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Role of Personality in an Integrated Conception of Psychopathology  

The multiaxial model of the DSM has been specifically composed to encourage integrative conceptions of the individual's manifest clinical symptoms in terms of their place between long-standing personality styles and current psychosocial stressors. Our task as clinicians is to understand the preceding interaction in order to achieve a conception of each patient's psychopathology that does not merely diagnose or document his or her symptoms, the physical diseases that parallel the Axis I clinical syndromes, but also contextualizes these symptoms with reference to the larger context of the individual's personality style of perceiving, thinking, feeling, and behaving.

The movement toward integrationism in the conception of disease is both an ideal and an historical fact, illustrated by the evolution of the health sciences through two recent paradigm shifts, as portrayed below.

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The series of concentric circles in the figure above represent revolutions that have occurred in medicine over the past century. In the center, we find Axis I, the so-called clinical syndromes, for example, depression and anxiety. These parallel the state of medicine a hundred or more years ago, when physicians defined their patients' ailments in terms of their manifest symptomatology, that is, their sneezes, coughs,  boils and fevers, labeling these "diseases" with terms such as "small pox," on the basis of their superficial appearance.

The outer ring of the figure parallels Axis IV of the DSM. The related medical paradigm shift occurred approximately a century ago when illnesses began to be viewed as the result of intrusive microbes which infect and disrupt the body's normal functions. In time, medicine began to assign diagnostic labels to reflect this new etiology, replacing its old descriptive terms. "Consumption", for example, was retitled "tuberculosis" to signify the assaulting bacterium.

Medicine progressed further beyond its turn-of-the-century "infectious disease" model, an advance most striking these last 25 years owing to immunological science. This progression reflects a growing awareness of the key role of the immune system, the body's intrinsic capacity to overcome the omnipresence in life of potentially destructive infectious and carcinogenic agents that pervade our physical environment. Medicine learned that it is not the overt symptoms, the sneezes and coughs, nor the intruding infections, the viruses and bacteria, that are the key to health or illness. Instead, health and disease were seen to be a function of the competence of the body's own intrinsic defensive capacities. Millon asserted in his theory that in psychopathology it is not the overt anxiety or depression, nor the stressors of childhood or contemporary life that are the key to psychological well-being. Rather, it is the mind's equivalent of the body's immune system, that structure and style of psychic processes that represents our overall capacity to perceive and to cope with our psychosocial world that is the key determinant of mental health or disorder; it is, in other words, the psychological structure and function we term personality.

Elements of evolutionary theory were introduced by Millon in a 1990 book owing to his belief that its essential principles operate in all aspects of nature and scientific endeavor, from cosmogony, at one end, to human interactions, at the other. Pathological forms of human functioning were interpreted by Millon as disruptions or imbalances in those evolutionary principles that foster the functions of survival and ecologic adaptation. From this viewpoint, personality maladaptations could not be fully understood by limiting attention, for example, solely to cognitive preconceptions, or to unconscious repetition compulsions, or to neurochemical dysfunctions. rather, each of these psychological dysfunctions represent a partial expression of evolutionary functions that have gone awry. Cognitions, unconscious structures, interpersonal styles, and neurohormonal dynamics were viewed, in this formulation, as structural forms or functional mechanisms that reflect evolutionary processes. Each evolutionary structure or function is important in that it serves to identify one clinical domain in which pathology manifests itself, and hence becomes one vehicle for specifying and understanding that pathology. But, each of these manifestations and correlates are not the totality of pathology, however, but one of several expressions and mechanisms of problematic evolutionary structure or functions in realms cognitive, behavioral, affective, as well as biologic.

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In his 1990 book, Millon conceptualized the theoretical grounding of clinically derived personality styles and disorders. As a result, Millon deduced that the principles and processes of evolution were universal phenomena, albeit expressed in nature's many realms at different levels and in different manifest forms. What was gratifying in this reconceptualization was the close correspondence between his earlier 1969 biosocial-learning theory and the key principles comprising his new 1990 evolutionary model. Additionally satisfying was that the ontogenetic theory of neuropsychological stages of development presented in 1969 similarly paralleled his theoretical formulations of evolutionary phylogenesis.

Millon came to believe that the widespread desire among theorists to unify science should not be limited to explicating physics; that is, it should be possible in all fields of nature that have been subdivided by habit, tradition, or pragmatics (e.g., economics, sociology, geology). He believed unification to be a worthy goal even within the newer sciences, such as personology. Efforts to coordinate the separate realms that comprise the study of personality and, more specifically, that of mental disorders would be particularly useful. Rather than developing independently and being left to stand as autonomous and largely unconnected professional activities and goals, a truly mature clinical science of mental functioning, one that would create a synergistic bond among its elements, would embody, five explicit elements:

  1. Universal scientific principles are grounded in the ubiquitous laws of evolutionary theory as found in nature. Despite their varied forms of expression (cosmology, biology), these principles may provide an undergirding framework for guiding and constructing numerous specific and focused subject-oriented theories of nature's structures and functions.

  2. Subject-oriented theories, or explanatory and heuristic conceptual schemas for specific subjects, such as personology and psychopathology. These theories should be consistent with established knowledge in both its own and related sciences and should enable reasonable accurate propositions concerning all clinical conditions to be both deduced and understood, enabling thereby the development of a formal classification system.

  3. Classification of personality styles and pathological syndromes, or a taxonomic nosology that has been derived logically from the subject areas' theory. The taxonomy should provide a cohesive organization within which its major subject categories can readily be grouped and differentiated, permitting thereby the development of coordinated assessment instruments.

  4. Personality and clinical assessment instruments, or tools that are empirically grounded and sufficiently sensitive quantitatively to enable the theory's propositions and hypotheses to be adequately investigated and evaluated. The clinical categories comprising its nosology should be able to be readily identified (diagnosed) and measured (dimensionalized), thus specifying target areas for interventions.

  5. Personalized therapeutic interventions, or planful strategies and modalities of treatment. These interventions should accord with the theory and be oriented to modify problematic clinical characteristics, consonant with an understanding of the whole person being treated.

The table below provides a simple summary of the preceding five elements, comprising what may be called the science of clinical psychology.

Most theories of the personality disorders have been developed within a particular and narrow orientation, such as the psychodynamic, the cognitive, the behavioral, the interpersonal, or the biophysical. Such theories are incongruent with nature itself, which reflects the patterning of variables across the entire matrix of the person. To be commensurate with the construct of personality, a theory must be based on nature's principles which span, or transcend, each of these multiple domains. Specific narrow domain approaches confuse part and whole. The principles of evolution reflect nature's basic functions, and serve to integrate the several domains that comprise personality.

Philosophers of science agree that it is theory which provides the conceptual glue that binds a classification nosology together. Moreover, a good theory not only summarizes and incorporates extant knowledge, it possesses what they call systematic import, that is, it can originate and develop entirely new observations and new methods. Such taxonomy must also "carve nature at its joints," so to speak. The philosopher of science Carl Hempel (1965) referred to this when he distinguished between natural and artificial classification systems.  As he wrote: "Distinctions between 'natural' and 'artificial' classifications may well be explicated as referring to the difference between classifications that are scientifically fruitful and those that are not: In a classification of the former kind, those characteristics of the elements which serve as criteria of membership in a given class are associated, universally or with high-probability, with more or less extensive clusters of other characteristics. ...a classification of this sort should be viewed as somehow having objective existence in nature, as 'carving nature at the joints'... (Aspects of Scientific Explanation, 1965, pp. 146-147). The ideal of a classification scheme which is "natural," is one which "inheres" in the subject domain, that is not "imposed" on it by committee consensus or statistical methodology. Such a system would be not only be sufficient with respect to the phenomena of a subject domain, but also logically necessary.

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The Polarity Model for Deriving Personality Styles and Disorders

Millon's theoretical model is grounded in evolutionary theory. In essence, it seeks to explicate the structure and styles of personality with reference to deficient, imbalanced, or conflicted modes of survival, ecological adaptation and reproductive strategy. The proposition that the development and functions of personologic traits may be usefully explored through the lens of evolutionary principles has a long, if yet unfulfilled tradition. Spencer (1870) and Huxley (1870) offered suggestions of this nature shortly after Darwin's seminal Origins was published. In more recent times, we have seen the emergence of sociobiology, an interdisciplinary science that explores the interface between human social functioning and evolutionary biology (Wilson, 1975, 1978).

Elements

Four domains or spheres in which evolutionary principles are demonstrated have been labeled by Millon as  Existence, Adaptation, Replication, and Abstraction. The first relates the serendipitous transformation of random or less organized states into those possessing distinct structures of greater organization; the second refers to homeostatic processes employed to sustain survival in open ecosystems; the third pertains to reproductive styles that maximize the diversification and selection of ecologically effective attributes; and the fourth concerns the emergence of competencies that foster anticipatory planning and reasoned decision-making. Polarities from the first three phases have been used by Millon to construct a theoretically-derived classification system of personality disorders.

Existence: The Pleasure-Pain Polarity.

The first phase, existence, concerns the maintenance of integrative phenomena, whether nuclear particle, virus, or human being, against the background of entropic decompensation. Evolutionary mechanisms derived from this stage regard life-enhancement and life-preservation. The former are concerned with orienting individuals toward enhancing survival and improvement in the quality of life; the latter with orienting individuals away from actions or environments that decrease the quality of life, or jeopardize existence itself. These may be called existential aims. At the human level of functioning such aims form, phenomenologically or metaphorically , a pleasure-pain polarity.

Adaptation: The Active-Passive Polarity.

To exist is but an initial survival phase. Once an integrative structure exists, it must maintain its existence through exchanges of energy and information with its environment. The second evolutionary stage relates to what is termed Modes of Adaptation; it is also framed as a two-part polarity, a passive orientation, that is a tendency to accommodate to one's ecological niche, versus an active orientation, that is a tendency to modify or intervene in one's surrounds. These modes of adaptation differ from the first phase of evolution, in that they relate to how that which exists is able to endure or continue to survive in its environment.

Replication: The Self-Other Polarity.   

Although organisms may be well-adapted to their environments, the existence of all life-forms is time-limited. To circumvent this limitation, organisms have developed  Replication Strategies, that is, ways in which to leave progeny. These strategies reflect what biologists have referred to as r- or self-propagating strategy, at one polar extreme, and K- or other-nurturing strategy, at the other extreme. Psychologically, the former strategy is disposed toward actions which maximize self-reproduction;; here, organisms are egotistic, insensitive, inconsiderate, and socially uncaring; while the latter strategy is disposed toward protecting and sustaining kin or progeny; this leads to actions which are socially affiliative, intimate, caring, and solicitous.

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Deriving Personality Disorders from Theory

Some personalities exhibit a reasonable balance on one or other of the three preceding polarity pairs. Individual differences in both personality features and overall style will reflect the relative positions and strengths of each polarity component. Personalities we have termed deficient lack the capacity to experience or to enact certain aspects of one or another of the three polarities (e. g., the schizoid has a faulty substrate for both "pleasure" and "pain"); those spoken of as imbalanced lean strongly toward one or another extreme of a polarity (e. g., the dependent is oriented almost exclusively to receiving nurturance from "others"); and those we judge conflicted struggle with ambivalences toward opposing ends of a bipolarity (e. g., the passive-aggressive vacillates between adhering to the expectancies of "others" versus enacting what is wished for one's "self'). The table below provides an overall summary of the derived types and disorders.

A COMPREHENSIVE CHART OF THEORY-DERIVED PERSONALITY DISORDERS

Personalities termed pleasure-deficient lack the capacity to experience or to enact certain aspects of the three polarities. The interpersonally-imbalanced lean strongly toward one or another extreme of a polarity. Finally, the intrapsychically-conflicted struggle with ambivalences toward opposing ends of a bipolarity.

Three additional pathological personality patternsóthe Schizotypal, Borderline, and Paranoidórepresent structurally-deficient personalities in the more advanced stages of pathology. Reflecting an insidious and slow deterioration of the personality structure, these differ from the basic personality disorders by several criteria, notably, deficits in social competence and frequent (but usually reversible) psychotic episodes. Less integrated in terms of personality organization and less effective in coping than their milder counterparts, they are especially vulnerable to the everyday strains of life.

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