Disorders of Personality: Introducing a DSM ICD Spectrum from Normal to Abnormal (Wiley Series on Personality Processes)

1109 Pages·2011·7.99 MB·English

by  Theodore Millon

DISORDERS OF
PERSONALITY
Disorders of Personality: Introducing a DSM/ICD Spectrum from Normal to Abnormal, Third Edition
by Theodore Millon
Copyright © 2011 by Theodore Millon, Author, Inc. All rights reserved.
By the Same Author
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ExperimentsinPsychology(C-A)
TheoriesofPsychopathology(E)
ApproachestoPersonality(E)
ModernPsychopathology(A)
ResearchMethodsofPsychopathology(C-A)
TheoriesofPsychopathologyandPersonality(E)
AbnormalBehaviorandPersonality(C-A)
MedicalBehavioralScience(E)
DisordersofPersonality(A)
HandbookofClinicalHealthPsychology(C-E)
TheoriesofPersonalityandPsychopathology(E)
PersonalityanditsDisorders(C-A)
ContemporaryDirectionsinPsychopathology(C-E)
TowardaNewPersonology(A)
PersonalityandPsychopathology(A)
DisordersofPersonality-II(A)
TheMillonInventories(E)
Psychopathy(C-E)
Personality-GuidedTherapy(A)
OxfordTextbookofPsychopathology(C-E)
PersonalityDisordersinModernLife(C-A)
HandbookofPsychology:V(C-E)
PersonalityDisordersinModernLife-II(C-A)
MastersoftheMind(A)
OvercomingResistantPersonalityDisorders(C-A)
ResolvingDifficultClinicalSyndromes(C-A)
ModeratingSeverePersonalityDisorders(C-A)
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MillonAdolescentPersonalityInventory(C-A)
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MillonAdolescentClinicalInventory(C-A)
MillonClinicalMultiaxialInventory-III(A)
MillonIndexofPersonalityStyles(C-A)
MillonPre-AdolescentClinicalInventory(C-A)
MillonCollegeCounselingInventory(C-A)
MillonPersonalitySpectrometer(C-A)
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DISORDERS OF
PERSONALITY
Introducing a DSM/ICD Spectrum
from Normal to Abnormal
Third Edition
Theodore Millon
John Wiley & Sons, Inc.
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LibraryofCongressCataloging-in-PublicationData:
Millon,Theodore.
Disordersofpersonality:introducingaDSM/ICDspectrumfromnormaltoabnormal/by
TheodoreMillon.—3rded.
p.;cm.
Includesbibliographicalreferencesandindex.
ISBN978-0-470-04093-5(cloth:alk.paper);ISBN978-0-470-89092-9(ebk);ISBN978-0-470-89100-1(ebk);
ISBN978-0-470-89101-8(ebk);ISBN978-1-118-09925-4(obook)
1.Personalitydisorders.2.Personalitydisorders—Classification.3.Diagnosticandstatisticalmanualofmental
disorders.5thed.4.Internationalstatisticalclassificationofdiseasesandrelatedhealthproblems.11threvision.
I.Title.
[DNLM:1.Diagnosticandstatisticalmanualofmentaldisorders.2.PersonalityDisorders.3.International
ClassificationofDiseases.4.PersonalityDisorders—classification.WM190M656da2011]
RC554.M542011
616.85’81—dc22
2010018069
PrintedintheUnitedStatesofAmerica.
10 9 8 7 6 5 4 3 2 1
DEDICATIONS
Tomymentors:GardnerMurphy,KurtGoldstein, and ErnstKris
Who built thefoundations
Tomy colleagues:MelSabshin,HerbReich, andNiels Strandbygaard
Who pavedtheway
Tothe APFTheodoreMillon Mid-CareerAwardees:
DrewWesten,RobertBornstein,RobertKrueger,Aaron Pincus,
MarkLenzenweger,Mark Blais, and BrentRoberts
Who, with mymostscholarly and innovative students:
MichaelAntoni, CarylBloom, NeilBockian, RogerDavis,Seth Grossman,
CarrieMillon, Sarah Minor, SteveStrack, and RobertTringone
Will carryourbest ideasand research forward
CONTENTS
Preface ix 9 AggrandizingStyles,DeviousTypes,
AntisocialDisorders:TheADA
PartI Historical,Theoretical,
Spectrum 423
andMethodologicalFoundations 1
PartIII IntrapsychicallyConflicted
1 Historical,Modern,andContemporary
Spectra 477
ApproachestoPersonology 3
10 ReliableStyles,ConstrictedTypes,
2 SourcesofPersonologicand
CompulsiveDisorders:TheRCC
PsychopathologicDevelopment 63
Spectrum 479
3 ClinicalMethodsandInstrumentsof
11 DiscontentedStyles,ResentfulTypes,
PersonalizedAssessment 119
NegativisticDisorders:TheDRN
4 LogicandModalitiesofPersonalized Spectrum 526
Psychotherapy 180
12 AbusedStyles,AggrievedTypes,
5 ClassificationConsiderations,DSM-5 MasochisticDisorders:TheAAM
Prelims,andProposalsfor Spectrum 572
Personology 232
13 AssertiveStyles,DenigratingTypes,
PartII InterpersonallyImbalanced SadisticDisorders:TheADS
Spectra 285 Spectrum 616
6 DeferentialStyles,AttachedTypes,
PartIV EmotionallyExtremeSpectra 661
DependentDisorders:TheDAD
Spectrum 287 14 ApatheticStyles,AsocialTypes,Schizoid
Disorders:TheAASSpectrum 663
7 SociableStyles,PleasuringTypes,
HistrionicDisorders:TheSPH 15 ShyStyles,ReticentTypes,Avoidant
Spectrum 330 Disorders:TheSRASpectrum 708
8 ConfidentStyles,EgotisticTypes, 16 DejectedStyles,ForlornTypes,
NarcissisticDisorders:TheCEN MelancholicDisorders:TheDFM
Spectrum 375 Spectrum 754
vii
viii CONTENTS
17 EbullientStyles,ExuberantTypes, 19 UnstableStyles,BorderlineTypes,
TurbulentDisorders:TheEET CyclophrenicDisorders:TheUBC
Spectrum 798 Spectrum 890
20 MistrustfulStyles,ParanoidTypes,
ParaphrenicDisorders:TheMPP
PartV StructurallyDefectiveSpectra 829
Spectrum 953
18 EccentricStyles,SchizotypalTypes, References 1009
SchizophrenicDisorders:TheESS AuthorIndex 1061
Spectrum 831 SubjectIndex 1079
PREFACE
Guidingtheprinciplesandcontentofthisbook Diagnostic and Statistical Manual of Mental
is Darwin’s concept of natural selection. In line Disorders(DSM-5),scheduledforpublicationby
with this ‘‘law’’, personology and personality the American Psychiatric Association in 2013.
disorderareconceivedasvarietiesofsuccessful AlthoughtheDSMwillbemorecomprehensive
and failed natural selection efforts by humans descriptively than its predecessors, it will not
as they attempt to achieve an optimal balance be sufficient in scope to provide fully detailed
among the three essential elements comprising clinical or theoretical presentations of the
life:(1)existentialsurvival(avoidingdeath/pain personalitystylesanddisordersitencompasses.
andenhancinglife/pleasure);(2)ecologicaladap- The lack of such materials will continue to
tation (environmental accommodation/passive be especially troublesome to those seeking
and environmental modification/active); and substantial information on the many historical,
species replication (maximizing reproduction/ modern,andcontemporaryconceptionsofthese
selfandnurturingprogeny/others). clinical impairments. These mental syndromes
The task of authoring and improving the have ‘‘come of age,’’ having been transformed
most successful professional-level book in the from a class of pathology possessing only inci-
field (the first two editions sold some 70,000 dentalrelevancetothediagnosticenterpriseinto
copies in 27 printings) is not merely to tweak onethatiscentraltotheDSM’smultiaxialformat
prioreditionsortotransmitrecentlyestablished andto professional’severydaywork.Although
knowledge, but to introduce substantive and cliniciansandresearcherswillfindconsiderable
innovativeideasthatwillfurtherguidedevelop- literatureonotherpsychopathologicsyndromes
mentsinthesubject.Ihavesoughttofulfillthis instandardtextsandjournals,suchinformation
latterrolebyprovidingastrongtheoreticalbase hasonlyrecentlybeguntoaccumulateforasmall
forallyingandintegratingnormalandabnormal numberofthepersonalitystylesanddisorders.
personality spectrum concepts in accord with Now that these syndromes have been assigned
Darwinian evolutionary ideas, as well as to the status of major clinical entities, the need to
elaborate a dimensional schema of traits for developacomprehensiveandinnovativeprofes-
therapeutic planning. I have also presented sionalreferenceandlearningtooltofillthevoidis
an entirely new personality classification—the allthemoreimportant.Itisinthesenseoffilling
ebullient/exuberant/turbulent spectrum—and thevoidthatthis thirdedition text,comprising
haveenrichedthetextwithextensiveup-to-date morethan1,000double-columnedpages,ascom-
research literatures, as well as to incorporate paredto the DSM’s much more modest Axis II
morethan50newtherapeuticallydetailedcases. section,maybeseenasaneededprofessional’s
This book may be seen as an introduction and advanced student’s companion volume to
and companion volume to the forthcoming both the DSM and the more likely even briefer
ix
x PREFACE
personality section of the ICD-11, the official whatdiseasethepatienthas,butratherwhothe
manualoftheWorldHealthOrganization. patientiswhohasthedisease.’’Styles,types,and
NotonlyhastheDSM-5committeealteredits disordersofpersonalityarenotmedicalentities;
name tothatofthePersonalityandPersonality nor should they be seen as human perversities
Disorders Work Group, but there has been an either. Viewed from an ecological and evolu-
increasing recognition in the field that normal tionary perspective, we conceive them as prob-
and abnormal personality conceptions be orga- lematic styles of human adaptation. They rep-
nized within a single conceptual framework. resent unique individuals whose constitutional
Proposing a single superordinate framework makeupandearlylifeexperienceshavenotonly
for unitizing normal and abnormal styles and misdirected their development, but have also
disorders hasbeenan energizingandchalleng- constructedanunsatisfyingsenseofself,aprob-
ingprospectamongrecentgenetic,clinical,and lematicwayofexpressingthoughtsandfeelings,
statisticalresearchers.Intriguingandpromising aswellasatroublesomemannerofbehavingand
thoughtheseeffortshavebeen,thereisnocon- relatingtoothers.Eachofthe‘‘classical’’person-
sensus as to which of them is likely to achieve alities,aswellastheirsubvarieties,demonstrate
a reasonable level of accord. It is in this book forusthemanycomplexstructuresandstylesin
where I have moved vigorously forward with whichwebecomethepersonsweare.
thenovelproposalthatacoordinatedstructural Ratherthanbeseenmerelyasasupplementto
model based on Darwinian theory can provide themoretraditionaldiagnosticentitiesofAxisI,
the overarching framework for identifying and personality serves as a distinctive context, a
articulating normal and clinical personality constraining and shaping pattern of persistent
styles,types,anddisordersspectra. influences that gives meaning and character
Given the fractionalized character of theory to whatever clinical disorders may also be
in personology, which heretofore has exhibited present in the individual, be it of a physical
no credible consensually shared concepts, nor nature, such as cancer or heart disease, or a
possessing a synthesizing framework to guide psychicone,suchasschizophrenia.Toillustrate
thefieldsatisfactorily,itappearedtomethatour within our own field, a unipolar depression
‘‘science’’shouldbegintosearchforanoverar- will be experienced and reacted to differently
ching substantive system that would galvanize in an individual with an avoidant personality
itsdisparateparts,asystemthatwasbuiltonthe than in one with a narcissistic personality. Not
variegatedbedrockofevolutionaryprinciples. only will dissimilar circumstances provoke the
Without evolution’s widely accepted intel- divergent vulnerabilities that characterize each
lectual grounding, I believe that our field will of these personalities, but they will also evoke
continue to be buffeted and misled by the contrastingwaysofperceivingandcopingwith
arcana of tangential concepts and doctrinaire thesecircumstances.Fortheseandotherreasons,
hypotheses,aswellasbyweaklydesignedexper- webelieve thatclinicians should beorientedto
imentsthatgainlegitimacyviacleverstatistical the‘‘contextofpersonality’’whentheydealwith
manipulation of data that offer the illusion of allmedicaldiseasesandallformsofpsychiatric
progress. disorders.
Ifourfieldistotrulyprogress,however,we Itisnooverstatementtodescribethegrowth
mustnotbetoofearfulofbeingtooimaginative of the field of personality disorders as expo-
or too timid to confront digressive ideologies nential since the first edition of this book was
or absurdist methodologies. It is time to put publishedthreedecadesago.Thespeedofboth
forth innovative and powerfulvisions that knit theoretical and empirical developments contin-
togetherthebestofourhistoricalachievements, uesatanacceleratedpace,fosteredgreatlybythe
aswellasthoseofothersubjectsthatderivefrom inauguralpublicationoftheJournalofPersonality
thetheoreticalfoundationofallourlifesciences, Disorders in 1987, and the formal organization
thatofevolution. of the International Society for the Study of
Thethesisorrationaleforthistextstemsfrom PersonalityDisordersin1988.Owingtomyclose
an ancient injunction to physicians: ‘‘Ask not participation and continued involvement in
PREFACE xi
bothventures,eachofwhichservesasaprimary refashionedwhatappeartobedivergentviewsto
vehicletoadvancethestatusandcross-cultural fitacoherentintegrativemodelthatcoordinates
importance of personologic studies, I have had normalities and abnormalities, as well as one
a front row seat as the quickening pace of grounded fundamentally in principles derived
this evolving field has progressed. Despite the fromevolutionarytheory.
ever-expanding nature of pertinent concepts The historical and conceptual background
and findings, there is little in this avalanche of this integrative Darwinian model is elabo-
of information and trends to which I have not rated in Chapters 1 and 5; Chapters 2, 3, and 4
beenprivy. providethelogicandtechniquesforunderstand-
As one of the first appointees in 1974 to the ing personality development, assessment, and
American Psychiatric Association’s Task Force therapy. The application of these concepts to
on Nomenclature and Statistics, the committee both the diagnosis of 15 personality spectra,
responsible for developing the DSM-III, I was normal and pathological and their treatment is
most fortunate to participate in the group’s elaboratedinChapters6to20.
deliberations from the very start. Especially Given the many advances in conceptual
gratifying were opportunities to persuade col- and empirical research these past two decades,
leaguesoftheutilityofaninnovativemultiaxial the time has come for developing fresh and
formatand,substantively,toprovidetheinitial far-reachingconceptualschemasthatinterweave
drafts and diagnostic criteria for each of the and coordinate knowledge gained in adjacent
personality disorders. Similarly, I was pleased fields of scientific endeavor. Toward that end,
againtobecalledontoserveasafullmemberof I have devised a new classification schema of
theDSM-IV,AxisIIWorkGroup.Thosewhoare personality spectra, one constructed from its
acquainted with my prior writings will recog- inception by coalescing principles drawn from
nizetheinfluenceIhadontheDSM-III(e.g.,the evolutionarytheoryandbiosocialdevelopment.
concept of an Avoidant Personality) and, more Chapters 1 and 5, in addition to reviewing
recently, on the DSM-IV (e.g., the concept of a historically diverse conceptionsof classification
Negativistic Personality Disorder). Though not anddeduction,providethetheoreticalrationale
amemberofDSM-5’sWorkGroup,manyofits and logic for an evolutionary approach to the
latestdevelopmentsderivepartoftheirimpetus origins and development of normal styles and
fromideaspresentedinrecentbooksandpapers pathological disorders of personality. Not only
ofmine. does the schema serve to connect personality
It was my intent to write a sequentially pathologytootherrealmsofscientifictheoryand
unifiedbook,onethatwoulddemonstratehow research,italsodemonstratesthedevelopmental
the many varieties of personality, normal and continuity of pathological functioning through-
pathological, could be logically derived from a outlifeandtheinterconnectionsthatexistamong
fewbasicconceptsandprinciples.Mostauthors ostensiblyunrelatedsyndromes(stillconsidered
in psychiatry and psychology split their texts discreteentitiesaccordingtotheofficialDSM).
down the middle, so to speak, providing little I have progressed in my work from what
ornocontinuitybetweenthetheoreticalnotions I first labeled a ‘‘biosocial framework’’ to one
theypresentedintheearlychaptersoftheirbooks I now term an ‘‘evolutionary model.’’ Despite
andthesyndromesthatcomprisedlaterones. theirseemingdivergence,thesetwoconceptual
Someauthorshaveshapedtheirmaterialsin schemas are both consonant and consistent.
linewithnarrowtheoreticalmodels,forexample, The former derives its constructs largely from
neurobiologic, statistical, or psychoanalytic; learning theory and undergirds developmental
inevitably, these works compressed the rich ontogenesis; the latter includes constructs
diversity of clinical data into Procrustean beds, derived from evolutionary theory that are
discarding what did not suit their author’s applicable both to phylogenesis and human
predilections. In the hope of gaining the best adaptivestyles.Inthisreformulation,elaborated
of both worlds—that is, of being logically and forthereaderinChapters1and5,Ibelievethata
sequentially consistent—I have adapted and majorstephasbeentakentocoordinateconcepts