Gender Bias in the Diagnosis of Personality Disorders Do Clinicians Have Gender Expectations

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Do certain personality disorders favor men and others favor women? The answer may depend on where you look. Because more women than men seek treatment for mental disorders, there are usually more women among the patients in mental health centers. Conversely, because more men than women are veterans, you would expect more male patients at Veterans Administration hospitals.

Nevertheless, certain personality disorders do seem weighted toward a particular gender. For some researchers (Kaplan, 1983; Pantony & Caplan, 1991), these discrepancies in diagnostic frequency, particularly in the larger number of females diagnosed borderline, dependent, and histrionic, are inherently sexist. However, although the DSM-IV agrees that these three are more frequently diagnosed in women, it also states that the paranoid, schizoid, schizotypal, antisocial, narcissistic, and obsessive-compulsive are more frequently diagnosed in men. If there is a bias, then, it would appear to go against the males.

One problem that creates bias is that certain diagnostic criteria seem to refer to both normalcy and pathology. Most people would argue that the histrionic criterion "consistently uses physical appearance to draw attention to self," for example, is exceptionally ambiguous in a society where a pleasing physical appearance is an expected part of the female gender role. Accordingly, where subjects have several traits of the histrionic personality, it is possible that clinicians might simply assume that this ambiguous criterion is met. Widiger (1998) argues that the more unstructured the interview situation, the more likely it is that clinicians will rely on sex stereotypic bias when diagnosing.

Even where diagnostic criteria are not ambiguous, it may nevertheless prove difficult to apply them equally across the sexes. The criteria for the dependent personality, for example, seems to emphasize as pathological female types of dependency, but fails to include masculine types of dependency. For example, Walker (1994, p. 36) argues that "men who rely on others to maintain their homes and take care of their children are . . . expressing personality-disordered dependency." Were this criterion added, many more men would certainly be diagnosed dependent.

Future DSMs must profit from these considerations if diagnostic criteria are to be devised that can replace implicit sex-stereotypic conceptions to be valid for both genders.

or emotionality of individuals and in the intensity of their activity cycles. Although A. H. Buss and Plomin (1984, p. 84) refer to it as consisting of "inherited personality traits present in early childhood," we might argue that temperament is the sum total of inherited biological influences on personality that show continuity across the life span. A case can certainly be made that temperament is more important than other domains of personality and more pervasive in its influence. Because our physical matrix exists before other domains of personality emerge, biologically built-in behavioral tendencies preempt and exclude other possible pathways of development that might take hold. Thus, although an irritable, demanding infant may mature into a diplomat famous for calmly understanding the issues on all sides, the odds are stacked against it. Similarly, a child whose personal tempo is slower than average is unlikely to develop a histrionic style, and an unusually agreeable infant is unlikely to develop an antisocial personality. Thus, biology does not determine our adult personality, but it does constrain development, channeling it down certain pathways rather than others, in interaction with social and family factors.

The doctrine of bodily humors posited by the early Greeks some 25 centuries ago was one of the first systems used to explain differences in personality. In the fourth century B.C., Hippocrates concluded that all disease stems from an excess of, or imbalance among, four bodily humors: yellow bile, black bile, blood, and phlegm. These humors were the embodiment of earth, water, fire, and air, the declared basic elements of the universe according to the philosopher Empedocles. Hippocrates identified four basic corresponding temperaments: choleric, melancholic, sanguine, and phlegmatic. Centuries later, Galen would associate each temperament with a particular personality trait; the choleric temperament was associated with irascibility, the sanguine temperament with optimism, the melancholic temperament with sadness, and the phlegmatic temperament with apathy. Although the doctrine of humors has been abandoned, giving way to the study of neurochemistry as its contemporary analogue, the old view still persists in contemporary expressions such as being sanguine or good-humored.

Constitution

Constitution refers to the total plan or philosophy on which something is constructed. The foremost early exponent of this approach was Ernst Kretschmer (1926), who developed a classification system based on three main body types—thin, muscular, and obese—each of which was associated with certain personality traits and psychopathologies. According to Kretschmer, the obese were disposed toward the development of manic-depressive illness, and the thin toward the development of schizophrenia. Kretschmer also believed that his types were associated with the expression of normal traits. Thin types were believed to be introverted, timid, and lacking in personal warmth, a less extreme version of the negative symptoms exhibited by withdrawn schizophrenics. Obese persons were conceived as gregarious, friendly, and interpersonally dependent, a less extreme version of the moody and socially excitable manic-depressive.

Kretschmer's work was continued by Sheldon (1942), who saw similarities between the three body types and the three basic layers of tissue that compose the embryo: ectoderm, mesoderm, and endoderm. The endoderm develops into the soft parts of the body, the mesoderm eventually forms the muscles and skeleton, and the ectoderm forms the nervous system. Each embryonic layer corresponds to a particular body type and is associated with the expression of certain normal-range personality characteristics. Accordingly, endomorphs, who tend toward obesity, were believed to be lovers of comfort and to be socially warm and goodwilled. Mesomorphs, who usually resemble athletes, were believed to be competitive, energetic, assertive, and bold. Ectomorphs, who tend toward thinness, were believed to be introversive and restrained but also mentally intense and restless. Although interesting, the idea of body types is no longer influential in personality theory. Rather than study the total organization of the body, researchers have begun to examine the role of individual anatomical structures in detail, many of which lie in the human brain.

Neurobiology

Research psychiatrist Cloninger (1986, 1987b) proposed an elegant theory based on hypothesized relationships of three genetic-neurobiologic trait dispositions, each of which is associated with a particular neurotransmitter system. Specifically, novelty seeking is associated with low basal activity in the dopaminergic system, harm avoidance with high activity in the serotonergic system, and reward dependence with low basal noradrenergic system activity. Novelty seeking is hypothesized to dispose the individual toward exhilaration or excitement in response to novel stimuli, which leads to the pursuit of potential rewards as well as an active avoidance of both monotony and punishment. Harm avoidance reflects a disposition to respond strongly to aversive stimuli, leading the individual to inhibit behaviors to avoid punishment, novelty, and frustrations. Reward dependence is seen as a tendency to respond to signals of reward, verbal signals of social approval, for example, and to resist extinction of behaviors previously associated with rewards or relief from punishment. These three dimensions form the axes of a cube whose corners represent various personality constructs (see Figure 1.5). Thus, antisocial personalities, who are often seen as fearless and sensation seeking, are seen as low in harm avoidance and high in novelty seeking, whereas the imperturbable schizoid is seen as low across all dimensions of the model. The personality disorders generated by Cloninger's model correspond only loosely to those in the DSM-IV. A number of personality disorders do not appear in the model at all.

A different approach, proposed by Siever and Davis (1991), is termed a psychobio-logical model. It consists of four dimensions—cognitive/perceptual organization, impul-sivity/aggression, affective instability, and anxiety/inhibition—each of which has both Axis I and Axis II manifestations. Thus, cognitive/perceptual organization appears on Axis I in the form of schizophrenia and on Axis II especially as the schizotypal personality disorder but also the paranoid and the schizoid. All exhibit a disorganization of thought, dealt with by social isolation, social detachment, and guardedness. Impulsiv-ity/aggression appears on Axis I in the form of impulse disorders and on Axis II particularly as the borderline and antisocial personalities. Borderlines are prone to sudden outbursts of anger and suicide attempts, and antisocials are unable to inhibit impulsive urges to violate social standards, for example, stealing and lying. Affective instability, a tendency toward rapid shifts of emotion, is manifested in the affective disorders on Axis I and in the borderline, and possibly histrionic, on Axis II. Anxiety/inhibition, associated with social avoidance, compulsivity, and sensitivity to the possibility of danger and punishment, is manifested in the anxiety disorders on Axis I and particularly in the avoidant personality on Axis II, but also in the compulsive and dependent.

Heredity

Genetics is a distal influence on personality. Researchers explore the influence of genes on behavior by searching for the presence of similar psychopathologies in siblings and relatives of an afflicted subject, by studying patterns of transmission across generations of the extended family, and by comparing the correlation of scores obtained on personality tests between sets of fraternal twins and identical twins reared together and apart. Other esoteric methodologies are also available, including structural equation modeling (Derlega, Winstead, & Jones, 1991) and Multiple Abstract Variance Analysis (Cattell, 1982). A comparison of correlations for identical twins reared together and apart shows that both are approximately equal, running at about 0.50 across a variety of personality

Cloninger Model

FIGURE 1.5 Cloninger's Neurobiological Model of Personality Disorders.

FIGURE 1.5 Cloninger's Neurobiological Model of Personality Disorders.

traits (Bouchard, Lykken, McGue, Segal, & Tellegen, 1990). Even measures of religious interests, attitudes, and values have been shown to be highly influenced by genetic factors (Waller, Kojetin, Bouchard, Lykken, & Tellegen, 1990).

Studies of the heritability of the personality disorders have been less definite. Trait researchers can avail themselves of large samples of normal subjects, but the sample sizes generated by personality disorders are comparatively small and highly pathological in comparison to normal samples, which can distort correlational statistics. Moreover, because personality disorders exist as overlapping composites of personality traits, genetic-environmental interactions are much more complex than for single traits alone. In a review of the evidence, Thapar and McGuffin (1993) argue that the evidence for heritability is most strong for antisocial and schizotypal personality disorders. In another review, Nigg and Goldsmith (1994) suggest that the paranoid and schizoid personality disorders may be linked genetically with schizophrenia. Another popular genetic hypothesis is that the wild emotional swings of the borderline personality are evidence of its association with the affective disorders, which include depression and manic-depression.

Livesley, Jang, Jackson, and Vernon (1993) sought to examine the heritability of 18 dimensions associated with personality disorder pathology, as assessed by the Dimensional Assessment of Personality Pathology (Livesley, Jackson, & Schroeder, 1992). They found that the dimensions of anxiousness, callousness, cognitive distortion, compulsiv-ity, identity problems, oppositionality, rejection, restricted expression, social avoidance, stimulus seeking, and suspiciousness all have heritabilities of between 40% and 60%. Because these are all facets of one or more personality disorders, their study provides indirect support that at least certain problematic traits are indeed heritable to a degree. For example, callousness is often thought of in association with the antisocial, sadistic, and narcissistic personalities, and stimulus seeking is associated with the histrionic and antisocial personalities. Cognitive distortion is associated with the schizotypal; suspicious-ness is obviously associated with the paranoid. Social avoidance is associated with the avoidant personality; oppositionality is likely associated with the negativistic personality. Other associations could also be drawn.

The Psychodynamic Perspective

Of the several classical perspectives on personality, the psychoanalytic is perhaps the most conceptually rich and yet the most widely misunderstood. Sigmund Freud, the father of psychoanalysis, was born in 1856. As the oldest child of an adoring mother whose belief in her son's destiny never flagged, Freud knew he would be famous. Naturally attracted to science and influenced by Darwin, he settled on a medical career and spent a period of time involved in pure research. Eventually, practical necessity intervened, and Freud began a more applied course, specializing in neurology and psychiatry. In 1885, he traveled to France and witnessed Jean Charcot cure a case of hysterical paralysis using hypnosis. Because the psychiatric treatments of the times were highly ineffective, Freud was impressed and began to experiment with the technique on his own, eventually developing the foundational ideas of psychoanalysis (Gay, 1988).

The Topographic Model

By the early 1890s, Freud and his friend Josef Breuer, a respected physician and original scientist in his own right, had begun to explore the use of hypnosis together. Breuer had already discovered that when subjects with hysterical symptoms talked about their problems during a hypnotic state, they often experienced a feeling of catharsis, or emotional release. Eventually, the two formed the theory that hysterical symptoms resulted from early sexual molestation, leaving memories so distressing that they were intentionally forgotten and could only be fully remembered under hypnosis. Later, Freud discovered that when these memories were completely recalled to consciousness in an emotional release, the symptoms disappeared. This became Freud's first theory of neuroses, the idea that behind every neurotic conflict lies a forgotten childhood trauma. Such memories are said to be repressed. Motivated to forget what it knows, the mind defends against the painful experiences by actively excluding them from conscious awareness. The past cannot be rewritten, but its impact can be contained. In fact, massive repression is one of the major coping strategies used by the histrionic personality, the contemporary parallel to the turn-of-the-century hysterical syndromes through which the basic principles of psychoanalysis were discovered.

Freud elaborated his insights into what is known as the topographic model, the idea that the mind has an organization or architecture that overflows consciousness and can be described in terms of different levels or compartments. At the foundation lies the unconscious, a mysterious realm consisting of everything that we cannot become aware of by simple reflection alone. According to classical psychoanalytic theory, the unconscious is the only part of the mind that exists at birth. Just above the unconscious lies the preconscious, which consists of everything that can be summoned to consciousness on command, for example, your phone number. And finally, there is the part of the mind that forms our waking lives, which we call conscious awareness. According to Freud, the desire to bring satisfaction to our unconscious instincts continues to be the main motivator in human behavior throughout the life span. By declaring the unconscious and its drives to be the origin and center of psychological existence, Freud effected a Copernican revolution against the Enlightenment rationalism that dominated the times. Behavior was not fundamentally rational; it was irrational. Just as the earth is not the center of the universe, conscious awareness is but a backwater that conceals the main currents of mental life. For this reason, the idea of making the unconscious conscious, the goal Freud and Breuer had in mind with hypnosis, is a major goal of many contemporary psychotherapies.

The Structural Model

Despite his original enthusiasm for hypnosis, in time, Freud developed additional techniques that allowed him to map the contents of the unconscious, such as free association. In doing so, he discovered an additional organizing principle, the structural model of id, ego, and superego. The id consists of the basic survival instincts and the two dominant drives of personality: sex and aggression. At birth, infant behavior is motivated by the desire for immediate instinctual gratification, which Freud referred to as the pleasure principle: I want what I want, and I want it now! In a way, the id is like a dictator that knows only how to repeatedly assert its own desires, something that makes the world a very frustrating place.

To relieve this frustration and ensure greater adaptability in the organism, a second part of the personality, the ego, develops to mediate between the demands of the id and the constraints of external reality. Whereas the id is fundamentally irrational, the ego is fundamentally rational and planful, operating on the reality principle. To be effective, the ego must perform sophisticated intellectual activities such as risk-benefit and means-ends analysis, projecting the consequences of various courses of action into the future, judging the range of possible outcomes and their respective cost and reward, all the while modifying plans and embracing alternatives as necessary.

Not every course of action that the ego might imagine is acceptable, however. Eventually, a third part of the personality emerges that internalizes the social values of caretakers, the superego. The process by which the superego forms is called introjection, which literally means "a putting inside." The superego consists of two parts, the conscience and the ego ideal: what you shouldn't do and what you should do and should become. The conscience is concerned with the morality principle, the right and wrong of behavior. In contrast, the ego ideal pulls each of us toward the realization of our unique human potentials. Breaking moral codes results in feelings of guilt; satisfying the ego ideal results in feelings of pride and self-respect.

For Freud, personality is seen as a war of attrition fought by three generals. As the executive branch of the personality, the ego must balance and mediate between constraints on all sides. On the one hand, the id, upwelling from below, is always percolating, yearning for gratification. On the other hand, the prohibitions of the superego prevent its desires from being directly satisfied. For this reason, the psychoanalytic perspective is often regarded as intrinsically pessimistic: Human beings are said to exist in a state of perpetual conflict between the needs and constraints of various parts of the personality. We can endure, but we cannot escape.

Many of the personality disorders are in exactly this situation. Avoidant personalities, for example, deeply desire close connectedness to others, but also feel a sense of shame about themselves so profound that very few such relationships are possible. Instead, avoidants retreat into a shell where they can at least be alone with their humiliating defects and deficiencies. Compulsive and negativistic personalities wrestle with issues related to the obedience versus defiance of authority. Compulsives express this conflict passively by overconforming to internalized superego demands; on the surface, they appear normal and in control, but beneath, they are taut, anxious, and ever circumspect of their own conduct. In contrast, the negativistic personality, formerly called the passive-aggressive, expresses conflict actively by vacillating between loyalty and insubordinate sabotage. Knowing the outcomes that others seek, they work subtly within the system to bring the plans of others to ruin or at least cause them great frustration. Only a subset of the antisocial personality, the psychopath, escapes conflict. Given their stunted superego development, psychopaths have no need to evaluate their actions according to some standard of right or wrong; instead, their ego is free to select any pathway to gratification that seems realistically possible, even if it includes de-ceitfulness, misconduct, or irreparable damage to the lives of others. Accordingly, they pause only when self-conscious of the raw punishment society might inflict on them because of their transgressions.

Defense Mechanisms

Because the ego is constantly trying to satisfy the impulsive demands of the id while honoring the constraints of reality and the moral constraints of the superego, awareness is always vulnerable to feelings of anxiety. On the one hand, id instincts are like barbarians at the gate, always threatening to break through ego controls and saturate behavior with raw animal forces. Awareness of this possibility produces what Freud referred to as neurotic anxiety. On the other hand, the superego demands perfection, threatening to flood awareness with guilt whenever the satisfaction of id demands is not sufficiently disguised, which Freud referred to as moral anxiety. One is a sinner; the other, a saint. Finally, threats from the external world can produce reality anxiety. If you hear on the radio that the stock market has just crashed, your concern about your investments is realistic. Whatever the source, anxiety is a signal to ego that some form of corrective action must be taken to reinforce its controls.

But how does the ego protect itself from being overwhelmed? In time, Freud and his disciples discovered the defense mechanisms. Through his studies of hysteria, Freud had already been led to the existence of the unconscious and the discovery that guilt can be transformed into a symptom. He found, for example, that uncontrollable aggressive urges might lead to a hysterical paralysis in the hand that might be used to strike someone. Although the goal is always the same—to protect the sanctity of awareness by reducing the level of perceived anxiety or threat—different defense mechanisms work in

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