of the disorders Assessment methodologies Treatment
I will briefly address each category in turn, starting with issues of definition.
DEFINITION
The words we use merit a brief comment, since the words personality, temperament, and character have been used interchangeably. Generally, a consensus has evolved to describe personality as a combination of temperament and character; temperament referring to constitutional and genetic factors and character referring
JOHN M. OLDHAM
415
to the personality attributes produced by experience and life events. Psychologists have been in the business of studying personality types for decades, but notions of personality types have been around since the Greeks. Not just that people are different, but that there are a limited number of persistent major categories of personality in which people fit, that have important implications. We are all familiar with the four types of temperament-sanguine, melancholic, choleric, and phlegmatic-proposed by Hippocrates in the 5th century B.C. Each of these types of temperament was presumed to be based on a predominant type of body ~'humor." Although the categories are different, the principles of this system are remarkably similar to a system proposed by Robert Cloninger in the June, 1987, issue of the Archives of General Psychiatry(2), where he proposed three major personality dimensions, each linked to a brain system with its principal monoamine neuromodulator. These categories are novelty seeking, harm avoidance, and reward dependence, based on dopamine-modulated behavioral activation, serotonin-modulated behavioral inhibition, and norepinephrine-modulated behavioral maintenance, respectively. The names have changed, and the science supporting these current proposals is substantial, but the principles are ancient. In spite of increasingly sophisticated models of personality types, such as Cloninger's, considerable controversy exists concerning the relationship between personality type, however classified, and personality disorder. Most of the more widely utilized pre-DSM-HI instruments for personality assessment, such as the Minnesota Multiphasic Personality Inventory(3), represent dimensional systems to study variations in personality traits in normal populations. Thomas Widiger and Allen Frances(4) have reviewed these and other contributions of psychology to this field, and they have argued persuasively in favor of a dimensional model of personality functioning. In contrast, DSM-III and DSM-III-R utilize a categorical approach, more typical of medical systems of classifying various types of pathology. Whether one prefers the categorical or the dimensional method of classifying personality, however, there is not good agreement whether personality pathology should be categorized with the same terms used to describe normal personality. Put another way, it is not clear whether a personality disorder represents the maladaptive result of too big a dose of a particular
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set of traits that otherwise might be called normal. Is ~the pathological" quantitatively or qualitatively different from ~the normal?" And in cases where Axis I and Axis II disorders are similar, is there a continuum? For example, does the successful obsessional businessman, due to too much 'Tactor x," develop an obsessivecompulsive personality disorder, and then, due to more "factor x," or ~factor y," develop obsessive-compulsive disorder itself?. Current research has not provided definitive answers for these questions, but this issue illustrates the way Axis I illness complicates attempts to define Axis II disorders. Does it make sense, to mention another example, to consider chronic schizophrenics, i.e., the subgroup of schizophrenics who are most chronically ill and unresponsive to treatment, on Axis II at all? A pervasive and chronic illness, surely, affects one's personality in a major way. It's not that chronic schizophrenics have no personality-type o r disord e r - o t h e r than their illness, but do the DSM-III-R categories apply to such populations? These and other questions of descriptive classification will, hopefully, be steadily clarified as the new assessment instruments are utilized more extensively. If we put aside this complicated issue of the relationship of personality type to disorder and focus on the personality disorders themselves, and if we agree to use DSM-III's categorical system, there are other areas of controversy under the broad heading of definition of the disorders. I will mention three: criteria format, disorder overlap and selection, and the role of theory. DSM-III-R adopted a uniform polythetic format for Axis II criteria sets, which represents an important correction of a problem in DSM-III. As Widiger and Frances pointed out, if two clinicians, using monothetic criteria, disagree on the presence or absence of a given criterion, they cannot agree on the presence of the disorder itself, and, as a result, reliability decreases(4). I have pointed out that prevalence rates of disorders so classified also decrease(5). In our pilot study of 60 cases(6), the Personality Disorder Examination (PDE) diagnoses adequate numbers of cases to analyze interrater reliability in 5 of the 11 DSM-III disorders; all 5 disorders (antisocial, borderline, compulsive, histrionic, and schizotypal) involved prototypic or polythetic criteria. In contrast, 5 (avoidant, dependent, narcissistic, passive-aggressive, and schizoid) of the 6 personality disorders that had base rates too low to analyze involved monothetic criteria sets. Thus, the format clearly affects the research find-
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ings, and this change in DSM-III-R has been an important one. Future research should clarify if a prototypic model for the disorders would be preferable. The second ongoing debate relates both to the degree of overlap among the disorders, and to whether DSM-III has included the most clinically meaningful disorders. Categories such as avoidant, dependent, and passive-aggressive disorders are viewed by some as pervasive generic traits rather t h a n discrete disorders. Other disorders may have been left out, and some Axis I disorders might more appropriately be classified on Axis II, such as dysthymic disorder or Briquet's syndrome. Certainly those of us who followed or were involved in the debate about masochistic personality disorder, which became self-defeating personality disorder, which split into self-defeating and sadistic personality disorders, were impressed by the complications seriously posed by such attempts at definition. "Psychopolitics" is a word that has been applied to this aspect of the process, and it is no simple matter to consider the fate of what we, the authors of the official terms, decide, when, for example, our patients get into the judicial system. Thirdly, there are skeptics who doubt whether personality types or disorders can be meaningfully classified into categories at all. Certainly, from a psychoanalytic point of view, attempts to classify personality disorders on the basis of atheoretical measurable or observable behavior alone inevitably disregard the complexity of unconsciously motivated behavior. And many clinicians have pointed out that DSM-III certainly is not theory-free, in spite of its goal to be so. As a psychoanalyst I am thoroughly convinced of the importance of the dynamic unconscious, but I believe that clinical research must begin with the least level of inference possible. In my opinion the approach taken by DSM-III and DSM-III-R, in spite of its shortcomings, has been a most progressive step in the right direction. I suspect that the criteria will change and that a number of the disorders may collapse into each other as the categories are re-defined based on research findings. The argument, however, t h a t some disorders should not be included in the diagnostic manual because there are no research data to validate their existence has always seemed a spurious one to me. We would certainly not suggest that there be no category called "headache," just because there may not be enough data. Clinicians know it exists because their patients tell them so, and their patients, suffering from this
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malady, need help. Likewise, our patients seek our help for disabling personality disorders, and our best clinical descriptions should be the starting place for our research. The data will follow, and will then help us subtype, refine, and clarify our diagnoses, leading to a better capacity to study etiology and treatment.
ETIOLOGY Uncertainty inevitably surrounds the etiology of personality disorders, even among those who agree on their descriptive definitions, since knowledge of etiology of all major psychopathology is still too limited. Yet we are in a time of exciting advancement in that knowledge. There has been an increasingly clear consensus that most types of psychopathology have both genetic and environmental origins, in varying percentages. Whereas several decades ago psychoanalysts were interested mainly in the psychogenic aspects of character pathology, more recently interest has been renewed in the role of genetic and constitutional factors in the etiology of the personality disorders. The specific DSM-III disorders most clearly linked to genetic defects may be schizotypal and antisocial personality disorders, but others have been suggested, such as borderline disorder as a variant of either affective disorders or impulsive disorders. Building on the New York Longitudinal Study, Thomas and Chess addressed many of these critical questions. As they put it, '~The beginnings of the scientific study of human psychological development and its pathological deviations were fashioned nearly a century ago by the creative seminal work of Sigmund Freud and Ivan Pavlov. They came to the study of h u m a n behavior from two different backgrounds-Freud as the neurologist and clinician, and Pavlov as a research physiologist. Their methods and conclusions were different, but both contributed basic creative insights into the dynamics of human psychological development. Both emphasized the process of the interaction of the biological and environmental in the formation of behavior patterns. Both traced the effects of life experience in transforming simple patterns into more complex ones. Both provided methods for the study of human psychological functioning which proved to be enormously productive in their hands and for succeeding generations of investigators.
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In a deep sense, we are all ~Freudians' and 'Pavlovians.'" This quote, from Thomas and Chess's recent volume entitled, "The Dynamic of Psychological Development"(7), clearly emphasizes the importance of both the biological contributions to behavior patterns, and the adaptational process to life events as they unfold. Their earlier work, '~Temperament and Development"(8) established unequivocally the persistence of stable behavior patterns identifiable early in infancy. The contributions they have made to this area are consistent with numerous converging findings from other infant observation work, from longitudinal studies extending throughout the life cycle, and from expanding data from animal researchers, demonstrating the profound but variable impact of environmental events on animals with genetically different behavior patterns. One critical emerging finding is not just that behavior is molded by genes and the environment, but that there is a remarkable plasticity to the brain. Even in primates, as Suomi(9) has reported, social ~therapy" can reverse behavioral abnormalities produced by social isolation. Many authors have emphasized these areas of importance, including Cooper(10), Kandel(ll), Pardes(12), and Reiser(13).
ASSESSMENT
Assuming one accepts a categorical diagnostic system such as that in DSM-III-R, there are still complicated issues related to standardized assessment methods. These fall mainly into three areas: state/trait issues, cross-sectional versus longitudinal issues, and information retrieval issues. The state/trait issue was alluded to above, in connection with the question of validity of personality disorders in patients with pervasive and chronic Axis I conditions. That question aside, it has been suggested that certain illnesses such as depression affect personality assessment(14). Depressed patients, even if asked to describe what they are like when not depressed, may not accurately do so but, instead, may describe themselves in ways heavily colored by their depressive mood; later evaluation, when they are no longer depressed, can give strikingly different pictures. Other disorders are likely to have similar effects. At the New York State Psychiatric Institute, we have done test-retest evaluations utilizing the PDE, at three-month inter-
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vals, on normal-weight bulimics. After three months of treatment, bulimic patients had significantly reduced numbers of personality disorders, compared to their presentation at the time of admission, well beyond that attributable to test-retest unreliability(15). Numerous other Axis I conditions, yet to be studied, may distort Axis II assessment. Parenthetically, it might be added, there may also be distorting effects of a major Axis I illness on the assessment of other Axis I conditions, yet methods like the Schedule for Affective Disorders and Schizophrenia (SADS)(16) have been used for years with the assumption that patients, for example, who are depressed, do not distort or overreport other Axis I psychopathology. A related issue is the cross-sectional versus longitudinal question. Even if no illness exists on Axis I, it is questionable whether in a single interview one can get an accurate portrait of a person's personality. Many experienced clinicians argue that only getting to know a patient over time can lead to a truly informed assessment. Spitzer has suggested the LEAD standard(17), referring to Longitudinal Evaluation by an expert utilizing All Data. We have reported pilot work comparing semi-structured interviews with this type of LEAD evaluation(18) on a long-term inpatient unit. Our preliminary data suggest that there is considerable unevenness in comparing evaluation methods, so that the semistructured interviews correlate quite well with the clinical evaluation for some disorders, but not well for others. A final assessment problem is that of information retrieval. By this I mean the difficulty posed by the existence of unconscious defense mechanisms which make information unavailable to the patient, and by the reluctance of patients to admit socially unacceptable behavior. Some investigators have suggested that an anonymous self-report instrument might allow patients to acknowledge certain behaviors, thoughts, or feelings t h a t they might otherwise hesitate to reveal(19), but such an approach has all the serious limitations of a self-report method. Our research group, in constructing the PDE, incorporated questions such as "Has anyone ever told y o u . . . ?" or "Has anyone ever accused you of... ?" in the hope that such information might be retrieved. Stangl, Pfohl, and their group from Iowa(20), when developing the Structured Interview for DSM-III Personality Disorders (SIDP), incorporated a requirement that information be obtained from a family member or significant other in addition to the patient. Although such an
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approach has appeal, it has its own complications, such as unavailability of, or psychopathology in, the family members themselves. The relative merits of these various approaches should become clearer as more studies emerge.
TREATMENT
The last of the four major areas of controversy that I will briefly discuss is treatment of the personality disorders. It is here that the aura of pessimism that characterized the quotation from the Harvard Mental Health Letter is most mirrored in the literature. In many ways, this sense of uncertainty is not surprising. In their chapter on "Treatment of Personality Disorders" in Volume 5 of the APA Annual Review, Liebowitz, Stone, and Turkat(21) point out that ~'few systematic studies exist to guide clinicians attempting to help troubled, and troubling, personality~disordered patients." Why so few systematic studies exist is a result of several factors, not the least of which is that, until recently, no standardized method of diagnosing the disorders existed. We are well on our way to overcoming this problem, as described above. A second, more perplexing problem, is the difficulty inherent in attempts to study long-term psychotherapy. In Smith, Glass, and Miller's metastatistical analysis, entitled "The Benefits of Psychotherapy"(22), they studied 475 controlled psychotherapy studies reported in the literature. The average duration of therapy for all 475 studies was 15.75 hours. Their conclusion, that psychotherapy is beneficial, is one supported by many converging lines of psychotherapy r e s e a r c h - a g a i n , however, usually studies of brief psychotherapy. The reason for this skew is apparent, due to the methodological complexity produced by increasing numbers of variables, the longer the treatment lasts. An unfortunate illusion has been created by this problem, however, since all too often one hears the conclusion that brief therapy has been proven more beneficial t h a n other forms of psychotherapy. It is just that we do not have good data about long-term psychotherapy, and we do about brief therapy. If there is a clinical tradition, in fact, it is t h a t personality disorders have been viewed as indications for long-term, psychodynamically-oriented psychotherapy or psychoanalysis. Auchin-
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closs and Michels(23) stated: '~Today it is generally accepted that character disorders, not neurotic symptoms, are the primary indication for analysis. Other therapies are often more effective and usually more efficient in treating symptoms. Psychoanalysis is indicated when the patient suffers from persistent maladaptive character traits or when the recurrence and stability of the symptoms suggest t h a t they are embedded in underlying character pathology t h a t cannot be disregarded in the treatment. In other words, psychoanalysis (as a technique) and character analysis have become synonymous." This view, t h a t the absence of major symptoms determines the choice of long-term treatment, must not be taken too literally. Gunderson and Pollack(24), discussing the therapeutic implications of the Axis I-Axis II division, said that '~it is often assumed t h a t Axis I disorders are best treated pharmacologically and that Axis II disorders are best treated psychotherapeutically." They urged that such an assumption entailed risks of insufficient or inappropriate treatment for many types of p a t i e n t s - f o r example, schizophrenics who need much more than just medication, and patients with personality disorders who need not just psychotherapy, but also medication. They cite Klerman and Weissman's work(25), which ~should have set a more balanced stage by showing the additive effects of pharmacotherapy and psychotherapy." Until more treatment studies provide more definitive data, clinical wisdom remains our best treatment guide, one which should continue to guide us as new research findings emerge.
CONCLUSIONS I have touched on four current areas of controversy in the field of the personality disorders-definition, etiology, assessment, and treatment. We are seeing steady progress in each of these areas. The implications of this progress are enormous, and the interest in this area is widespread, not just among psychiatric health professionals or among patients and their families and friends, but also among the public at large. In spite of overwhelmingly important need to continue and further research in major areas such as schizophrenia and the affective disorders, there is also a tremendous amount of disability,
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personal distress, and public health expense as a result of the personality disorders. I hope I am correct in believing that not only is this being increasingly appreciated, but that significant advances are well under way.
REFERENCES 1. The Harvard Medical School Mental Health Letter, vot. 4 number 3:1-4, 1987. 2. Cloninger CR: A systematic method for clinical description and classification of personality variants. Archives of General Psychiatry 44:573-588, 1987. 3. Morey L, Waugh M, Blashfield R: MMPI scales for DSM-III personality disorders: their derivation and correlates. Journal Personality Assessment 49:245-251, 1985. 4. Widiger T, Francis A: The DSM-III personality disorders. Archives of General Psychiatry 42:615-623, 1985. 5. Oldham JM: DSM-III personality disorders: assessment problems. Journal of Personality Disorders 1(3):241-247, 1987. 6. Loranger A, Susman V, Oldham J, et ah The personality disorder examination: a preliminary report. Journal of Personality Disorders 1:1-13, 1987. 7. Thomas A, Chess S: The Dynamic of Psychological Development. New York, Brunner/ Mazel, 1980. 8. Thomas A, Chess S: Temperament and Development. New York, Brunner/Mazel, 1977. 9. Suomi S: Response styles in monkeys: experimental effects, in Biologic Response Styles: Clinical Implications. Edited by Klar H, Siever LJ. Washington, American Psychiatric Press, 1985. 10. Cooper AM: Will neurobiology influence psychoanalysis? American Journal of Psychiatry 142:1395-1402, 1985. 11. Kandel ER: From metapsychology to molecular biology: explorations into the nature of anxiety. American Journal of Psychiatry 140:1277-1294, 1983. 12. Pardes H: Neuroscience and psychiatry: marriage or coexistence? American Journal of Psychiatry 143:1205-1212, 1986. 13. Reiser M: Toward a Convergence of Psychoanalysis and Neurobiology. New York. Basic Books, 1984 14. Hirschfeld R, Klerman G, Clayton P, et ah Assessing personality: effects of the depressive state on trait measurement. American Journal of Psychiatry 140:695-699, 1983. 15. Ames-Frankel J, Devlin MJ, Walsh BT, et al: Personality disorder diagnoses in patients with bulimia nervosa: clinical correlates and changes with treatment. Journal of Clinical Psychiatry (53:90-96, 1992). 16. Spitzer RL, Endicott J: Schedule for Affective Disorders and Schizophrenia (SADS) (3rd ed.) New York: Biometrics Research, New York State Psychiatric Institute, 1978-79. 17. Spitzer RL: Psychiatric diagnosis: are clinicians still necessary? Comprehensive Psychiatry 24:399-411, 1983. 18. Skodol AE, Rosnick L, Kellman, et al: Validating structured DSM-III-R personality disorder assessments with longitudinal data. American Journal of Psychiatry 145:1297-1299, 1988. 19. Oldham JM, Clarkin J, Appelbaum A, et ah Identity, defenses, and reality-testing in borderlines, in The Borderline: Current Empirical Research. Edited by McGlashan T. Washington, American Psychiatric Press, Inc., 1985. 20. Stangl D, Pfohl B, Zimmerman M, et al: A structured interview for the DSM-HI personality disorders. Archives of General Psychiatry 42:591-596, 1985. 21. Liebowitz M, Stone M, Turkat DA: Treatment of personality disorders, in Psychiatry Update. Edited by Francis A, Hales R. Washington, APA Annual Review Vol. 5, 1986.
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22. Smith ML, Glass GV, Miller T: The Benefits of Psychotherapy. Baltimore. Johns Hopkins University Press, 1980. 23. Auchincloss J, Michels R: Psychoanalytic theory of character, in Personality Disorders. Edited by Frosch J. Washington, American Psychiatric Press, 1983. 24. Gunderson JG, Pollock WS: Conceptual risks of the Axis I-II division, in Biological Response Styles: Clinical Implications. Edited by Klar H, Siever L. Washington, American Psychiatric Press, 82-95, 1985. 25. Klerman GI, DiMascio A, Weissman MM, et al: Treatment of depression by drugs and psychotherapy. American Journal of Psychiatry 131:186-191, 1974.
