Major Theories of Personality Disorder, Second Edition

People with personality disorders share an uneasiness in their own skin. There are no birds here with deployed plumage flying toward the silvery tree (1), only women and men “each unhappy…in [his or her] own way” (2) . They may feel aimless or ashamed, disgraced or doubtful, empty or envious, fearful of others or insatiably needing them. They may forever search for figures to admire while also being unable to commit to life-long goals, nurturing relationships, intimacy, and the pursuit of meanings. They may try to divine what life holds for them through magical signs from far-away planets and galaxies. They may be hesitant or impulsive, or unstable, needing constant admiring recognition, or they may entirely lack feelings for others and become social outcasts. Their lack of ease thus interferes with their human relationships and their creative, productive activities. Indeed, they may well feel like Huraki Murakami’s Frog: “What you see with your eyes is not necessarily real. My enemy is, among other things, the me inside me. Inside me is the un-me” (3) .

Ultimately, theories of disordered personalities are hypotheses—working models—of the pathogenic sources and developmental evolution of these persons’ affects, behavior, perception of self or others, of their anguish, as well as of potential ways to relieve their inordinate malaise and enable them to alter their unsuccessful adaptation to life.

In this second edition of Major Theories of Personality Disorder, the editors, Dr. Mark Lenzenweger and Dr. John Clarkin, two distinguished authorities in personality disorder research, have assembled a group of recognized leaders in their respective fields to present a rich collection of different perspectives on these disturbances. The current edition has two new points of view added to those represented in the earlier version. The senior authors of the other chapters are the same as in the 1996 edition. References are complete through 2003, with occasional 2004 citations.

In the introductory chapter, The Personality Disorders, the editors confront the following significant issues: 1) the controversial nature of categorical versus dimensional conceptualizations of personality disorder diagnostic features; 2) the high degree of overlap among currently defined axis II personality disorders; 3) the absence of published data derived from a large sample of carefully assessed cases in which individual criterion items confirm our current DSM-IV-TR disorder structure; 4) the lack of long-term stability in actual patients of the current criteria of personality disorders; and, finally, 5) the lack of a “gold standard” of validity against which personality disorder diagnoses could be measured.

This introduction is followed by in-depth discussions of seven major theories of personality disorders.

“A Cognitive Theory of Personality Disorders” is presented by Dr. James L. Pretzer and Dr. Aaron T. Beck. The discussion of goals, principles, process, assessment instrumentation, and treatment, including a three-page section on Future Directions, is unchanged from that in the first edition of this volume. New material is only in the seven pages covering validity and effectiveness. Among the 106 references cited, only seven date since 1996. A difference between cognitive therapy and dialectical behavior therapy is alluded to but not discussed.

The following chapter, “A Psychoanalytic Theory of Personality Disorders,” by Dr. Otto Kernberg and Dr. Eve Caligor, is a creative, lucid, updated conceptualization and retelling of Dr. Kernberg’s seminal and broadly based contributions to the field of personality organization and of personality disorders. Although Dr. Kernberg has told the details of his theory—that such patients have disorders of self-object relations—many times with great vigor, persuasive capacity, and passion—starting first with his 1967 article on Borderline Personality Organization (4) —the authors’ narrative here is fleshed out with a myriad of details that posses immediacy, emotional power, and resonance, including a discussion of temperament, of inborn activation thresholds for both rewarding and aggressive affects, and of the capacity for “effortful control.” Dr. Kernberg has originated a structural interview to evaluate personality organization and has developed, together with his collaborators, a specific approach for the treatment of patients with severe personality disorders, expressive, transference-focused psychotherapy (TFP-B) (5), as well as an approach for individuals with neurotic personality organization (TFP-N) (6), both of which are briefly described in this chapter. The authors integrate their theory with those of Margaret Mahler, on pre-oedipal separation-individuation and object constancy (p. 125), and of developmentalists like Daniel Stern, on inborn capacities for differentiation of self from non-self and the cross-modal transfer of sensorial experiences in early infancy to construct a model of self (p. 123).

The chapter on attachment-based Interpersonal Theory of Personality Disorders, using a structural analysis of social behavior (SASB) to undertake interpersonal reconstructive therapy (IRT), has been completely and very successfully re-written for this edition by Dr. Lorna Smith Benjamin. With such concepts as free associative path and internalized representations on the one hand, and learned interpersonal patterns and gifts of love on the other, it pays homage to both its psychoanalytic and cognitive behavioral therapeutic antecedents, but draws on optimally effective interventions from many schools of psychotherapy. According to Dr. Benjamin, most of the goals described in the 1996 version of this chapter have been achieved; a treatment manual and software have been published.

In a related chapter entitled “A Contemporary Integrative Interpersonal Theory of Personality Disorders,” new to the current edition, Dr. Aaron Pincus describes “individual differences in personality disorder phenomenology through the structural models, operational definitions, and empirical methods of the interpersonal tradition” (p. 316). Analysis of social behavior on the Interpersonal Circle allows him, for instance, to distinguish valuably between two forms of narcissism: the grandiose and the hypersensitive, closet narcissist. Overall, a tremendous effort is expended on rather mechanical taxonomy: the accountancy, classification, and quantification of phenomenology, less on clinical interpretation or personal meaning of instantaneously observed behavior.

Missing at this juncture is, surprisingly, a chapter on Heinz Kohut’s perspective on narcissistic personality disorders as resulting from a developmental arrest caused by early traumatization from chronically failing attitudes of early caregivers. According to Kohut, and self-psychologists in general, under such circumstances the therapist’s difficult rehabilitative task is to recognize the patient’s inevitable feelings of unmet expectations and to interpret, hopefully to resolve, these reactivated narcissistic needs within the framework of the idealizing and mirroring transferences these individuals develop (7) .

The chapter entitled “An Attachment Model of Personality Disorders,” by Dr. Björn Meyer and Dr. Paul Pilkonis, is an important new addition to the current edition. They discuss Bowlby’s work on the attachment behavioral system, Ainsworth and colleagues’ discovery of distinct infant attachment patterns—secure, ambivalent, and avoidant—as causal factors in the development of personality disturbances and the complex evidence for the role attachment disturbances can play in the etiology and maintenance of personality pathology. They conclude sensibly that insecure attachment should be viewed as a risk factor, but not as an absolute determinant of adult personality disturbances.

In the chapter “Personology: A Theory Based on Evolutionary Concepts,” Dr. Theodore Millon and Dr. Seth D. Grossman describe their creation of a clinical taxonomy, linked to assessment instruments, and their synergistic model of psychotherapy as “a psychologically designed composite and progression among diverse techniques” (p. 385), e.g. behavior modification procedures, cognitive methods, followed by interpersonal techniques. They memorably consider each DSM disorder a “‘pure prototype’…an anchoring referent about which ‘real patients’ vary” (p. 375).

The final daunting and provocative chapter of this volume, “A Neurobehavioral Dimensional Model of Personality Disturbances,” by Dr. Richard A. Depue and Dr. Mark F. Lenzenweger, examines the neurobiology of anxiety, impulsivity, and aggression as they relate to higher-order neurobehavioral systems, personality traits, and personality disturbances. The authors “conceive of personality disturbance as emergent phenotypes arising from the interaction of…neurobehavioral systems underlying major personality traits” (p. 436). They have created a multidimensional visual model of personality disturbance, the three axes of which “are defined by neurobehavioral systems rather than traits” (p. 436): 1) behavioral approach on the vertical y-axis, 2) affiliative reward on the z-axis, and 3) neural constraint on the horizontal x-axis. Within this three-dimensional model “the phenotypical expression of personality disturbance represented by the… reaction surface in the figure…is continuous in nature, changing in character gradually but seamlessly across the surface in a manner that reflects the changing product of the multidimensional interactions…[T]he magnitude of disturbance at any point of the surface is variable, waxing and waning with fluctuations in environmental circumstances, stressors, and interpersonal disruptions…over time” (p. 437). I cannot even begin to do justice in this space to the authors’ uncanny articulation of the subject’s complex, sophisticated details.

These cutting edge essays allow the post-postmodern psychiatrist to view personality disorders through various windows; to choose a paradigm; to decide what he or she needs to listen for, perceive, and comprehend; to use, whenever necessary, “impure interventions” culled from other modes of understanding; and, finally, to hone his or her own voice. Reading this illuminating volume, then consulting it again, will serve that purpose.