In the last two decades, the study of personality and its disorders has become central to the study of abnormal psychology. Chapter 1 introduces the emergence of this new discipline by analyzing the constructs of personality and personality disorders, by comparing and contrasting the basic assumptions that underlie approaches to these constructs, and by presenting the fundamentals of the classical perspectives on personality, which are essential to the understanding of the clinical chapters that follow. The word personality is derived from the Latin term persona, originally representing the theatrical mask used by ancient dramatic players. Today, personality is seen as a complex pattern of deeply embedded psychological characteristics that are expressed automatically in almost every area of psychological functioning. That is, personality is viewed as the patterning of characteristics across the entire matrix of the person. Personality is often confused with two related terms, character and temperament. Character refers to characteristics acquired during our upbringing and connotes a degree of conformity to virtuous social standards. Temperament, in contrast, refers not to the forces of socialization, but to a basic biological disposition toward certain behaviors.
Understanding personality disorders requires an understanding of their role in the study of abnormal behavior. Diagnostic criteria are the defining characteristics used by clinicians to classify individuals within a clinical category. Each disorder has its own unique list. In general, the list of criteria for the personality disorders runs either seven, eight, or nine items, each of which details some characteristic trait, attitude, or behavior strongly related to that particular disorder. A personality trait is a long-standing pattern of behavior expressed across time and in many different situations. Where many such personality traits typically occur together, they may be said to constitute a personality disorder. When all of these characteristics are taken together, they constitute a personality prototype.
The mental disorders in the DSM are grouped in terms of the multiaxial model. Each axis represents a different kind or source of information. The multiaxial model exists because some means is required whereby the various symptoms and personality characteristics of a given patient can be brought together to paint a picture that reflects the functioning of the whole person. The multiaxial model is divided into five separate axes, each of which gets at a different source or level of influence in human behavior. Axis II, the personality disorders, provides both a substrate and context for understanding the symptoms of Axis I. Every personality style is also a coping style, and personality is a cardinal organizing principle through which psychopathology should be understood.
Normality and abnormality cannot be distinguished on a completely objective basis. Normality and pathology usually reside on a continuum. Personality disorders do seem to be characterized by three pathological characteristics. First, personality disorders tend to exhibit a tenuous stability, or lack of resilience, under conditions of stress. Second, personality-disordered subjects are adaptively inflexible. Disordered personalities create vicious cycles by repeating their pathology again and again.
In personality, the dominant perspectives are psychodynamic, biological, interpersonal, and cognitive. Biological influences on personality may be thought of as being either proximal or distal. Distal influences originate within our genetic code and often concern inherited characteristics transmitted as part of the evolutionary history of our own species. Other biological influences in personality focus on proximal causes, influences that exist because we are complex biological systems. When the structures that underlie behavior differ, behavior itself is affected. Two such concepts important to personality are constitution and temperament.
The word temperament came into the English language in the Middle Ages to reflect the biological soil from which personality develops. Temperament is an underlying biological potential for behavior, seen most clearly in the predominant mood or emotionality of an individual and in the intensity of his or her activity cycles. As such, it refers to the sum total of inherited biological influences on personality that show continuity across the life span. 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. Constitution refers to the total plan or philosophy on which something is constructed. The foremost early exponent of the constitutional 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.
More recently, neurobiological models have been proposed by Cloninger (1986, 1987b), as well as by Siever and Davis (1991). Cloninger's model is based on the interrelationship of three genetic-neurobiologic trait dispositions, each of which is associated with a particular neurotransmitter system: dopaminergic, serotonergic, or noradrenergic. Each is hypothesized to dispose the individual toward a different type of behavioral tendency. Siever and Davis suggest a psychobiological model consisting of four dimensions—cognitive/perceptual organization, impulsivity/aggression, affective instability, and anxiety/inhibition—each of which has both Axis I and Axis II manifestations.
The most distal influence in personality is genetics. 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. The evidence for a genetic influence on personality is strongest for antisocial and schizotypal personality disorders. Other evidence suggests that the paranoid and schizoid personality disorders may be linked genetically with schizophrenia. A 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.
Of all the classical perspectives on personality, the psychoanalytic is perhaps the most conceptually rich. Sigmund Freud, the father of psychoanalysis, was born in 1856. Freud's first theory of neuroses emerged from his work with hypnosis and referred to the idea that behind every neurotic conflict lies a forgotten childhood trauma. The memories of that trauma 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. Eventually, Freud elaborated his insights into 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: the unconscious, the preconscious, and conscious awareness. Later, Freud developed a structural model of the mind constituted by the id, consisting of the basic survival instincts and drives; the ego, which develops to mediate between the demands of the id and the constraints of external reality; and the superego, which represents the internalized social values of caretakers. The id works on the basis of the pleasure principle, whereas the ego works on the reality principle. Breaking moral codes results in feelings of guilt, while 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.
The workings of the id, ego, and superego produce different types of anxiety, which is a signal to the ego that something must be done. In time, Freud and his disciples discovered the defense mechanisms. Although every individual uses a variety of defenses, each personality disorder seems to prefer a particular subset of defense over the others. These can be used to construct a defensive profile that illustrates how that personality disorder protects itself from internal and external sources of anxiety, stress, and challenge.
According to Freud, personality develops through a series of five psychosexual stages. Over the course of normal maturation, each psychosexual stage naturally gives way to the next, presenting the individual with a sequence of maturational challenges. In the psychodynamic perspective, character has a technical meaning, referring to the way in which the ego habitually satisfies the demands of the id, superego, and environment. Since the study of personality begins with the psychodynamic study of character, many of the personality disorders have direct characterological counterparts. As later analytic writers became interested in the relationship among character, defense, interpersonal conduct, and cognitive style, the relationship between character and personality has grown even stronger.
The final stage in the development of the psychodynamic perspective is called object relations. Every instinct has an aim and an object. The aim is always the satisfaction of instinctual desires. The object is something in the outside world through which this aim can be achieved. For Freud, the id instincts formed the basis of human nature. In contrast, modern object relations theory is simultaneously cognitive and interpersonal, emphasizing first, that the outside world is known through mental representations or internal working models, and second, that the contents of these models are interpersonal, being developed largely during early childhood from experiences with caretakers and significant others, prior even to the development of self-awareness. The foremost object relations thinker in the personality disorders is Kernberg, who advocates classifying various personalities, some from the DSM and some from the psychoanalytic tradition, in terms of three levels of structural organization—psychotic, borderline, and neurotic— which represent degrees of organization or cohesiveness in the personality.
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