Personality disorders |
To what extent are personality disorders hypothetical constructs? Discuss with particular reference to aetiology and treatments for TWO personality disordersAs its name suggests, a personality disorder is a problem rooted in personality. Unlike some other classes of psychological disorder, a personality disorder is seen as something inherent or internal in a person, rather than a result of something that has happened to them. As a result its aetiology is analysed in the same vein as that of personality: genetics, the family peer groups and random life events. Personality disorders are formally defined in the Diagnostic and Statistical Manual (DSM). The DSM-IV (APA, 2000) lists ten different types of personality disorders, which fall into three clusters: odd/eccentric, dramatic/emotional/erratic and anxious/ fearful. This typology of personality disorders has long been considered controversial and perhaps this is a direct result of the failure of the classifications to be made on an empirical basis. There is now a large weight of empirical evidence that suggests these classifications of personality are not providing valid or even useful delineations of psychological disorders. In order to analyse this evidence, two personality disorders, borderline personality disorder and paranoid personality disorder, as defined within the DSM-IV (APA, 2000), will be briefly introduced and then the evidence surveyed.
 The diagnostic criteria for borderline personality disorder (BPD) are described in the DSM-IV as including unstable interpersonal relationships, an unstable self-image and an overall marked instability. One of the clearest diagnostic criteria is a fear of abandonment. This links into the BPD client's lack of a sense of self-worth. The client may also suffer from rapid mood-swings and may often be very difficult to deal with in a therapeutic situation. Like all of the personality disorder, BPD is considered very difficult to treat because the sufferer will not often realise or acknowledge that they have a problem. It is often argued, especially by those working from a cognitive behavioural perspective, that the roots of BPD lie in core beliefs obtained during childhood (Grant, 2004). Core beliefs considered 'normal' allow people to view the world and themselves in a balanced way with the requisite flexibility. A person is continually subjected to a range of both negative and positive attitudes towards the self that require balancing. In contrast, those with BPD are likely to have obtained negative messages about themselves from their parents and consequently are unable to balance the positive and negative attitudes coming from people around them. Cognitive Therapy will concentrate on helping sufferers combat these negative belief and indeed the negative beliefs that they are bound to have about the process of therapy and the therapist (Beck & Freedman, 1990).
As the title of paranoid personality disorder (PPD) suggests, this type is characterised by pattern of extremely distrustful behaviour towards others. The DSM-IV describes people suffering from this disorder as likely to appear cold, objective and rational, while often displaying hostile, sarcastic and stubborn behaviours. People with PPD are likely to suspect the worst of other people, in other words that other people will attempt to harm, deceive or betray them. As a result of this they find it very difficult to form close personal ties as trust is an important component of a healthy relationship. In addition, because of their distrustful behaviour they tend to provoke hostility in other people towards themselves. In treating PPD through cognitive therapy, Beck & Freedman (1990) assert that one of the most important aspects is gaining the trust of the individual. People with PPD are likely to have grown up in environments in which they received a large amount of criticism. Consequently it will be important not to challenge their beliefs too directly as this could be seen as an attack on themselves. Progress in treating this disorder is likely to be slow. Both of these thumbnail sketches of two personality disorders are, by necessity, extremely brief, and make the symptoms sound as though they are categorical and absolute. This closely reflects how they are described in the DSM-IV and how they are meant to be interpreted. The empirical evidence has shown that the ideas of strict categorical boundaries are, in some cases, quite far removed from reality. One of the main criticisms of the construct of personality disorders is built on empirical studies carrying out factor analysis of the criteria for each disorder. Researchers here are looking at the discriminant validity of the categories, or in other words, they are asking whether there is really any significant difference between the categories. Research such as Clark, Livesley & Morey (1997) in their review of the data, have shown that the discriminant validity of the categories is often low. Similarly, the same kind of scepticism operates at all levels of the DSM categories, including the three clusters of personality disorders. The clustering of the personality disorders might suggest that there is some commonality between the disorder within the clusters, and therefore, there may be some blurring of the distinctions. Costa & Widiger (1994) report on previous evidence of factor analysis of the symptoms of the personality disorders and found that in fact there was justification for four separate clusters of disorders (Hyler & Lyons, 1988) instead of the three axes in the DSM-IV. This is one line of empirical evidence that points to the idea that personality disorders may, indeed, be mere hypothetical constructs, rather than solid categories. Another clue that the categories are not as rigid as claimed is contained in studies that examine commorbidity. Several of these have found that people who receive one diagnoses of a personality disorder will often receive another diagnosis of a personality disorder (Westen & Shedler, 2000). This is further evidence that the personality disorders are not discrete. Quite apart from questions of which category people fit into, is the question of whether they fit into any category at all. In Westen & Arkowitz-Westen's (1998) survey of clinicians currently treating neurotic individuals they found that fully 60% of the patients could not currently be categorised under the DSM-IV. Some parts of the each category may fit with a particular person, for example in the case of BPD, the person may display a genuine fear of abandonment, but none of the other symptoms fit with the categorical construct. How is this person to be diagnosed? Does this person have a genuinely 'personality disorder'? Conceptually, the categories of personality disorders are not based on solid ground. According to the DSM-IV, the theoretical discrimination of the categories is supposed to use cognition, emotion, interpersonal functioning and impulse control as its basis. Unfortunately the criteria provided for each of the personality disorders do not realistically address each of these different areas in enough detail. On top of this, there is no single theoretical basis on which the personality disorders are categorised. It is starting to become clear that part of the problem in attempting to describe a person in terms of categories is that it's very difficult to fit the personality problems that present to a clinician in a limited set of categories. Not only that, it can be positively misleading. Also, there is a need for conceptual coherence in the categorisation of personality disorders - some organising principle. What answers, then, have been proposed to this problem? What is clear from the attempt to create a classification of personality disorders is that there are two fundamental questions: what factors can be clustered together in order to describe a type of disorder and what individual differences might there be? This has suggested to many researchers parallels with personality theory. One of the primary conceptual problems, that of having categories, is dealt with in personality theory by the use of dimensions or spectrums of each trait. This idea immediately raises the question of how many dimensions should be posited. There have been a number of attempts to create a satisfactory model with a dimensional structure, mostly using factor analysis. For example Cloninger (1994) proposed a model comprising three character dimensions of self-directedness, cooperativeness and self-transcendence, with four temperament dimensions of reward dependence, harm avoidance, novelty seeking and persistence. Costa & Widiger (1994) however, are critical of this model, as well as other variations, and are the main proponents of applying the Five Factor Model (FFM) of personality dimensions to personality disorders. The FFM is born out of a long history in personality psychology of the analysis of traits that has produced five top level factors. It is claimed that its dimensions describe everyone's personality. Presenting their evidence built up in a series of studies, they show how the FFM consistently correlates particular factors across different samples. For example BPD can be seen as an excessively high level of neuroticism in the FFM. An immediate conceptual advantage of considering personality disorders on a number of dimensions is that it provides answers to a number of the questions raised in the empirical evidence. Commorbidity for example can be seen as a result of the sharing of high levels on some of the personality factors. Many of the personality disorders have in common high levels of neuroticism, the differentiation between them can be seen in the other personality dimensions. One of the other main advantages of using the FFM is in realigning the way personality disorders are seen, in that they then become part of the spectrum on which normal personality is seen. In this way personality disorders are connected with 'normal' personalities and become more humanised. While the FFM approach has provided a useful alternative to describing personality disorders, some researchers have valid criticisms. Clark (1993a) has suggested that the FFM approach has only provided mixed results, claiming that only some of the dimensions are related. In order to address some of these concerns, a different series of dimensions was built from the ground up. This contains three top level dimensions of negative temperament, positive temperament and disinhibition. Morey, Warner, Shea, Gunderson, Sanislow, Grilo, Skodol & McGlashan (2003) later tested these ideas by applying a personality test based on these dimensions to patients who had already been diagnosed with one of five primary diagnoses. The results showed that this model, like the FFM approach had some use in discriminating the personality disorders. A fundamental aspect of personality disorders is that their aetiology is presumed to be of psychosocial origin rather than of biological origin. Livesley, Schroeder, Jackson, & Jang (1994) (as cited in Farmer, 2000) questions whether this is, in fact the case. They argue that the evidence shows that personality disorders have both psychosocial and biogenetic origins. In addition they also question the assumption that personality disorders are enduring and lifelong conditions as opposed to other psychological disorders which are deemed transient and variable. This has a significant impact in the treatment of these kinds of disorders - perhaps, contrary to assumptions that arise from categorical construct - the cause is not hopeless after all? Conceptually as well, this is important, as with many psychological aspects, it is very difficult to separate the different factors like environment from genetic factors as the two are certain to interact (Weston & Shedler, 2000). Much of evidence suggests that personality disorders as defined in the DSM-IV are hypothetical constructs, adopted for the convenience of having particular categories, rather than being based on the empirical evidence. Indeed in an international survey of psychologists and psychiatrists the majority were dissatisfied with the concept of personality disorders (Maser, Kaelber, & Weise, 1991). Perhaps the rise of these personality disorders are an attempt to label behaviour that is out of line with societal norms as somehow deviant. Whatever the cause of the rise of these labels, it is clear that there is an urgent need for the revision of these categories, to more accurately reflect the people who are presenting to clinicians. The use of the trait dimensions seems like a good alternative solution - whether it is using the FFM or developing an alternative with the help of practicing clinicians. In doing so the empirical evidence that psychologists have built up is used to analyse a range of disorders which psychiatrists have traditionally analysed in categorical fashion. The hypothetical construct of categories may still be useful as a shorthand for discussion but should be brought together with dimensional traits into a hybrid system (Weston & Shedler, 2000).
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