Personality disorders: Contemporary Perspective

By: THEODORE MILLON et al.

The interpersonal perspective argues that personality is best conceptualized as the social product of interactions with significant others. From beginning to end, we are always trans-acting either with real or imagined others and their expectations. Personality cannot be understood from the inside out, because it is intrinsically immersed in context. Harry Stack Sullivan is regarded as the father of interpersonal perspective.

Sullivan’s contribution lay in realizing that some forms of mental disorder, while perhaps most dramatically and tangibly manifest through the individual, are nevertheless created and perpetuated through maladaptive patterns of social interaction and communication. The issue with which Sullivan struggled, the essential basis of the interpersonal approach, concerns the nature of the self. Implicitly, all of us regard the self as a thing, a concrete entity or substance with sharply defined boundaries, like a rock. If so, we should know exactly who we are all the time. According to Sullivan, that is not the case. No essential self lies hidden beneath the veils of the unconscious. Instead, there is only a self-concept that is continually being defined and redefined by the interpersonal communications of others.

After Sullivan, the next important figure in the emerging interpersonal movement was Timothy Leary, who believed that personality should be thought of in terms of levels, not unlike the psychodynamic idea of levels of consciousness: public communication, conscious description, private symbolization, attributions, unexpressed unconscious, and values. Leary also contributed to the development of the interpersonal circumplex, a figure that organizes personality constructs like the segments of a circle, which is formed by crossing the two content dimensions believed to define interpersonal communication—dominance and affiliation. Interpersonal principles map directly to the circle. According to complementarity, for example, interpersonal behavior is designed to elicit from others actions that validate the sense of who we are. Pathologically rigid individuals possess a constricted conception of self. Only a particular kind of response from others is experienced as validating, and only this kind of response is sought from interpersonal interactions. Since their needs are strong and consistent, individuals with a constricted self-concept may be experienced as controlling or coercive. The most creative contemporary development of interpersonal theory is Benjamin’s (1974, 1996) SASB.

The SASB seeks to integrate interpersonal conduct, object relations, and self-psychology in a single geometric model. Cognitive psychology began in the 1950s as a reaction against behaviorism. As an information processor, the mind actively gathers and selects information about the world, self, and others at both conscious and nonconscious levels. When cognitive distortions cohere as a pattern, they may be thought of as cognitive styles. Different personalities process consensual reality in different ways. Each of the personality disorders has its own style of cognitive processing.

Cognitive therapists hold that behavior can be explained by examining the contents of internal mental structures called schemas. Schemas are assumed to mediate cognitive processing at every level, from sensation to paradigms, and on to action plans that the organism can use to affect the world. Like a cognitive filter, they are ever ready to be applied to create an interpretable world. Everything put through the filter is automatically processed. As such, their primary advantage lies in allowing experience to be processed with great efficiency. The information-processing economy that schemas afford, however, also comes at a cost. Because schemas necessarily exist between the raw data of sensation and the meaningful world of subjective experience, they introduce interpretive biases that preempt other construals, possibly distorting consensual reality. Beck et al. (1990) applied the cognitive perspective to the personality disorders, describing the schemas, or core beliefs, that shape the experience and behavior of personality-disordered individuals. In addition, they emphasize the importance of cognitive distortions. These are chronic and systematic errors in reasoning, which promote the misinterpretation of consensual reality.

In personality, the inductive perspective is intimately tied up with the history of psychology. The most influential factor model of personality is the Five-Factor Model, derived from analyses of various personality inventories, not words from the dictionary. As the name indicates, this model consists of five broad higher order factors: Neuroticism, Extroversion, Openness to Experience, Agreeableness, and Conscientiousness. In turn, each dimension consists of several lower order facet traits, thus lending the model a hierarchical structure.

The evolutionary-neurodevelopmental model believes that evolution is the logical choice as a foundation for an integrated science of the person. Psychological health is dependent on the fit between the entire configuration of a person’s characteristics and potentials with those of the environments in which the person functions. The first task of any organism is its immediate survival. Organisms that fail to survive have been selected out, so to speak, and fail to contribute their genes and characteristics to subsequent generations. Evolutionary mechanisms related to survival tasks are oriented toward life enhancement and life preservation. Such mechanisms form a polarity of Pleasure and Pain. Behaviors experienced as pleasurable are generally repeated and generally promote survival, while those experienced as painful generally have the potential to endanger life and thus are not repeated. The second evolutionary task faced universally by every organism is adaptation. To exist is to exist within an environment.

Organisms must either adapt to their surroundings or adapt their surroundings to conform to and support their own style of functioning. The choice is essentially between a Passive versus Active orientation, that is, a tendency to accommodate to a given ecological niche and accept what the environment offers, versus a tendency to modify or intervene in the environment, thereby adapting it to themselves. The third universal evolutionary task faced by every organism pertains to reproductive styles, essentially sociobiological mechanisms, that each gender uses to maximize its representation in the gene pool. All organisms must ultimately reproduce to evolve. A parallel framework of neurodevelopment is outlined to demonstrate the ontogenetic stages through which humans progress so as to acquire the sensitivities and competencies required to function in accord with their evolutionary origins.

According to evolutionary theory, personality is manifested in eight different domains: expressive acts, interpersonal conduct, cognitive style, defense mechanisms, self-image, object-representations, morphologic organization, and mood-temperament.

References

Personality Disorders in Modern Life, second edition, 2000, 2004 by John Wiley & Sons, Inc.

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Personality Disorders: Classical Foundations

Development of Personality Disorders
Assessment and Therapy of the personality Disorders

Development of Personality Disorders

By: THEODORE MILLON et al.

The obstacles confronting investigators engaged either in the design, execution, or interpretation of studies of personality disorders are formidable. Numerous questions have been raised about both the methodological adequacy of earlier research and the likelihood that these studies will prove more fruitful in the future.

Since it is impossible to design an experiment in which relevant variables can systematically be controlled or manipulated, it is impossible to establish unequivocal cause-effect relationships among these variables and personality pathology. Investigators cannot arrange, no less subvert and abuse, an individual or a social group for purposes of scientific study; research in this field must, therefore, continue to be of a naturalistic and correlational nature. The problem that arises with naturalistic studies is the difficulty of inferring causality; correlations do not give us a secure base for determining which factors were cause and which were effect. For example, correlations between socioeconomic class and personality disorders may signify both that deteriorated social conditions produce mental disorders and that mental disorders result in deteriorated social conditions.

Throughout the literature were comments indicating the lack of definitive research to support assertions about the role of pathogenic factors in personality pathology. That pathogenic factors of both a psychosocial and biologic nature are significantly involved seems axiomatic to most theorists, but science progresses not by supposition and belief but by hard facts gained through well-designed and well-executed research. This paucity of evidence does not signify neglect on the part of researchers; rather, it indicates the awesome difficulties involved in unraveling the intricate interplay of influences productive of personality pathology. Despite these apologetics, there is reason for caution in accepting the contentions of pathogenic theorists.

We have no choice but to continue to pursue the suggestive leads provided us both by plausible speculation and exploratory research; difficulties notwithstanding, we must caution against inclinations to revert to past simplifications or to abandon efforts out of dismay or cynicism. Our increasing knowledge of the multi-determinant and circular character of pathogenesis, as well as the inextricable developmental sequences through which it proceeds, should prevent us from falling prey to simplifications that led early theorists to attribute personality pathology to single factors. Innumerable pathogenic roots are possible; the causal elements are so intermeshed that we must plan our research strategies to disentangle not isolated determinants but their convergencies, their interactions, and their continuities.

References

Personality Disorders in Modern Life, second edition, 2000, 2004 by John Wiley & Sons, Inc.

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Personality Disorders: Classical Foundations

Personality disorders: Contemporary Perspective
Assessment and Therapy of the personality Disorders

Assessment and Therapy of the personality Disorders

By: THEODORE MILLON et al.

The assessment and therapy should be continuous with personality as an integrative construct. Assessment is the basis of therapy. The clinician should gain a complete scientific understanding of the interaction of current symptoms, personality traits, and psychosocial factors. The axes of the multi-axial model should be separately assessed and then integrated into a single composite, the case conceptualization.

In the relationship between pure and applied science, the nomothetic approach seeks to find universal principles applicable to all individuals in a population. The idiographic approach emphasizes the complexity of the individual seeking to understand the totality of a single person. In diagnosing a person, the DSM attempts to retain the best of a construct-centered approach, while allowing for a measure of individuality. First, the DSM allows multiple personality disorder diagnoses to be assigned. Combinations of two, three, or even four personality disorders are not uncommon. Second, each personality disorder is operationalized as a prototype that consists of many characteristics.

There are probably hundreds of ways of satisfying the diagnostic criteria for any two personality disorders. Such vast possibilities are intended to accommodate individuality within the diagnostic system, while the shorthand of diagnostic labels nevertheless recognizes that all subjects who receive the same diagnosis bear a family resemblance. In any categorical classification system, the question is which labels the subject will receive. The idiographic perspective, however, reminds us that taxonomies take us only so far—that diagnostic constructs are only reference points that facilitate understanding, against which the individual should be compared and contrasted. Because the goal is an idiographic understanding of the person, assessment is really an endeavor to show the limitations of the diagnostic system with respect to the person at hand.

In contrast to the physical sciences, measurement instruments in personality and psychopathology are inherently imprecise. Five broad sources of information are available to help describe the clinical problem. Each has its own advantages and limitations. In the first source, the self-report inventory, subjects literally report on themselves by completing a standard list of items. In the second source of information, rating scales and checklists, a person familiar with the subject completes this form in order to provide an alternative perspective. Third, in the clinical interview, the clinician asks the questions and the subject responds verbally, often in a free form style. The clinician is free to following any particular line of questioning desired and usually mixes standard questions with those specific to the current problem. Finally, the fourth source, projective techniques, is an attempt to access unconscious structures and processes that would not ordinarily be available to the subject at the level of verbal report. The use of intimates of the subject who can act as informants, perhaps a spouse, teacher, parent, or good friend, someone who can provide perspective on the problem, might also be considered a source of information. Physiological measurements, neurotransmitter or hormone levels, for example, provide a final source, though these are not available to most therapists.

Measurement in all sciences is limited by biasing and distorting factors. Certain distortions arise because of the personality style of the respondent or interviewer. Different personalities construe the world in different ways. Other limitations on clinical information arise from subjects’ motives and their level of personality pathology. In other cases, some personalities consciously distort information to somehow take advantage of the system or avoid some unpleasant consequence of their own behavior. Most self-report instruments have indexes that can detect attempts to fake good or fake bad, though they must be interpreted cautiously in the context of other test information. Whatever the situation, clinicians are always advised to keep the principle of self-interest firmly in mind.

Most patients who require psychological testing present with one or more Axis I disorders. Traits refer to long-standing personality characteristics that endure over time and situations. In contrast, states refer to potentially short-lived conditions, usually emotional in nature. Anxiety, depression, and loss of reality contact can all affect the results of personality testing. Crossover effects from state to trait are an expectable part of assessment and must be considered by whomever interprets the test results.

Psychological tests can be interpreted at different levels: items, scales, and profiles. The item is the standard stimulus in psychological assessment. Since every subject who completes an instrument answers the same items, their responses can be directly compared to those of others. A scale is composed of many items that tap the same psychological construct, so that a scale score reflects a summary of the particular behaviors expressed in those same item responses. A set of scale scores is referred to as a profile or profile configuration. The profile stands in place of the person as a collection of scales, just as a collection of items stands in place of the construct they assess.

A variety of self-report instruments are available to assess the personality disorders. With more than 550 items, the Minnesota Multiphasic Personality Inventory-2 (MMPI) is not so much a standardized test as a standardized item pool that belongs to psychology itself. Literally hundreds of personality scales have been derived from the MMPI throughout its long career. In fact, there are now more auxiliary scales than there are items on the MMPI. The Millon Clinical Multi-axial Inventory (MCMI), now in its third edition, is far the most widely used personality disorder test. A principal goal in constructing the MCMI-III was to keep the total number of items constituting the inventory small enough to encourage use in all types of diagnostic and treatment settings, yet large enough to permit the assessment of a wide range of clinically relevant behaviors. At 175 items, the final form is much shorter than are comparable instruments, with terminology geared to an eighth-grade reading level. As a result, most subjects complete the MCMI-III in 20 to 30 minutes. The inventory is intended for subjects believed to possess a personality disorder and is generally not used with normals. The MCMI is frequently used in research. More than 650 publications to date have included
or focused primarily on the MCMI, with approximately 60 to 70 new references currently published annually. Both the MMPI and MCMI have variants designed for use with adolescents.

A number of clinical interviews are available for the personality disorders. The Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) is a semi-structured diagnostic interview assessing the 12 personality disorders included in DSM-IV. The Structured Interview for DSM-IV Personality (SIDP-IV; Pfohl et al., 1997) is a semi-structured clinical interview that assesses all the personality disorders of the DSM-IV, plus the self-defeating personality from the revised third edition of the DSM (the sadistic personality is not included).

The history of psychotherapy is fraught with dogmatism. In the past few decades, however, dissatisfaction with school-oriented therapy (e.g., behavioral, psychodynamic), together with a new emphasis on efficacy motivated by managed care, has led to the development of compromise approaches. Three trends currently dominate: First, brief therapy claims to achieve as much or greater progress in less time by carefully selecting patients and providing highly structured forms of intervention specific to the presenting problem. Second, the common factors approach seeks to unify much of psychotherapy by identifying factors common to all effective therapies. The argument here is that all therapies are more alike than different, and a better psychotherapy can be created by returning to the core principles and techniques from which particular therapies diversify. Third, therapeutic eclecticism holds that the techniques of various schools should be incorporated into treatment as necessary, without regard for the theoretical model in which the technique was first developed. While these contemporary trends all represent an innovative improvement over the past, they nevertheless share an important shortcoming: They fail to develop forms of psychotherapy specific to Axis II and, therefore, implicitly treat the personality disorders as if they were identical with the symptom disorders of Axis I.

Synergistic psychotherapy, on the other hand, is concerned with the application of multiple techniques, potentially drawn from every domain of personality, but selected specifically to exhibit an emergent efficacy beyond what would be expected from the application of any technique alone. Potentiated pairings draw on two or more techniques applied simultaneously to overcome problematic characteristics that might be refractory were each technique administered separately. Potentiated pairings are designed to be applied simultaneously. In contrast, catalytic sequences plan the order of interventions as a means of optimizing their impact. The ability to borrow and interweave techniques from multiple perspectives gives synergistic psychotherapy tremendous scope: Since personality is cognitive, interpersonal, psychodynamic, and biological, the nature of the personality construct itself dictates that techniques can, should, and must be pulled from any of these perspectives as needed.

References

Personality Disorders in Modern Life, second edition, 2000, 2004 by John Wiley & Sons, Inc.

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Personality Disorders: Classical Foundations

Personality disorders: Contemporary Perspective
Development of Personality Disorders

Personality Disorders from the Appendices of DSM-III-R and DSM-IV

By: THEODORE MILLON et al.

Although the term masochistic was coined in reference to a specific male sexual perversion, it quickly became associated with the feminine and submissive. Hence, it has become a politically charged construct that has been dropped from the DSM-IV. The masochistic personality also has several normal variants that are often described as saintly. For example, Oldham and Morris’s (1995) self-sacrificing style lives to serve others. Millon’s yielding style is moving closer toward the pathological end of the spectrum in that this style tends to remain deferential to others despite possessing superior abilities.

Several variants of the masochist blend with other personality traits. The self-undoing masochist blends traits with the avoidant personality where failure brings some kind of relief from anxiety. Possessive masochists blend with negativistic traits and tend to try to guilt others into staying with them. Oppressed masochists combine depressive traits with the masochistic ones and tend to complain about their terrible lives although they do not necessarily enjoy their sufferings. Virtuous masochists are a blend with histrionic traits as well as dependent ones and are stoic in their suffering, while continually manipulating others with their generous giving. Masochists share many traits with other personalities, including the depressive, dependent, compulsive, and borderline personalities. They are also vulnerable to developing dysthymia, panic disorders, and somatoform disorders.

Like the term masochism, sadism has become a politicized construct. Originally coined in response to the Marquis de Sade, who derived sexual pleasure by causing others to suffer, it quickly came to describe other, nonsexual behaviors. Also like masochism, sadism has been dropped from the DSM-IV, although it was only in the appendix of the DSM-III-R. While true sadists are only seldom encountered in everyday life, sadistic traits and behaviors are all around us.

Millon’s controlling style is an example of normal variants of the sadistic personality who enjoy using their power to direct and intimidate others. Some combinations with other personality traits are possible. Explosive sadists possess borderline traits and seem to use their aggression as an outlet for emotions rather than like other sadists who use it to gain control. The tyrannical sadist possesses features of the negativistic or paranoid and is particularly frightening and cruel. The enforcing sadist has many compulsive traits and acts like society’s sadistic superego. The spineless sadist is combined with avoidant traits where hostility is a kind of a counterphobic act. The sadist also shares many traits with negativists, antisocials, paranoids, and narcissists. They are also vulnerable to certain Axis I disorders such as anxiety disorders, substance abuse, and paranoid fears.

For depressive personalities, being depressed is more than a symptom. Like a person suffering from depression, depressive personalities feel sad and guilty, but their emotional state is indicative of an entire matrix of pervasive and long-standing characteristics of feeling worthless and inadequate. On the continuum toward normality, people with depressive traits may be reflective of negative aspects but are not overcome by them and are self-conscious of their standing but able to take criticism constructively.

There are several variations of the depressive personality that mix with other personality traits. The ill-humored depressive is a mixture with the negativistic personality that complains endlessly and is chronically irritable. The voguish depressive is a mixture with histrionic or narcissistic features that sees suffering as noble. Self-derogating depressives possess some dependent features where they feel guilt and must discharge it though self-punishment. The morbid depressive shares features with the masochistic personality and frequently blends into an Axis I clinical depression. The restive depressive has avoidant features, expressing anguish and agitation. Depressives may share many traits also with the schizoid, compulsive, and borderline personalities. They are also often diagnosed with dysthymia, major depressive episodes, as well as with anxiety syndromes.

Negativists vacillate between feelings of dependence and a need for self-assertion, usually feel misunderstood, and act out their frustrations in indirect ways. Normal traits of this personality may be seen when people feel overcontrolled by someone and have fantasies about ways to make the overcontrolling person suffer. More normal variants may possess the same basic tendencies but are able to function in society and get along with others socially.

Several variations on the negativistic personality exist. The circuitous negativist is a mixture with dependent traits that covertly undercuts others. The abrasive negativist shares traits with the sadistic personality and is more overtly hostile and vile to others. The discontented negativist is a combination of the negativist with depressive traits, a person that constantly gripes. Vacillating negativists are mixed with borderline traits and experience rapid changes in their emotions and attitudes. The negativist shares many qualities with other personality types, including the paranoid, narcissistic, antisocial, and masochistic. Anxiety, phobias, depressive episodes, and paranoid decompensation are but some of the Axis I types of disorders to which the negativist is vulnerable.

References

Personality Disorders in Modern Life, second edition, 2000, 2004 by John Wiley & Sons, Inc.

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Obsessive-Compulsive Personality

By: THEODORE MILLON et al.

The obsessive-compulsive personality struggles to contain conflict between obedience and defiance by overconforming to rules and strictures, becoming almost a caricature of order and propriety. Western society seems to encourage these traits by valuing hard work, efficiency, and attention to detail, but at the disorder level, order turns into perfectionism and discipline into rigidity. Compulsives become preoccupied with rules and lists, force others to conform to their rules, and become so overwhelmed by details of life that decisions become impossible.

Within a normal range, Oldham and Morris (1995) describe the conscientious style, who is particularly hard working and devoted to moral principles and order, while Millon’s (Millon et al., 1994) conforming style is more concerned with following rules and conventions, tending to exhibit black-and-white thinking, and shunning emotionality. The compulsive personality is rarely confused with other personality patterns, although it is theoretically related to the dependent personality, the schizoid personality, and the paranoid personality.

A variety of adult subtypes of the compulsive personality exist. Conscientious compulsives exhibit a strong conforming dependency, puritanical compulsives are particularly troubled by ambivalence and prone to displacing their aggression in sadistic ways, bureaucratic compulsives use external structures to compensate for their internal ambivalence and may become sadistic, parsimonious compulsives are preoccupied with hoarding, and bedeviled compulsives are blended with the negativistic personality.

Freud explains the compulsive personality as a fixation at the anal stage of psychosexual development. Anal-retentive types are believed to be caused by a rigid, impatient, or demanding attitude taken by parents toward toilet training and children subsequently internalizing a harsh superego, ready to condemn themselves for thoughts and actions. Alternatively, children may react by becoming anal-expulsive types, a strategy of resisting parental controls. Later, ego psychologists and object relationists shifted the focus to the compulsive personality’s intolerance of ambiguities, with the use of a host of defense mechanisms such as reaction formation, displacement, undoing, and isolating affect to overcome feelings of anger and insecurity aroused by the conflicts.

From an interpersonal perspective, we can see that compulsives are extremely deliberate in their social interactions. They seem incapable of spontaneity, instead following almost a flowchart for personal interactions. Their interpersonally distant and calculating qualities can be seen clearly in the work setting by their interactions with superiors and subordinates. As in the psychodynamic perspective, parental overcontrol is one factor contributing to the development of the compulsive personality. Interpersonal psychologists believe that parental failure to reward real achievements is also a contributing element.

Cognitions seem to play a large part in the functioning of the compulsive personality. Abhorring ambiguity, compulsives need to categorize their thoughts into discrete compartments and cling to order and rules as a defense against the dangerous unknown. Having an unflagging focus on minute detail, compulsives often miss the big picture and usually fail to recognize the emotional nuances of a situation. So fearful of making an error, many compulsives become mired in a paralysis of analysis. Compulsives have overdeveloped schemas for control, responsibility, and systematization and are trapped by black-and-white thinking, “should” statements, and ruminating about the past and future, causing them to miss out on most of the joys of life.

The compulsive personality is prone to displaying other symptoms when experiencing stress; obsessive-compulsive disorder (OCD), other anxiety disorders, somatoform disorders, dissociative disorders, and depression are the most common.

In therapy, compulsive personalities are likely to intellectualize their experiences and refuse to open up emotionally, but this does not mean that therapy cannot be successful. Couples therapy, psychodynamic therapy with dream analysis and free association, and framing therapy as scientific research are all useful techniques in treating the compulsive personality. Issues of control and power are likely to take center stage in therapy.

References

Personality Disorders in Modern Life, second edition, 2000, 2004 by John Wiley & Sons, Inc.

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Dependent personality

By: THEODORE MILLON et al

Dependents arrange their lives to ensure a constant supply of nurturance and guidance from their environment. They can be described as self-effacing, obsequious, docile, and ingratiating. Many search for an all-powerful magic hero, someone who will take care of them, save them from the competitive struggles of life, and protect them from any possibility of harm. Given a nurturing and understanding partner, dependents often function with ease, being sociable, warm, affectionate, and generous.

One normal variant of the dependent is Oldham and Morris’s (1995) devoted style, who is caring and puts the needs of others first. Another is Millon’s (Millon et al., 1994) agreeing style, who is cooperative and amiable. A healthy dependent is capable of genuine empathy for others and has the capacity to give unconditional love. The more pathological variants fuse their identity with that of others and become inextricably enmeshed with others.

There exist several adult subtypes of the dependent personality. The adult subtypes include the disquieted dependent, who displays a mixture of avoidant and dependent personalities; the accommodating dependent, who has an insatiable need for affection and nurturance and often shares traits with the histrionic; the immature dependent, who never develops competencies and remains childlike; the ineffectual dependent, who reflects a combination of schizoid and dependent features; and the selfless dependent, who is known for idealization and total identification.

Psychodynamically, the dependent can be thought of as fixated at the oral stage of development. For the dependent, this fixation is thought to have occurred through indulgence at the oral stage rather than through frustration. They tend to rely on introjection and idealization, generally of partners, as defense mechanisms. They may also use denial to avoid feelings of anxiety that introjection does not abolish.

Interpersonally, dependents are often seen as generous and thoughtful, overly apologetic, or even obsequious. Beneath their warmth and friendliness, however, lies a solemn search for assurances of acceptance and approval. To achieve their interpersonal goals, dependent personalities attach themselves to others, submerge their own individuality, deny points of difference, and avoid expressions of power. Interpersonal formulations of the development of the dependent personality emphasize parental overprotection, overconcern, overnurturance, and active discouragement of autonomy as the major developmental pathways. Some parents never allow their children to develop independently. In effect, they remove any need to explore the world by bringing the world to the child. Other family members and peer group experiences can also contribute to the development of a dependent personality.

The cognitive perspective asserts that the helpless façade that dependents project eventually works its way into their self-concept. Accordingly, the self-schema of dependents includes both positive and negative qualities. On the positive side, dependents see themselves as considerate, thoughtful, and cooperative; on the negative side, they often tell themselves that they are helpless and completely alone in the world. To remedy these deficits, dependents often form conditional beliefs; for example, they can survive only if someone protects them, or if they are alone, they will die. Dependents are cognitively immature. They seldom look inward and possess only vague ideas about their self-identity and direction.

The evolutionary developmental perspective conceptualizes dependents as arranging their lives to ensure a constant supply of nurturance from the environment, but doing so in a passive way. They avoid developing competencies that would allow them to actively adapt to their surroundings.

The dependent personality disorder is related to several other personality disorders including the histrionic, avoidant, and masochistic. Dependents are extremely vulnerable to developing anxiety disorders such as generalized anxiety disorder, phobias, agoraphobia, and panic attacks. Additionally, dependents often develop depression, dissociative reactions, and display physical symptoms such as assuming the “sick role.”

Psychotherapy can be effective in treating the dependent personality. Most dependents are highly motivated to remain in therapy, as the therapeutic relationship itself naturally supplies them with the very resources they feel are deficient in their everyday lives. The strength and authority of the therapist is comforting and reassuring and provides the idealized omnipotent figure that dependents seek to rescue them in time of need. Moreover, dependents are usually ready to trust and to talk with a therapist. Cognitive techniques can be used to challenge dependents’ propensity toward black-and-white thinking with the goal of engaging dependents in a more active style of problem solving that disconfirms life as an existence of total helplessness and moves them toward a more competent self-image. Psychodynamic exploration may also be effective in helping dependents understand the developmental basis from which maladaptive patterns arose, though insight alone is unlikely to be sufficient in producing personality change.

References

Personality Disorders in Modern Life, second edition, 2000, 2004 by John Wiley & Sons, Inc.

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Avoidant Personality

By: THEODORE MILLON et al.

Avoidants are painfully sensitive to humiliation and social disapproval, and they actively seek protection from the perceived inevitable threats of others in the environment. The DSM-IV describes avoidants as exhibiting a pattern of inadequacy and a fear that their shortcomings will expose them to judgment and ridicule. Several normal variants have been proposed, including Oldham and Morris’s sensitive and vigilant styles and the hesitating pattern by Millon, Weiss, Millon, and Davis.

The basic avoidant pattern is often mixed with other personality traits that are evidenced in several subtypes. The conflicted avoidant includes features of the negativistic personality where the basic withdrawal of the avoidant pattern is combined with the negativist’s tendency toward interpersonal guerrilla warfare. The hypersensitive avoidant includes features of the paranoid personality but exhibits greater reality contact. Phobic avoidants combine features of the dependent and avoidant personalities, being especially prone to experiencing social phobias. The self-deserting avoidant combines social avoidance with the ruminative self-devaluation of the depressive personality.

Most psychodynamic thinkers still consider the avoidant as part of the schizoid personality. However, three major psychodynamic theorists described personality patterns that are distinctly like the avoidant. Menninger (1930) described the isolated personality, Fenichel (1945) formulated the notion of a phobic character, and Horney (1937) developed the concept of the detached type, individuals who believe, “If I withdraw, nothing can hurt me.” As a defense, avoidants actively interfere with their painful preoccupations and tensions by intruding irrelevant thoughts or distorting their substantive meaning. In addition, avoidants indulge themselves excessively in fantasy and imagination, both as a means of replacing anxiety-arousing cognitions of inadequacy and low self-worth and as a means of gratifying needs that cannot be met due to social withdrawal.

Avoidants may be seen as having a highly developed ego ideal, including a high level of aspiration and desires for self-actualization, paired with an intensely condemning superego that constantly finds fault with and disapproves of their every behavior. In effect, they have internalized parental standards of high achievement and social success, combined with blame and shunning for the smallest mistakes.

From a cognitive perspective, an information-processing model seems particularly useful in understanding the avoidant personality. The very contents of the cognitions seem to establish a pathological reciprocity with the structure of cognition, perpetuating the disorder. As avoidants consistently scan their environment for signs of danger, their information-processing system becomes flooded with excessive stimuli that prevent them from attending to other features. The cognitive perspective also holds that beliefs about the world, self, and others are critical in determining behavior (Beck et al., 1990).

Avoidants’ core beliefs, which are usually below the level of conscious awareness, are held to be unconditionally and eternally true. They influence how other beliefs are organized, especially when predicting the consequences of various courses of action, expressed as conditional if-then beliefs.

From an interpersonal perspective, the avoidant has a perpetual sense of social unease. This is not limited to a crowd of people; a single person can activate these feelings. Instead of confronting their anxiety, they escape social encounters whenever possible, only serving to perpetuate their problems. By narrowing their range of interpersonal experiences, they fail to learn new ways of behaving that might bring them greater self-confidence or a sense of personal worth. Their personality also seems to attract those who enjoy shaming and ridiculing them. Benjamin’s SASB model captures the interpersonal development of the avoidant personality: Beginning life with normal attachment, caretakers’ criticisms of flaws eventually result not only in avoidants’ developing a poor self-image but also in helping them develop strong self-control and restraint that causes their hypersensitivity to error. Certain traumatic childhood experiences such as physical abuse, incest, or molestation may be sufficient to produce a lifelong pattern of social avoidance and interpersonal fearfulness that resembles the avoidant pattern (Stone, 1993).

Although in most cases a biological disposition is insufficient to result in an avoidant personality, there is evidence of some biological influence; however, specifics remain highly speculative. Some researchers (Siever & Davis, 1991) regard anxiety inhibition as providing one of the core psychobiological dispositions in the development of the avoidant personality. Some of the feelings of inadequacy in avoidants may have a basis in slow or uneven maturation, as this can elicit teasing from peers. The avoidant personality may also have a basis in biological temperament; although shyness is not specific to the avoidant personality, its presence does suggest a sense of inner shame or self-doubt characteristic of the avoidant.

The avoidant personality was originally conceived in 1969 as the actively detached pattern from Millon’s biopsychosocial theory of personality. This means that there is a conflict between the person’s desire for social contact and fear of exposure to shame for seeking it. Millon’s more contemporary evolutionary theory (1990; Millon & Davis, 1996) maintains the active-detachment hypothesis but more clearly posits the motivating aim of protection against pain, to the extent of a virtual denial of life-enhancing possibilities. Whether by hereditary predisposition, a caustic and critical upbringing, or some blend of these two influences, the avoidant continually learns that psychic safety is a first priority worthy of taking all actions to ensure. As he or she gets more isolated by virtue of this approach, interpersonal skills among peers fail to develop, and those abilities that have developed dissipate.

Avoidants share characteristics with other personalities including schizoids, schizotypals, and paranoids. They are also part of the anxiety spectrum. Historically, the central features characterizing the avoidant personality have been scattered throughout clinical literature. The avoidant was often confused with other personalities, such as the schizoid, and even confused as a pathway to developing schizophrenia. Avoidants are especially vulnerable to developing other clinical syndromes. Anxiety disorders, particularly generalized anxiety, social anxiety, and obsessive-compulsive disorder, are common in avoidants. They are also vulnerable to developing somatoform disorders, particularly body dysmorphic disorder, dissociative disorders, depressive disorders, and schizophrenic disorders.

The therapeutic prognosis for the avoidant personality is remarkably poor. The most basic characteristics of the avoidant run counter to the basic requirements of psychotherapy. Because of their intense sensitivity to negative evaluation, the therapeutic relationship is critical. Patience seems to be a key quality for the therapist to build a trusting relationship with the avoidant. Cognitive and cognitive-behavioral techniques seem to have some benefits, all designed to help avoidants overcome their social fears and gain a better sense of self-worth. Working from an interpersonal perspective, Benjamin (1996) suggests that avoidants possess a deep reservoir of anger and that the antidote to this pattern is accurate empathy and uncritical support. Family, couples, and group therapy can be beneficial in breaking patterns that perpetuate avoidant behavior.

Psychodynamic treatment emphasizes a strongly empathic understanding of the experience of humiliation and embarrassment and insight into the role of early experiences in creating present emotions.

References

Personality Disorders in Modern Life, second edition, 2000, 2004 by John Wiley & Sons, Inc.

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