As a naive medical student in a busy hospital emergency department, I once expressed scepticism about the clinical effectiveness of psychiatry to a consultant psychiatrist. I was feeling frustrated by and annoyed with a young woman, whose repeated nocturnal presentations to the emergency department over several weeks with self-inflicted lacerations to her wrists and forearms, all the while screaming drunken locker-room epithets at the harried nurses and doctors, had provided me and a couple of my friends with our basic training in surgical suturing techniques, and our first clinical experience of the borderline personality disorder.
The psychiatrist, a softly-spoken, kindly man, sighed, and uttered one of those memorable clinical aphorisms, part wisdom, part oversimplification, which abound in medicine: ‘Patients with mental illness suffer, those with personality disorders tend to make others suffer; we can treat the former, the latter we try to manage’. That was in 1969. Today, over four decades later, seven treatment models of proven effectiveness are available to treat that woman’s personality disorder. This represents one of psychiatry’s most remarkable and least publicized achievements.
In this essay I summarize how the concept of personality disorder developed in psychiatry, mentioning some contributors of key ideas about causation, classification and treatments. Contrary to the aphorism, patients diagnosed with personality disorders do suffer, as do their intimates, colleagues, and clinicians. Whatever their ontological status, personality factors influence a psychiatric patient’s cooperation with treatment, relationships with clinicians, ‘treatment-resistance’, and propensity to suicide.
Contemporary texts of the history of personality disorders locate the origins of the concept with Hippocrates (or the authorities subsumed under his name), who, in the 4th century BC explained disease to be caused by an imbalance in the four ‘humours’: choleric (yellow bile), melancholic (black bile), sanguine (blood), and phlegmatic (phlegm). Galen described personality types that corresponded to these putative humoral perturbations. This model dominated European medicine till the late 17th century, its demise hastened by William Harvey’s demonstration in 1628 of the circulation of the blood and the structural and functional constitution of the human body. A science of personality, its disorders, and its relationship to psychiatric illnesses is yet to be articulated, though recognition of such ‘comorbidity’ is hardly new. In 1621, the reclusive Oxford clergyman, Richard Burton, subscribed to the Hippocratic model that considered an excess of black bile to be the cause of his melancholia, but he also clearly regarded the entire human personality to be implicated: ‘And who is not a Fool, who is free from Melancholy? Who is not touched more or less in habit or disposition? … And who is not sick, or ill-disposed, in whom doth not passion, anger, envy, discontent, fear and sorrow reign?’ (1). Nor is the debate over the status of personality disorder as genuine pathology a recent phenomenon. On the eve of the Revolution, in a France awash with ideas of rationality, free will, and scepticism about divine authority, the medical superintendent of the Chartenton mental asylum declared of its most infamous inmate: ‘the Marquis de Sade is not mad; his only sickness is vice’.
Soon after, Pinel famously removed the shackles of patients in the Saltpetrière Hospital. Faithful to his stance of objective observation, rational explanation, and humane care, Pinel also described a condition of ‘manie sans delire’ in people who harmed themselves and displayed impulsive, often antisocial acts while fully aware of the irrationality of their actions. He described: ‘… maniacs who gave no evidence of lesion of understanding, but who were under the dominion of instinctive and abstract fury, as if the faculties of affect alone had sustained injury’ (2). The similarities with contemporary description of borderline personality disorder (BPD) are striking.
The historian of psychiatry Gregory Zilboorg described Pinel’s views as the first victory in the history of psychiatry of the alliance between rationality and humanism. By contrast, Michel Foucault saw Pinel’s therapy not as an expression of innate humanism, but as the dawn of disciplinary practices spearheaded by the emerging professions of medicine, psychiatry, education, and criminology, which deploy their expert knowledge to facilitate the surveillance and control of citizens in order to create ‘normal’ (i.e. compliant, productive) subjects of the state. Such historically contingent forms of knowledge (epistemes) define health and sickness, normality and disorder, the methods of inquiry, and how such knowledge is deployed. For Foucault, the domains of the epistemic/clinical are totally imbricated with the judicial/political. As examples, one might point to the psychiatric diagnosis and ‘treatment’ of political and religious dissidents in the 1960s and 1970s in the then Soviet Union, and recent publicity that some American soldiers charged with killing innocent civilians either while in a war zone, or upon their return home, were suffering from BPD, whose effects had been amplified by their combat experiences.
While Pinel claimed his observations to be objective, a moral dimension to this description was added in England in the early 19th century, when personality disorder was subsumed under the category of ‘moral insanity’, which predominated among men. By contrast, women were prone to hysteria: ‘an immoderate sensitiveness, a tendency to refer everything to themselves, great irritability, senseless caprices, inclination to deception, jealousy and prevarication’ (3).
During the 20th century, personality disorders emerged in the psychiatric nomenclature as a diagnostic category distinct from both the neuroses and the psychoses. An exception was the view of Adolf Meyer, who argued that a person was a psychiatric unity, in whom forms of psychopathology represented a spectrum of reactions to adverse environmental experiences. Meyer’s views dovetailed with psychoanalytic ideas and were very influential in the United States in the middle third of the century.
Two broad streams of thought predominated: descriptive psychopathology and psychoanalysis. Both of them encompassed the notion that particular personality types predispose to the development of particular neuroses or psychoses. This is reflected in the terminology. After a period of eclipse, this view has regained credibility.
Emil Kraepelin did not identify personality disorders as a separate diagnostic group until the 8th edition of his Handbook (1913). There he described the personality predispositions to the two major psychoses: the cyclothymic type, prone to mania, and the autistic (shy, seclusive, passive) type prone to dementia praecox (later renamed schizophrenia). Eugene Bleuler referred to the latter kind of personality as ‘schizoidal’. Kraepelin described subtypes for each major personality disturbance, including the affective—people with an ‘irritable’ or ‘excitable’ temperament, who resemble contemporary descriptions of BPD.
Kraepelin relied on longitudinal observations of behaviour, and patients’ reports of subjective experience, to argue that mental disorders were discrete, categorical entities. This view strongly influenced DSM approaches in the latter third of the 20th century.
Schneider’s influential Psychopathic Personalities (1923) led to the eclipse of the terms ‘character’ and ‘temperament’, which previously had often been used as synonymous with personality, while he also restricted the term ‘psychopathic’ to refer to a subclass of abnormal personalities rather than an umbrella term for all forms of mental illness. Schneider did not consider personality disorders to be diagnostic categories; rather they were ‘forms of being’ which deviated from the social mean in either a statistical or ideal sense, wherein personality reflected ‘a stable composite of feelings, values, tendencies and volitions’ (4).
The second major stream of thought concerning personality was psychoanalytic. While he saw himself as upholding the Enlightenment ideal of Reason, Freud was also influenced by romanticism. Its exemplar was the ill-fated, fictional character, Werther, in Goethe’s The Sorrows of Young Werther (1774), who commits suicide in despair at the selfish, shallow, and callous qualities that modern life demands of people. The book triggered a wave of ‘copycat’ suicides among young people.
In the first half of the 20th century, modernism celebrated Freud’s idea that the psychological foundations of a person’s character lay veiled behind the apparent rationality and morally sanctioned practices of everyday life. In the late 20th century postmodernism claimed an affinity with yet another interpretation of psychoanalysis when arguing that personality has no foundation or ‘essence’. Instead, time-honoured notions of identity and the self were comforting illusions, the products of the unconscious, contingent relational and linguistic worlds into which individuals are born and which they internalize.
Freud himself initially wrote little about personality and its disorders. The main exceptions are his description of the anal character, with its traits of orderliness, parsimony, and obstinacy, and its characteristic ego defences, and his biographical study of Leonardo da Vinci where he speculated on the relationship between personality, neurosis, and creativity.
In his charming 1916 paper ‘Some character types met in psychoanalytic work’, Freud sketched three character types: the ‘Don Juan’ character (a form of male hysteria), ‘those wrecked by success’ (a form of self-defeating tendencies), and ‘criminal from sense of guilt’ (a form of antisocial behaviour).
Building on his ideas of mourning, Freud’s structural model described the unconscious process of ‘identification’ which influences the child’s ego development. Identification involves unconsciously taking on characteristics of a loved person as a defence against the pain of losing or being punished by them. Freud also described a product of identification, the ego-ideal, derived from the child’s recognition of the expectations and aspirations his parents may have of him. The ego-ideal is relevant to psychoanalytic formulations of the narcissistic personality disorder.
Freud also introduced the phenomenon of ‘repetition compulsion’, the recurrent attempts to master unconscious conflicts that underpin personality. These three concepts—defences, identification, and repetition compulsion—are clinically relevant and enduring ideas Freud contributed to our understanding and treatment of personality disorders. Anna Freud subsequently introduced the idea of developmental lines: that is, how each ego function evolved throughout life through the interaction of drives, maturation of ego defences, and life’s challenges. Wilhelm Reich focused on how defences and the developmental conflicts they were deployed to solve constituted an individual’s ‘character armor’. His ideas marked an important transition in psychoanalysis from the treatment of the symptomatic neuroses (e.g. hysteria, obsessions, phobias) to that of personality (character) pathology, which became the principal domain of psychoanalytically informed therapy in the latter part of the 20th century.
This, in turn, prompted a continuing debate as to how the interpretation of conflict and defences, the hallmark of ‘classical’ psychoanalysis for symptomatic neuroses should be modified to treat character neuroses (i.e. personality disorders). Symptomatic neuroses reflect conflicts over unconscious sexual and aggressive drives for which therapy offers the means to recognize and ‘own’ them, while personality disorders refers to the patient’s lack of stable identity and self-coherence, for which therapy offers a reparative experience so as to feel oneself more integrated.
Erik Erikson constructed a life-cycle model of personality based on ‘developmental tasks’. Acquiring a sense of stable identity is a developmental task of adolescence, one of whose pathologies is ‘identity diffusion’ (5). This concept became a feature of Otto Kernberg’s formulation of BPD, particularly relevant to the vexed question of making this diagnosis in adolescents. Adolescents are often moody and transiently emotionally unstable; this must be differentiated from emerging personality pathology, psychosis, or major mood disorder.
George Vaillant usefully arranged the defences in a hierarchy of developmental maturity, ranging from primitive and immature (e.g. projection, psychotic denial) seen in psychoses and severe personality disorders, to mature such as humour and altruism. Vaillant’s long-term study of a cohort of American male medical students, and his biographical essays about famous individuals (6), show that while the lives of some people with personality pathology follow a seemingly inexorably doomed trajectory, significant personality change for the better may occur throughout life, facilitated by such relationships as marriage and grandparenthood, and psychotherapy.
An partial integration of aspects of Kraeplin’s descriptive psychopathology and psychoanalytic conceptualizations of mental illness formed the basis of the first and second editions of the American Psychiatric Association (APA) Diagnostic and Statistical Manual (DSM). The World Health Organization (WHO) developed its own taxonomy, the International Classification of Diseases (ICD), which is similar in many respects to the DSM.
The first edition of the DSM (DSM-I) was developed in the United States after World War II by hospital doctors and military psychiatrists seeking a reliable nomenclature to differentiate people who were ‘genuinely’ mentally ill from those whose ‘bad’ behaviour was not a sign of an underlying mental illness. DSM-I reflected an American style of clinical practice influenced by the ideas of Adolf Meyer and psychoanalysis, buttressed by projective tests (the Rorschach and Thematic Apperception Test), and psychological questionnaires that did not differentiate clearly between personality disorders and other psychiatric syndromes.
Typified by Freud’s case of the ‘Wolf Man’, psychiatrists had described patients who, while not displaying sustained, clear-cut anxiety, depression, or psychosis, nevertheless suffered vaguely defined, partial manifestations of such disorders, considerable emotional distress, unstable or impoverished social relationships, and recurrent work difficulties. In the 1930s psychoanalysts suggested that such patients were ‘on the border’ between psychoses and neuroses, and they became known as having ‘borderline personality disorder’.
During their treatment three phenomena became apparent. First, the developmental issues they described were concerned with issues from the earliest phases of psychosocial development, where the patient’s fundamental sense of self often appeared to be at stake, rather than the developmentally more advanced conflicts about self-assertion and sexuality Freud had described. Secondly, when treated in psychoanalysis some patients deteriorated or became caught in repetitive cycles of desperate, sometimes suicidal neediness, alternating with angry accusations of betrayal or rejection by their long-suffering psychotherapists and hospital staff. Thirdly, though often profoundly distressed and possibly suicidal, they generally did not develop a psychosis, or if they did, it was short-lived, without deteriorating into schizophrenia.
For such patients, the multiaxial DSM-III (published in 1980) introduced the personality diagnoses of BPD and narcissistic personality disorder. It provided a special designation, Axis II, for the classification of personality disorders. DSM-III claimed adherence to Kraeplin’s method of objective, ‘theory-free’ observation. So while the terminology of borderline and narcissistic personality in psychoanalysis and DSM-III were and still are similar, they are the product of two different methods of enquiry, resulting in some confusion.
Another group of patients, who displayed subtle difficulties in cognitive processing and eccentric ways of assessing their environment, were diagnosed in DSM-III as schizotypal which, together with the schizoid personality (the loner), were formulated as lying on a biological continuum with schizophrenia.
In 1941 Hervey Cleckley (7) published his famous monograph The Mask of Sanity, in which he carefully described the psychopathic personality. Its core features of callousness, unemotionality, lack of remorse or guilt, lack of empathy, and an inability to accept responsibility for one’s actions were incorporated by Hare (8) into an assessment scale for this disorder. In clinical practice, the manipulative, exploitative, and sometimes violent nature of the psychopath, especially one whose personality includes powerful narcissistic and sadistic traits, may confound or disturb clinicians, particularly those who have either denied the severity of the psychopathology or believed that they could save the patient from himself. The anxiety and uncertainty such patients arouse may be a factor in the ill-fated Dangerous and Severe Personality Disorder Programme (DSPD) in the United Kingdom, which has raised concerns that some psychiatrists misrepresented or misjudged the clinical and ethical difficulties involved in its implementation.
Controversy still attends the failure of DSM-III to differentiate clearly between psychopathy and antisocial personality disorder (ASPD). The pathology of the former is probably genetically, neurobiologically, developmentally, and psychodynamically different from ASPD. The latter may refer to behaviours which violate social norms, but without displaying the features described by Cleckley.
In DSM-III the hysterical personality was renamed ‘histrionic’, describing the emotionally shallow but flamboyant, self- dramatizing, attention-craving person. Some psychoanalysts have used the term ‘histrionic’ to describe a borderline level of functioning person, with a vulnerable sense of self (what the psychoanalyst Elizabeth Zetzel described as the ‘bad’ hysteric), while retaining the term ‘hysterical personality’ for a better-integrated patient whose anxiety is largely confined to expressions of sexuality in relationships (Zetzel’s ‘good’ hysteric).
The resulting clusters of personality disorders agreed upon in the DSM-III were Cluster A (odd or eccentric): paranoid, schizoid, and schizotypal; Cluster B (dramatic, emotional, or erratic): antisocial, borderline, histrionic, and narcissistic; and Cluster C (anxious or fearful): avoidant, dependent, and obsessive-compulsive. The groupings have persisted in subsequent DSM editions. Amid ongoing controversy, several other types of personality disorder appeared and disappeared in subsequent revisions of DSM. These include the depressive, sadomasochistic, and passive-aggressive personality disorders, terms which clinicians often find useful, but which formal research does not (yet) warrant according the status of distinct categories. Given the overlap between the various personality subtypes, and the lack of a sharp cut-off between normality and psychopathology, current thinking favours a dimensional rather than categorical approach to classification.
Using techniques of play to understand the inner world of children, Melanie Klein concluded that unconscious fantasies of self and other, shaped by innate sexual and aggressive drives, were present from the earliest days of postnatal life. Her contemporary Donald Winnicott emphasized how the thoughts, feelings, and actual behaviour of the mother, particularly her ability to understand and respond appropriately to the baby’s needs (what he termed the ‘facilitating environment’) influenced the baby’s personality development.
Although Klein did not address the personality disorders directly, her account of ‘positions’ (9) helped shed light on the subject as the following clinical vignette illustrates.
‘Anna’, a patient with a BPD, unexpectedly brings her 2-year old son to a psychotherapy session. Calm, almost cheerful, she begins with an anecdote about a recent matter she had handled competently. Then, as she turns to describing her ‘empty’ depression the toddler begins to fidget, crawls over her chest, partly obscuring her view of me, and begins to whimper. Anna’s demeanour changes abruptly; she flushes angrily, heaves the child off her lap and dumps him roughly on the floor beside her armchair. ‘You’re a pest, Charlie, Charlie bad boy!’, she hisses, then, turning to me apologizes ‘I’m sorry, doctor’ (she usually calls me Ed), ‘I should have fed him before coming, or left him somewhere, but I couldn’t find a sitter, I’m sorry.’
Anna seems to be experiencing her child as totally bad, and does not understand his behaviour. She also feels a failure, and ‘knows’ (via projection) that I judge her accordingly. Instantaneously, therapy has been transformed into a kangaroo court, with the three participants ‘trading’ perceptions of victim and victimizer. Anna’s emotionally charged judgment is total, totally bad, with little room for shades of grey. Klein referred to this as a part-object experience, where a partial view of self or other becomes the whole.
I also feel a tension in myself. I feel protective towards Charlie and have an urge to ask Anna not to be so harsh, since his trivial misbehaviour probably reflects his sensitivity to her distress. Yet, if I say this, she might feel unfairly judged or criticized. If I say nothing, I collude with her hostility and unfair criticism of him.
Klein described how such recursive intersubjective experiences are caused by projective identification. In projective identification one person in a relationship unconsciously splits off and projects an unacceptable or painful aspect of themselves into a recipient who receives it and feels a subjective impulse to respond unthinkingly so as to rid himself of the projected feeling. So, Anna struggles with her sense of innocence, and vulnerability; unconsciously, she splits off and projects her sense of badness into Charlie and into me. This creates my countertransference discomfort.
If her husband has a Cluster B personality disorder, he might, via projective identification, experience Anna’s distress and anger as criticism, and feel that she expects him to act decisively on her behalf. He might also perceive Charlie as ‘all bad’ for having upset Anna, for devaluing his status as a caring husband, and causing their marital tension, whereupon he might punish Charlie severely. Anna and her husband might thereby re-establish an idealized sense of goodness about themselves as individuals and as a couple, and locate the badness outside their relationship, in ‘guilty’ Charlie (or in me, if they believed I judged them unfairly). Such family dynamics often underpin marital violence and child abuse, and failures of therapy.
Instead of either trying to protect Charlie or ignoring the situation so as not to upset Anna, I try to ‘mentalize’ my experience (i.e. I try to bear the feelings and reflect upon their nature and possible significance for both Anna and me). I try to offer Anna a way of understanding herself, Charlie, and me in this context in a way that differs from her emotionally fraught, judgmental, ‘all good’ vs ‘all bad’ way. I say:
‘Anna, when Charlie interrupted you, I think he made you angry. Maybe he made you feel that that you’re not worthy of care. It’s as if you feel Charlie takes over and says that you don’t matter because you did something wrong.’ Anna became tearful, and talked about her intolerance of mistakes, and self-blame following even trivial errors. She began to realize that blaming Charlie was a defence against feelings of self-blame and unworthiness that dominated her view of herself.
Klein described the switches between these all-good vs all-bad states of mind as characteristic of the paranoid–schizoid position. The ‘positions’ are not stages of personality development but configurations of a person’s experience of self and others which recur throughout life. In the paranoid–schizoid position the defences are pathological denial, splitting, projection, and toxic projective identification. Together with extremes of idealization or denigration of oneself or others, they are typical of the BPD.
In the depressive position, Klein posited that more mature defences enable a person to develop a capacity to tolerate emotional ‘shades of grey’ in himself and others, and to bear his own mixed feelings towards others. He also recognizes that he lacks the valuable qualities the other offers, and for which he is genuinely grateful, without recourse to envy, false humility, contemptuous devaluation, or omnipotent control. These latter characteristics constitute what Winnicott termed the manic defence (10).
Instead of genuine grief, loss in the paranoid–schizoid position, according to Klein, is defended by denial, contempt for self-weakness, scornful devaluation of others, and ‘entitled’ anger. Rosenfeld (11) called this ‘malignant narcissism’. It is manifest in many severe forms of personality psychopathology, and may be particularly relevant to the dynamics of the suicide risk of a person for whom such an act may appeal as the last-ditch expression of self-assertiveness and self- validation. Winnicott (12) proposed the notion of the ‘false self’, wherein the child unconsciously modifies its developing ways of knowing and being in order to conform to the expectations and needs of parental figures. Personality disorders reflect one possible outcome of this experience. They are prone to ‘basic anxieties’, which include the fear of falling forever, going to pieces, having no relationship to the body, having no orientation in the world, and a sense of total isolation. Such agonizing fears are difficult to express in words, perhaps corresponding to what the philosopher Søren Kierkegaard called ‘nameless dread’. The British psychoanalyst Ronald Britton (13) noted that the metapsychology of personality pathology implied by the formulations of Klein and Winnicott could be translated into the respective meta-theologies of the English poets John Milton and William Blake. Milton viewed intrinsically flawed human nature as striving towards an ideal self (God), but subverted by Satan (malignant narcissism, intrinsic pride/envy). Blake saw the true self (the innocence of the child’s innate primary narcissism, the beautiful/divine) as subverted by worship of the false self imposed by the demands of the external world (the god of organized religion/external authority/societal norms).
Translated into clinical practice, the Miltonian patient (the hostile-dependent Borderline, with all the badness inside) desperately needs the idealized other (lover or therapist) to save her from the tyranny of her inner world, without which she is overcome by rage, wounded pride, revenge, and despair. Conversely, the Blakean patient (the help-rejecting Narcissist, with the all the goodness inside), believes that total control over oneself, expressed as arrogant self-sufficiency, is a necessary bulwark against the inevitable humiliation and abandonment by untrustworthy others. Rosenfeld (14) similarly distinguished between what he termed the thin-skinned and thick-skinned narcissist respectively. These formulations are part of a more general vulnerability seen in patients with personality disorders which Balint termed the ‘basic fault’ (15).
These ideas were developed by John Bowlby (16); in his attachment theory he hypothesized that a child’s sense of secure attachment to its mother, or lack thereof, could have major effects on the child’s development throughout life. Based on Mary Aisnworth’s descriptions of specific attachment patterns, and measured by Mary Main’s Adult Attachment Interview Scale (16), researchers showed how attachment patterns shape the content and form of adults’ autobiographical narratives, and influence parenting styles, including attunement and responsiveness to their own children.
Fonagy and colleagues (16) have shown that an adult with BPD often had a disorganized attachment style in early childhood, resulting in difficulty in mentalizing. Fonagy (17) further demonstrated that childhood abuse has specific damaging effects on the brain’s attachment system, resulting in the subjective experience of an ‘alien self’, an experience so intolerable, that unless it is externalized via projective identification into another person, self-attack or suicide may feel like one’s only option. The other, into whom such projections and projective identification occurs, is then experienced by the patient as a dangerous, alien other. This may explain some of the subjective and interpersonal difficulties of patients with BPD.
Claiming affinity with the ideas of Wilhelm Reich and Anna Freud (though, curiously, omitting any mention of his contemporary, Winnicott), Heinz Kohut (18) argued that the personality trait of narcissism has a separate line of development throughout life, parallel to the capacity for object relations. Narcissism may be healthy and normal, rather than a stage in normal development to be resolved in order for the child to develop the capacity for mature love relations in adulthood. Rather than conflicts about unconscious sexual and aggressive drives as described by Freud and Klein, Kohut suggested that the narcissistically vulnerable person suffers from a deficit in his sense of self, caused by a failure of adequate parental mirroring of, and empathy for, the young child’s states of mind.
Otto Kernberg’s (19) formulation of BPD integrates Kleinian and Freudian approaches in a model where a patient’s unconscious representations of self and other, and the affective link between them, are activated by the patient’s relationship with the therapist and with significant others. Kernberg emphasizes unconscious aggression (which may have a genetic predisposition) expressed in the patient’s affects, and split-off in relationships. He proposes three levels of personality organization. The psychotic level includes schizoid and schizotypal personality disorder, and is a partially expressed form of psychosis. The borderline level includes BPD and severe narcissistic personality disorder, and utilizes defences of the paranoid–schizoid position. At the milder end of severity, the split is between sensual and affectionate feelings rather than with the whole self. The neurotic level displays an integrated, stable but conflicted sense of self, conforming to Klein’s depressive position. While at first glance it may appear difficult to reconcile Kernberg’s psychodynamically based system with the Kraeplenian-influenced DSM, it is possible that Kernberg’s model may describe endophenotypes, while the DSM describes their phenotypic manifestations.
The role of genetic, epigenetic, and other biological factors in the genesis of personality disorders have become the subject of burgeoning research in recent decades. Children who go on to develop BPD have a high prevalence of learning difficulties and attention deficit hyperactivity disorder (ADHD), and a tendency to dissociative states when emotionally aroused. This suggests that a neurodevelopmental defect may contribute to or amplify the failed empathy and destructive interpersonal relationships such children experience, leading to insecure attachment (20).
Animal studies have shown that disruptions of early maternal handling, grooming, and attachment cause abnormalities in the corticotrophin stress response, the oxytocin–vasopressin system, and the genes that codes for serotonin (5HT) transport. This increases the reactivity of the anterior cingulate–amygdala circuitry, creating a neuro-biological vulnerability to BPD (21).
In psychopathic personality disorder a gene–environment interaction has been demonstrated between maltreatment in childhood and activity of the monoamine oxidase A (MAOA) gene, such that a child with low-level activity of MAOA is more susceptible to the adverse effects of childhood maltreatment (22). Children and adults with a psychopathic (callous–unemotional) personality profile have been found to have a reduced amygdala response to what normal subjects experience as frightening or distressing imagery. This reduced response may account for the high failure of psychological therapies with such patients.
Seven treatment models of proven effectiveness currently exist for the treatment of BPD: mentalization-based therapy (MBT), transference-focused psychotherapy (TFP), the conversational model (influenced by Kohut), cognitive analytic therapy (CAT), cognitive behaviour therapy or schema-focused therapy(CBT/SFT), dialectical behaviour therapy (DBT), and a general psychiatric model utilizing principles common to all these models (23). I shall concentrate on the psychodynamically informed models with which I am most familiar in my clinical practice.
The demands patients with personality disorders make on their clinicians are considerable. As Gabbard (24) perceptively documented, boundary violations often occur when a therapist feels impelled (by projective identification and the dynamics of the transference–countertransference relationship) to believe that only he can cure the patient’s distress or save them from suicide. The resultant boundary violations may range from inappropriate disclosure by the therapist of personal information to the patient, or out-of-hours social meetings with the patient, to sexual relations. By contrast, according to Winnicott, appropriate psychotherapy is akin to offering the patient the ‘good-enough’ parenting he may not have had (or, from Klein’s perspective, that he may have ‘spoiled’ because of this own innate aggression and envy). The therapist creates a ‘holding environment’ in which the patient feels psychologically ‘held’, understood, and gradually learns to recognize and understand himself the way the therapist does.
Kohut advocated that in psychotherapy with narcissistic personality disordered patients, the therapist should adopt a stance of empathic mirroring (therapist as a ‘self object’), rather than interpreting the patient’s conflicts in the transference. In this way, he would foster a strong (albeit temporary) idealization of the patient’s self and the therapist. This is the natural response of the young child to feeling understood and validated by a powerful parental figure. When experienced in a therapy context this repairs the patient’s sense of self, and reduces the need for the narcissistic defences the patient has been unconsciously using to protect himself against the consequences of parental empathic failure.
Kohut’s concept of empathy is intuitively appealing for many practitioners, though he did not describe how the capacity for empathy actually develops in a person. It is probably based on projective identification and the resulting processes of attunement, reverie, holding (in mind), and primary maternal preoccupation, as described in detail by British Kleinians and object relations clinicians (although they did not use the term ‘empathy’). Its neurobiological foundations may be the system of mirror neurons in the brain, specialized nerve cells which fire in anticipation of one’s own actions or upon observing or imagining the behaviour of others. This may form part of the neurological substrate of understanding the meaning of another’s behaviour (25). Two forms of empathy and their anatomical correlates have been described (26). The inferior frontal gyrus (Brodman’s area 44) is involved in an emotional form of empathy (a prereflective, prelinguistic form of affective recognition or ‘emotional contagion’), while the ventromedial areas of the cortex (Brodman’s areas 10 and 11) subtend a cognitive form of empathy (perspective-taking, mentalizing, and having a ‘theory of mind’). The controversy between the two broad approaches to the psychodynamic psychotherapy of personality disorders (interpretation/insight vs empathy/reflection) may reflect the relation between these two neurobiological systems.
Bateman, Fonagy, and colleagues’ model of MBT (27) has been devised to help patients improve their reflective function by developing an understanding of their affects and cognitions, and a corresponding understanding of the mind of others. Kernberg has criticized the model because while it modifies both the patient’s experience of the ‘alien’ (victimized) self, and the ‘alien’ other by whom the patient feels persecuted or betrayed, it does not adequately challenge the split-off victimizing or persecuting aspect of the patient and its consequences for the other who is the recipient of such unacknowledged aggression from the patient. Kernberg’s TFP (28) aims to integrate the split-off parts of the personality, particularly aggression, arguing that without this, the patient may improve symptomatically, and therapy might be mutually gratifying for therapist and patient, but the latter’s relationships outside therapy may remain dominated by splitting, self-idealization, and destructive forms of projective identification. Such criticism also applies to CBT and related therapies. Although Kernberg offers anecdotal evidence in support of such criticism, this has not yet been systematically tested.
Kernberg’s approach has in turn been criticized because if the patient experiences interpretations as highlighting reprehensible or shameful aspects of his personality, he is likely to feel attacked or judged by the therapist, resulting in iatrogenic retraumatization. One possible solution emerging from the clinical experiences of skilled psychotherapists offering longer-term therapy for patients with BPD is that the initial (supportive/reflective) phase of therapy seeks to repair the patient’s sense of self, using the therapist’s empathy, ‘holding’, and reflective function, so that the vulnerable patient learns to mentalize. In the later (expressive/interpretive) phase of therapy, judicious interpretation may address those split-off, emotionally charged aspects that Kernberg warns are avoided in the first phase.
Alternatively, it may be possible to do both concurrently. The therapist’s prefatory remarks and tentative way of offering an interpretation minimize its judgmental quality and conveys the therapist’s genuine concern for the patient. For example, ‘I have an impression …’, ‘Is it possible that you might be feeling …?’, ‘I wonder if …’. Then, if the patient does feel blamed or judged, this may be explored further, using both empathy and judicious interpretation.
The above controversy highlights the universal difficulty any person has in simultaneously understanding both his own states of mind and those of others, though it is much more difficult for people with personality disorders. Some therapies (e.g. Kohut’s) emphasize the former, Kernberg’s the latter. Recognizing that the transference straddles both, John Steiner differentiated between patient-focused interpretations (i.e. what the therapist thinks the patient is feeling about himself) and therapist-focused interpretations (what the therapist thinks the patient is feeling about the therapist).
Alternative or supplementary forms of therapy to the patient–psychotherapist dyad are group therapy, pioneered by W. Bion, and the therapeutic community of Maxwell-Jones, in the 1950s and 1960s, and applied by Main (29) to inpatient care of patients with BPD and other disorders. These approaches, which have been adapted to day hospital and outpatient settings, recognize that the patient may either project into or become the receptacle for the projections of others, including other patients and staff. Attention to these dynamics reduces the behaviour escalation, rejection, and scapegoating which are often enacted within the group or ward by patients and staff. These principles are relevant for all psychiatric patients. Family therapy, involving psychoeducation and exploration of family dynamics, including traumas, secrets, and losses, has also been applied.
Although their contribution is often modest, psychotropic medications, including antidepressants, low-dose antipsychotics, and mood stabilizers are sometimes effective in treating BPD, especially those patients with pervasive anger or marked affective instability. Low-dose serotonin reuptake inhibitors (SSRIs) or a monoamine oxidase inhibitor (MAOI) may be useful in treating the Cluster C avoidant personality disorder, which may reflect the latter’s neurochemical links with social anxiety.
A psychiatrist working alone may offer both psychotherapy and medication, provided that considerations about the latter do not dominate treatment sessions. Where treatment is divided between two or more clinicians, their respectful, regular collaboration and clear delineation of responsibilities will help avoid rivalry, unconscious splitting, and destructive projective identification.
Comorbidities commonly occur between personality disorders and Axis I disorders, including anxiety disorders, major depression, and alcohol and substance abuse. The presence of one or more personality disorder often increases the severity and reduces the effectiveness of treatment of the Axis I disorder (30). However, when effective, treatment of the Axis I disorder may improve the personality disorder, and vice versa.
Given the complexity, heterogeneity, and comorbidities of BPD, it is unlikely that of the psychotherapy models shown to be effective, one will prove superior for all patients. A rationale for matching patient and model or a flexible, integrated model are needed. Much less is known about the nature and treatment of other personality disorders.
Criticisms abound of the DSM Axis II. Experienced clinicians have claimed that it does not adequately represent the realities of clinical practice, particularly the unconscious meaning of the patient’s interpersonal difficulties. For example, anger in a person with BPD may signify fear of rejection; in a narcissistic personality disorder, anger may reflect challenges to self-worth; in a dependent personality disorder, fear of rejection might lead initially to anxiety rather than anger, so anger is not mentioned as a diagnostic feature. However, in the course of therapy, the patient may recognize that anger unconsciously fuels his anxiety. In clinical practice such themes defy a clear taxonomy.
Including a particular personality characteristic in more than one diagnostic category leads to one or more comorbidities, while excluding it is inconsistent with clinical reality. The Sheldon–Westen Assessment Procedure (SWAP) (31) addresses this problem in terms of a patient’s resemblance to a prototype along several dimensions. For example, the characteristic ‘lacking in empathy’ appears differently in different prototypes of personality disorders. The narcissistic personality disorder does not readily recognize the needs of others (SWAP describes this as the internalizing mode), the antisocial recognizes the needs of others but may try to exploit them (SWAP’s externalizing mode), while the borderline cannot understand others when he is overwhelmed (SWAP’s borderline mode).
The DSM does not rate the severity of personality disorders. Many patients may not meet all the DSM criteria for a diagnosis of a personality disorder, yet suffer deeply and also cause great distress to others. For example, patients with BPD who attempt suicide have a suicide rate of approximately 1% per year, which means tragically, that over the course of a decade, 10% of such patients, most of them young adults, will have killed themselves. Many others do not commit suicide, but lead lives of recurrent chaos, anger, and desperation.
Another criticism levelled against the DSM is its neglect of clinically useful psychodynamic constructs, such as defences, unconscious guilt, and transference patterns, in favour of relatively naive Kraeplinian descriptions of observed behaviour.
People do not live in a social vacuum. DSM ignores contextual (particularly family), cultural, racial, gender, socioeconomic, and historical factors which influence personality development. Behaviour or attitudes deemed pathological in one culture may be considered normal or desirable in another. For example, a woman’s constant deference to her husband might be considered appropriate in a traditional Japanese or Middle Eastern family, but deemed submissive or dependent in Western society. The diagnosis of a personality disorder may be particularly questionable in a member of a group in society which is marginalized, oppressed, or disenfranchised. However, recognizing the effects of physical and psychological trauma on personality development may mean that the person receives effective therapy rather than a punitive judicial response.
Another question concerns the stability of personality disorders over time. By definition, they are ‘enduring’ or ‘lifelong’. However, longitudinal studies, including Vaillant’s study of Harvard medical students and studies of BPD (32), indicate that, notwithstanding fluctuations, a trend towards amelioration of personality dysfunction often occurs over time, usually years. Relationships with emotionally significant others have been found to be a factor in this improvement, though the direction of causality is unclear. However, patients who experienced childhood physical and sexual abuse and have PTSD-like experiences have a poorer prognosis, and usually need longer-term psychotherapy.
These considerations suggest that integrating Axis I with Axis II on a continuum of severity better reflects clinical reality. One resulting classification is derived from Robert Cloninger’s Temperament and Character model (33) which describes two domains of personality structure: Temperament, based on associative or procedural learning, and Character, based on insight learning. Temperament, which may be genetically based (the DRD4 and SLC6A4 genes are implicated), consists of four dimensions, each linked to a genetically influenced neurotransmitter function: harm avoidance (serotonin and GABA), novelty seeking (dopamine), reward dependence(noradrenaline and serotonin), and persistence (glutamate and serotonin). Character, the result of social learning or life experience, consists of three activities: self-directedness, cooperation, self-transcendence. In this model, Cluster B personality disorders, which include BPD, narcissistic personality disorder, and histrionic personality disorders, are low on self-directedness and cooperativeness, and high in novelty seeking. Cluster C personality disorder patients, which include dependent and avoidant personality disorders, are high in harm avoidance.
Another model, using behavioural genetics, describes how the component traits of a personality disorder (e.g. affective instabilty and impulsivity in the BPD) are exaggerations of traits found in normal personalities (34).
In the DSM-V, personality disorders are described as dimensionally arranged traits rather than distinct categories, reflecting a person’s ability to fulfil basic life tasks: for example, having a coherent and adaptive internal working model of self and others, capacity for long-term intimate relationships, and capacity for stable employment. ‘Middle America’s’ values underpin these criteria, and psychodynamic constructs are still omitted.
The transmission of personality psychopathology across the generations lies at the heart of the historic nature–nurture debate. Today, we can better understand this.
Some predisposition to and transmission of psychopathology are genetically mediated to varying degrees (35), sometimes for specific personality disorders (schizotypal personality has abnormalities in dopamine metabolism, BPD has abnormalities in serotonin); while in others familial psychopathology (e.g. anxiety) acts as a genetically mediated but non-specific predisposition to an array of psychiatric disorders, including personality disorders. Both patterns are nature’s contribution.
Equally, parents with a psychiatric illness (including personality disorder) or physical illness may be impaired in their ability to empathize with and respond supportively to their child (36). This constitutes the faulty nurture dimension. Twin studies demonstrate that the picture is further complicated by the fact that children have genetically influenced capacities to elicit, to be affected by, and to report positive and negative patterns of parental behaviour (37,38).
Defective nurture influences neurobiological processes in the child; for example, the disturbed parent uses primitive defence mechanisms when relating to their child. These defences which may include toxic projective identification, may result in neuro-biologically mediated, non-genetic, insecure attachment patterns in the child, negative identifications, a fragile or deficient sense of self, and a hypersensitive readiness to ‘fight–flight’ responses in relationships. All this may predispose to the development of BPD in early adulthood.
The study of personality disorders arose from the belief that some fundamental process makes us who we are—unique as individuals, yet sharing characteristics which lead us to relate, for better or worse, to one another. Many disciplines have searched for these foundations—clinical psychiatry, psychoanalysis, neuroscience, poetry, literature, philosophy, history, and political science. In addition to the privilege of practicing a medical specialty, the delight of being a psychiatrist for me is the freedom to explore how these differing disciplines contribute to the study and treatment of personality disorders.
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