Personality Disorders: Toward the DSM-V
Publication Year: 2007
Personality Disorders: Toward the DSM-V offers a scientifically balanced evaluation of competing theoretical perspectives and nosological systems for personality disorders. Editors William T. O'Donohue, Scott O. Lilienfeld, and Katherine A. Fowler have brought together recognized authorities in the field to offer a synthesis of competing perspectives that provide readers with the richest and most nuanced assessment possible for each disorder. The result is a comprehensive, current, and critical summary of research and practice guidelines related to the personality disorders.
Focuses on controversies and alternative conceptualizations: Separate chapters are dedicated to each personality disorder and considered from various points of view.; Presents authoritative perspectives: Leading scholars and researchers in the field provide a critical evaluation of alternative perspectives on each personality disorder.; Frames the current state ...
- Front Matter
- Back Matter
- Subject Index
- Chapter 1: Introduction: Personality Disorders in Perspective
- Chapter 2: Alternatives to DSM-IV: Axis II
- Chapter 3: Paranoid Personality Disorder
- Chapter 4: Schizoid Personality Disorder
- Chapter 5: Schizotypal Personality Disorder
- Chapter 6: Antisocial Personality Disorder and Psychopathy
- Chapter 7: Borderline Personality Disorder
- Chapter 8: Histrionic Personality Disorder
- Chapter 9: Narcissistic Personality Disorder
- Chapter 10: Avoidant Personality Disorder
- Chapter 11: Dependent Personality Disorder
- Chapter 12: Obsessive-Compulsive Personality Disorder
- Chapter 13: Passive-Aggressive, Depressive, and Sadistic Personality Disorders
[Page ii]In memory of David Thoreson Lykken (1928–2006), valued mentor, brilliant thinker, courageous scholar, and pioneer in the study of personality disorders.
Copyright © 2007 by Sage Publications, Inc.
All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher.
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Library of Congress Cataloging-in-Publication Data
Personality disorders: Toward the DSM-V/[edited by] William O'Donohue, Katherine A. Fowler, Scott O. Lilienfeld.
Includes bibliographical references and index.
ISBN 978-1-4129-0422-3 (pbk. : alk. paper)
1. Personality disorders. 2. Psychotherapy. I. O'Donohue, William T. II. Fowler, Katherine A. III. Lilienfeld, Scott O., 1960-[DNLM: 1. Diagnostic and statistical manual of mental disorders. 2. Personality Disorders. 3. Personality Disorders—classification.
WM 190 P4676 2007]
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Foreword[Page vii]Washington University
The study of personality disorders is at a critical point in its development. Human beings are naturally curious about their inner nature and what motivates their feelings, thoughts, and behavior. The study of human personality has an ancient and rich history that has led to many insightful theories and approaches to both well-being and personality disorder. In the mid 20th century, personality theory and research flourished with the genius of many diverse thinkers, such as Freud, Allport, and Eysenck (Hall & Lindzey, 1970). Subsequently, work on personality was mostly stagnant, with little empirical research on personality and a clinical shift to categorical, behavioral, and biological approaches to mental disorders until the publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980). DSM-III was both atheoretical and poorly grounded empirically, and most DSM categories had little construct validation. These limitations may have led psychiatry unwittingly toward the field's current state of diagnostic dysfunction (Cloninger, Svrakic, & Przybeck, 2006).
Nevertheless, DSM-III placed personality disorders on a separate axis, which called attention to the importance of diagnosing personality disorders. There was a rapid increase in research and publications about personality and its disorders. Reliable methods for the assessment of personality and its disorders were developed, including both categorical and dimensional approaches (Cloninger, 1999b). Work on the etiology, development, and treatment of personality disorders began with renewed enthusiasm. New organizations for the study of personality disorders and the Journal of Personality Disorders were
Author's note: Correspondence concerning this paper should be addressed to C. Robert Cloninger, M.D., Wallace Renard Professor of Psychiatry, Genetics, & Psychology, Washington University, St. Louis, Missouri 63131. E-mail: email@example.com[Page viii]founded to bring together clinicians and researchers from psychology, psychiatry, and related areas. However, during the past decade the field has once again become stagnant. Publications and research continue, but the field is not really moving forward.
Progress in understanding personality disorders is currently paralyzed by a pervasive reluctance or resistance to face fundamental questions about human nature. Most work either is atheoretical, such as that based on DSM categories or descriptive personality tests derived by factor analysis, or is designed to confirm preexisting theories, such as behaviorism or psychoanalysis. There is no progressive program of hypothesis testing and refinement to answer the basic questions about human nature that have always inspired passionate interest in personality. Researchers with different assumptions about human nature collect themselves into narrow social networks that are self-affirming but blind or aggressive toward the assumptions and work of others. In compliance with tradition and funding pressures, research is mostly focused on evidence for the validity of discrete categories. The most important work on personality is now being done outside the field of personality disorders, mostly by neuroscientists using functional brain imaging and developmental biologists studying gene-environment interactions (Kaasinen, Aalto, Nagren, & Rinne, 2004; Keltikangas-Jaervinen, Raeikkoenen, Ekelund, & Peltonen, 2004; Pezawas et al., 2005). There is so much conflict about the content of the dimensions of personality among clinicians investigating personality disorder that some clinicians seriously advocate describing personality using checklists of the symptoms of the current committee-defined categories (Skodol et al., 2005) rather than resolving the number and content of personality dimensions scientifically. There is so much overlap among putative categories of personality disorder that the most common diagnosis is personality disorder not otherwise specified (Verheul & Widiger, 2004). Yet little work is done to apply and further evaluate evidence that the presence of any personality disorder can be reliably made by evaluating core features common to all personality disorders, such as self-directedness and cooperativeness (Cloninger, 2000).
Research on dimensional approaches is also not progressing because advocates of particular models are strongly resistant to communication and fundamental change. When alternative three- and five-factor models were found not to explain some aspects of human personality (Zuckerman & Cloninger, 1996), advocates of alternative models continued to debate the advantages of one incomplete model over another incomplete model (Widiger, Simonsen, Sirovatka, & Regier, 2006). For example, models of personality based on lexical traditions in English and other languages initially suggested that there were only five factors of personality. More thorough studies found evidence for seven dimensions of personality, showing that the evidence for only five was based on incomplete lists of descriptors that neglected words for positive and negative valence (Waller, 1999; Waller & Zavala, 1993). Even when their own data show that positive and negative valence adds to the prediction of personality pathology beyond markers of the Big Five, proponents of the Big Five have continued to argue that five factors are comprehensive (Simms, 2007). When five-factor [Page ix]models were unable to explain most of the variance in a specific sixth dimension, such as spirituality or self-transcendence as measured by the Temperament and Character Inventory (Cloninger, 2006a; Zuckerman & Cloninger, 1996), they tried to ignore this by saying that spirituality was not something they wanted to measure, despite its importance for psychopathology and well-being (Cloninger, 2004). Like the absentminded White Queen in Alice in Wonderland, something is not real unless you want it to be. But facts do not change just because we want to ignore them.
Psychosocial and neurobiological research has also revealed that human personality is an expression of nonlinear dynamic systems involving many genetic and environmental variables that influence development (Cloninger, Svrakic, & Svrakic, 1997). Yet personality researchers continue to depend on categorical systems or factor-analytic methods that ignore nonlinear dynamics. The result is that descriptions of personality disorders and of personality factors provide a view of differences between people that does not correspond well to the internal dynamics or motivation relevant to personality development or treatment (Cervone, 2004). Social-cognitive psychologists generally ignore the work of personality researchers because DSM and factor-analytic models do not provide a model of the within-person structure of personality. It is possible to model the within-person structure of personality, as I do in my seven-factor psychobiological model, but the result is not what is given by the linearity assumptions made by factor analysis (Cloninger, Svrakic, & Przybeck, 1993). For example, neuroticism is a factor in most factor-analytic models of personality, but a person can be high in neuroticism if he or she has an anxiety disorder without personality disorder or if he or she has a personality disorder without prominent anxiety. In fact, neuroticism is a composite of two traits regulated by different genetic determinants and different brain networks, which I have called harm avoidance and self-directedness (Cloninger, 2006a). Harm avoidance (but not self-directedness) is strongly related to individual differences in anxiety regulation mediated by limbic structures such as the connectivity of the amygdala and the subgenual anterior cingulate cortex (Pezawas et al., 2005). In contrast, self-directedness (but not harm avoidance) is related to individual differences in executive cognitive processes mediated by the prefrontal cortex (Cloninger, 2004). Yet people trained in personality psychology and factor analysis often ignore the extensive and important work being done regarding the psychosocial and neurobiological bases of personality development (Kaasinen et al., 2004; Kaasinen, Maguire, Kurki, Bruck, & Rinne, 2005; Keltikangas et al., 2004), thereby treating each human being as a black box devoid of inner experience and emitting only self-reports or externally observable behaviors. Don't we need to focus on inner experience if the distress and behaviors associated with personality disorders are the expression of maladaptive regulation of inner experiences?
Much current psychotherapy research about personality disorders is consumed by an effort to demonstrate efficacy and effectiveness so that they can be considered evidence-based therapies, like the drugs that meet FDA standards (Westen & Morrison, 2001). Advocates of different forms of [Page x]treatment, such as dialectical behavior therapy or transference-based psychotherapy, compare one treatment to another but seem reluctant to report that outcomes are largely explained by aspects of treatment common to all effective therapies, such as a helping therapeutic alliance (Gerstley et al., 1989; Lambert, 2004). There is little evidence of the importance of specific procedures for specific diagnoses, and yet the number of different evidence-based psychotherapies is growing like the number of newly patented medicines. Unfortunately, there is no corresponding increase in the average levels of happiness and mental health in the general population as a result of either the new medications or the new psychotherapies (Cloninger, 2004). Where has the field gone wrong?
Can a field of research be described as having a malaise or stagnation akin to a personality disorder? Such a statement would mean that the field is making untested and maladaptive assumptions about inner experience and behavior that are pervasive and inflexible and that impair scientific progress. The field of research on personality disorder seems to be infected with such a malaise, which I hope is curable. Committee-defined criteria and factor-analytically derived tests are no substitute for a coherent and testable theory of personality and its disorders.
In their insightful introduction, Fowler, O'Donohue, and Lilienfeld describe 13 serious problems that plague the field. These are the unanswered fundamental issues that I have suggested are the cause of a serious malaise and stagnation of the field. They include the basic questions about whether personality disorders really exist as categories and about the number and content of the dimensions of personality. Until these questions are answered, it is difficult or impossible to make progress on derivative issues of construct validity, such as the etiology, course, and treatment of personality disorders. How do you describe the causes and course of something that doesn't exist as a taxon or discrete category (Meehl, 1995)? If you could, why would you want to when you could obtain more complete information by characterizing continuous dimensions of clinical variability and their configural interactions? Perhaps unique configurations of traits do have distinct developmental trajectories and require specific treatment procedures (Cloninger & Svrakic, 1997). Even if that is the case, as I think it may be, then we need to know precisely how to specify those configurations in a highly reliable fashion before progress can be made (Kendell, 1982). In my opinion, an integrative approach is also needed that considers the path to well-being (Cloninger, 2006b) and not just particular states of disability (Skodol et al., 2005).
The contributors to this important book have done an excellent job on their assignments to deal with individual putative categories of personality disorder. There is impressive individual and group talent at work in the field of personality disorders. The diversity of their perspectives and recommendations illustrates, nevertheless, the serious problems that beset the field as a whole. The differences in perspective across chapters reveal much [Page xi]about the controversies within the field. Most chapters do focus on one putative category of personality disorder, and the majority of these relate one category of personality disorder on Axis II of DSM to one category of mental disorder on Axis I of DSM. For example, there are several pairs of Axis I–Axis II relationships discussed as parts of a continuous spectrum or frequently comorbid conditions: paranoid personality disorder with delusional disorder, schizotypal personality disorder with schizophrenia, avoidant personality disorder with social anxiety disorder, obsessive-compulsive personality disorder with obsessive-compulsive disorder, and depressive personality disorder with major depressive disorder. Of course, there are serious questions about the categorical nature of both Axis I and Axis II conditions (Kendell, 1982), so such pairings really tell us little about the fundamental question regarding categories and dimensions. The categories of Axis I provide little validity for personality categories because the Axis I conditions also have serious problems with uncertain boundaries, extensive comorbidity, and nonspecific response to treatment. Counterbalancing the chapters emphasizing spectra bridging Axis I and Axis I, Widiger notes the incomplete coverage of personality disorder by existing categories, and Morey and Hopwood emphasize the high prevalence of personality disorder not otherwise specified. But does it make sense to try to correct this problem by fewer dimensions than are known to exist or by putative categories with little construct validity?
The current criteria for most putative categories are criticized, except for obsessive-compulsive personality disorder, which is regarded as part of a spectrum with obsessive-compulsive disorder, body dysmorphic disorder, and pathological gambling. Such spectra are also controversial, however, with body dysmorphic disorder more closely resembling social anxiety disorder and pathological gambling overlapping with impulse control disorders like antisocial personality. So should we make body dysmorphic disorder part of the avoidant–social anxiety spectrum, or avoidant personality disorder part of the obsessive spectrum?
More generally, how do the various spectra overlap? Do they overlap as extensively as the clusters of personality disorders do? Disease spectra and the personality clusters to which they are related can be specified by their deviation on specific temperaments: Cluster A and related Axis I disorders with low reward dependence (i.e., aloof and cold), Cluster B and related Axis I disorders with high novelty seeking (i.e., impulsive and quicktempered), and Cluster C and related Axis I disorders with high harm avoidance (i.e., anxious and pessimistic; Battaglia, Przybeck, Bellodi, & Cloninger, 1996; Cloninger, 2000; Goldman, Skodol, McGrath, & Oldham, 1994; Mulder & Joyce, 1997). As a result, clusters and the spectra related to them exist in all possible combinations rather than being mutually exclusive. The various clusters and syndromes within clusters show complex patterns of overlap and differentiation that can be better represented as a multidimensional configuration than by a unidimensional [Page xii]spectrum or set of independent spectra (Svrakic, Whitehead, Przybeck, & Cloninger, 1993).
For example, Patrick questions the adequacy of the behavioral criteria for antisocial personality disorder, preferring the concept of psychopathy as described by Cleckley and later Hare. The criteria for antisocial personality disorder are specified as reliably rated behaviors based on the classical work of Lee Robins (1966), so it is comparable to Axis I syndromes such as social anxiety rather than disorders specified in terms of inner experience and motivation, as personality traits are usually defined. When antisocial syndromes are assessed in terms of personality and inner experience, at least two configurations of personality traits are identified: both groups are immature in character traits such as self-directedness and cooperativeness, high in novelty seeking, and low in reward dependence, but primary psychopaths (“antisocial personality disorder”) are low in harm avoidance, and secondary psychopaths (“borderline personality disorder”) are high in harm avoidance (Cloninger, 2005). Some suggest that primary psychopathy is a taxon with poor response to treatment, but it can also be well described as an extreme configuration of traits normally distributed in the general population (Cloninger, 2005).
Likewise, some evidence for the categorical nature of schizophrenia (Cloninger, Martin, Guze, & Clayton, 1985; Lenzenweger, McLachlan, & Rubin, 2007) and schizotypy (Lenzenweger & Korfine, 1992) has also been presented, but the separation of even these putative categories from neighboring conditions is at best incomplete and weak. Early concepts of etiology that motivated categorical models, such as single genes or single traumatic events, have been found to oversimplify the complex adaptive systems underlying the development of psychopathology. Current research indicates that configurations of multiple sets of genetic and environmental variables influence the development of psychopathology, thereby motivating the search for the best ways to deconstruct the complex determinants of mental disorders in terms of either symptoms or the causes of symptoms (Cloninger, 2004). In fact, all the personality disorders, including schizotypal personality, can be defined as extreme configurations of normal personality traits (Cloninger, 1999a). Categorical thinking is now more of a hindrance to understanding personality disorders and psychopathology than it is a benefit.
None of these controversies would matter much except that people with personality disorders frequently have short and miserable lives, as well as a serious and costly impact on society through their maladaptive behaviors. Therefore, the stagnation of the field in not being able to face and answer the fundamental questions about the nature of personality and its disorders is unsatisfactory and harmful. It is remarkable that so many obviously bright people cannot find a way to communicate with one another in an open-minded way so that they can make progress beyond what was known two decades ago when the same questions were being asked and tentatively [Page xiii]answered (Cloninger, 1987; Cloninger et al., 1993; Svrakic et al., 1993). Personality and its disorders are too important to be treated like a private cottage industry in which no one is permitted to question the local authority's basic assumptions.
Personality disorders are too important for us to rely on poorly grounded dimensional representations of unvalidated categories without resolving the number and content of the underlying dimensions, even if they are not currently familiar to clinicians. The field needs to move forward, not wallow in stagnant pools of ignorance and illusion.
At least for the personality disorders, DSM is really only a system of classification for cataloguing and billing purposes and does not even begin to be an adequately validated scientific basis for research and treatment. As long as research classification and case descriptions are based on such an antiquated categorical system, little or no progress in understanding disorders of personality is likely, as evidenced by the current impasses stalemating the field.
Personality Disorders is an important book because it clearly exposes the major controversies facing the field. Each chapter is an erudite contribution that stands on its own quality. In addition, the insightful reader will be able to compare the divergent, and sometimes contradictory, perspectives and conclusions of different chapters. Consideration of the contradictions and unanswered questions throughout the book reveals the harsh consequences of blind reliance on false assumptions about how nature can be carved at its joints, when there are actually no such joints.References[Page xvi]American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author.1996). Temperament dimensions explain the comorbidity of psychiatric disorders. Comprehensive Psychiatry, 37, 292–298. http://dx.doi.org/10.1016/S0010-440X%2896%2990008-5, , , & (2004). The architecture of personality. Psychological Review, 111(1), 183–204. http://dx.doi.org/10.1037/0033-295X.111.1.183(1987). A systematic method for clinical description and classification of personality variants: A proposal. Archives of General Psychiatry, 44, 573–587. http://dx.doi.org/10.1001/archpsyc.1987.01800180093014(1999a). Measurement of psychopathology as variants of personality. In C. R.Cloninger (Ed.), Personality and psychopathology (pp. 33–66). Washington, DC: American Psychiatric Press.(Cloninger, C. R. (Ed.). (1999b). Personality and psychopathology. Washington, DC: American Psychiatric Press.2000). A practical way to diagnose personality disorder: A proposal. Journal of Personality Disorders, 14(2), 99–108. http://dx.doi.org/10.1521/pedi.2000.14.2.99(2004). Feeling good: The science of well-being. New York: Oxford University Press.([Page xiv]2005). Antisocial personality disorder: A Review. In World Psychiatric Association (Series Ed.) & M.Maj (Vol. Ed.), Evidence and experience in psychiatry: Vol. 8. Personality disorders (pp. 125–129). London: Wiley. http://dx.doi.org/10.1002/0470090383.ch2(2006a). Personality as a dynamic psychobiological system. In T. A.Widiger, E.Simonsen, P.Sirovatka, & D. A.Regier (Eds.), Dimensional models of personality disorders: Refining the research agenda for DSM-V. Washington, DC: American Psychiatric Association.(2006b). The science of well-being: An integrated approach to mental health and its disorders. World Psychiatry, 5, 71–76.(1985). Diagnosis and prognosis in schizophrenia. Archives of General Psychiatry, 42, 12–25. http://dx.doi.org/10.1001/archpsyc.1985.01790240017002, , , & (1997). Integrative psychobiological approach to psychiatric assessment and treatment. Psychiatry, 60, 120–141., & (1993). A psychobiological model of temperament and character. Archives of General Psychiatry, 50, 975–990. http://dx.doi.org/10.1001/archpsyc.1993.01820240059008, , & (2006). Can personality assessment predict future depression? A twelve-month follow-up of 631 subjects. Journal of Affective Disorders, 92(1), 35–44. http://dx.doi.org/10.1016/j.jad.2005.12.034, , & (1997). Role of personality self-organization in development of mental order and disorder. Development and Psychopathology, 9, 881–906. http://dx.doi.org/10.1017/S095457949700148X, , & (1989). Ability to form an alliance with the therapist: A possible marker of prognosis for patients with antisocial personality. American Journal of Psychiatry, 146(4), 508–512., , , , , & (1994). Relationship between the Tridimensional Personality Questionnaire and DSM-III-R personality traits. American Journal of Psychiatry, 151, 274–276., , , & (1970). Theories of personality. New York: Wiley., & (2004). Insular dopamine D2 receptors and novelty seeking personality in Parkinson's disease. Movement Disorders, 19(11), 1348–1351. http://dx.doi.org/10.1002/mds.20191, , , & (2005). Mapping brain structure and personality in late adulthood. NeuroImage, 24, 315–322. http://dx.doi.org/10.1016/j.neuroimage.2004.09.017, , , , & (2004). Nature and nurture in novelty seeking. Molecular Psychiatry, 9(3), 308–311. http://dx.doi.org/10.1038/sj.mp.4001433, , , & (1982). The choice of diagnostic criteria for biological research. Archives of General Psychiatry, 39, 1334–1339. http://dx.doi.org/10.1001/archpsyc.1982.04290110084014(Lambert, M. J. (Ed.). (2004). Bergin and Garfield's handbook of psychotherapy. New York: Wiley.1992). Confirming the latent structure and base rate of schizotypy: A taxometric analysis. Journal of Abnormal Psychology, 101(3), 567–571. http://dx.doi.org/10.1037/0021-843X.101.3.567, & (2007). Resolving the latent structure of schizophrenia endophenotypes using expectation-maximization–based finite mixture modeling. Journal of Abnormal Psychology, 116(1), 16–29. http://dx.doi.org/10.1037/0021-843X.116.1.16, , & ([Page xv]1995). Bootstraps taxometrics: Solving the classification problem in psychopathology. American Psychologist, 50(4), 266–275. http://dx.doi.org/10.1037/0003-066X.50.4.266(1997). Temperament and the structure of personality disorder symptoms. Psychological Medicine, 27, 99–106. http://dx.doi.org/10.1017/S0033291796004114, & (2005). 5-HTTLPR polymorphism impacts human cingulate-amygdala interactions: A genetic susceptibility mechanism for depression. Nature Neuroscience, 8(6), 838–834. http://dx.doi.org/10.1038/nn1463, , , , , , et al. (1966). Deviant children grown up: A sociological and psychiatric study of sociopathic personality. Baltimore: Williams & Wilkins.(2007). The Big Seven model of personality and its relevance to personality pathology. Journal of Personality, 75(1), 65–94. http://dx.doi.org/10.1111/j.1467-6494.2006.00433.x(2005). Dimensional representations of DSM-IV personality disorders: Relationships to functional impairment. American Journal of Psychiatry, 162(10), 1919–1925. http://dx.doi.org/10.1176/appi.ajp.162.10.1919, , , , , , et al. (1993). Differential diagnosis of personality disorders by the seven-factor model of temperament and character. Archives of General Psychiatry, 50, 991–999. http://dx.doi.org/10.1001/archpsyc.1993.01820240075009, , , & (2004). A meta-analysis of the prevalence and usage of the personality disorder not otherwise specified (PDNOS) diagnosis. Journal of Personality Disorders, 18, 309–319., & (1999). Evaluating the structure of personality. In C. R.Cloninger (Ed.), Personality and psychopathology (pp. 155–197). Washington, DC: American Psychiatric Press.(1993). Evaluating the Big Five. Psychological Inquiry, 4, 131–134. http://dx.doi.org/10.1207/s15327965pli0402_13, & (2001). A multidimensional meta-analysis of treatments for depression, panic, and generalized anxiety disorder: An empirical examination of the status of empirically supported therapies. Journal of Consulting and Clinical Psychology, 69(6), 875–899. http://dx.doi.org/10.1037/0022-006X.69.6.875, & (Widiger, T. A., Simonsen, E., Sirovatka, P. J., & Regier, D. A. (Eds.). (2006). Dimensional models of personality disorders: Refining the research agenda for DSM-V. Washington, DC: American Psychiatric Association.1996). Relationships between Cloninger's, Zuckerman's, and Eysenck's dimensions of personality. Personality and Individual Differences, 21, 283–285. http://dx.doi.org/10.1016/0191-8869%2896%2900042-6, & (
First of all, we would like to acknowledge our chapter contributors. We know that it can be a challenge for busy and productive individuals to take time out of their professional and personal lives to write a book chapter. We very much appreciate their time, dedication, and excellent work. Second, we'd like to thank our editor at Sage, Veronica Novak, whose patience, support, and astute judgment were invaluable in completing this project. We extend our thanks to Kassie Graves and the art department personnel at Sage, who were also very helpful. Without their support and professionalism this book would not have been possible. Third, we'd like to thank Rachel Keith for her perspicacious and astute editing and proofing. She made this often arduous process a pleasure. Fourth, we'd like to thank the wonderful individuals who helped us finish this book, especially Crissa Draper, Amy Harper, and Lauren Tolle. Finally, we'd like to thank our families, Jane, Katie, Anna, and Sahil, for being there.[Page xviii]
About the Editors[Page 391]
William O'Donohue, Ph.D., is a licensed clinical psychologist and professor of psychology at the University of Nevada, Reno. Dr. O'Donohue has received over $1,500,000 in federal grant money from sources including the National Institute of Mental Health and the National Institute of Justice. In addition, he has edited more than 35 books, written more than 70 book chapters, and published more than 100 articles in scholarly journals. Dr. O'Donohue is currently directing a major treatment development/outcome evaluation project involving integrated care.
Katherine A. Fowler, Ph.D., completed her doctoral degree in clinical psychology at Emory University in Atlanta, Georgia, in 2007. She will begin a postdoctoral research fellowship in clinical neuroscience at the National Institute of Mental Health in Bethesda, Maryland, upon graduation. Her research interests include conceptualization, biological and etiological foundations, and assessment of psychopathic personality, multivariate statistical modeling, and the influence of personality on violence and criminality. Her clinical interests include behavior therapy, personality assessment, and forensic evaluation.
Scott O. Lilienfeld, Ph.D., is associate professor of psychology at Emory University in Atlanta, Georgia. Dr. Lilienfeld is founder and editor of the new journal Scientific Review of Mental Health Practice and is past (2001–2002) president of the Society for a Science of Clinical Psychology, which is Section III within Division 12 (Society of Clinical Psychology) of the American Psychological Association (APA). He also served as the Division 12 program chair for the 2001 APA Convention. He is a member of eight journal editorial boards, including those of Assessment, Psychological Assessment, and Clinical Psychology Review, and he has served as an external reviewer for over 50 journals and several grant proposals. Dr. Lilienfeld has published over 160 articles, book chapters, and books in the areas of personality disorders (particularly psychopathic personality), personality assessment, anxiety disorders, psychiatric classification and diagnosis, and questionable practices in clinical psychology. In 1998, Dr. Lilienfeld received the David Shakow Award for Outstanding Early Career Contributions to Clinical Psychology from APA Division 12.[Page 392]
About the Contributors[Page 393]
Jennifer Bartz, Ph.D., received her doctorate in psychology from McGill University in 2004 and is currently a postdoctoral research fellow at the Mount Sinai School of Medicine in New York City, where her research focuses on the neurobiology of obsessive-compulsive spectrum disorders. Dr. Bartz's main research interests include personality factors related to the desire for structure and intolerance for uncertainty and how they influence people's understanding and experience of their social world as well as adult attachment and the role of insecure relational schemas in close relationship development.
David P. Bernstein, Ph.D., is associate professor in the Department of Medical, Clinical, and Experiment Psychology at Maastricht University, the Netherlands, where he also directs the Personality Disorders section of the Experimental Psychopathology Research Institute (EPP). He is former president of the Association for Research on Personality Disorders and a vice president of the International Society for the Study of Personality Disorders. His major areas of research and clinical interests are personality disorders, psychological trauma, and forensic issues. His current focus is on developing and testing the efficacy of treatments for severe personality disorders in forensic patients.
Pavel S. Blagov, M.A., is a doctoral candidate in clinical psychology at Emory University, where he obtained a master's degree in psychology. His research interests include personality pathology classification and emotional influences on reasoning. His current research focuses on subthreshold personality constellations, histrionic personality disorder in adults and adolescents, psychopathy, and motivated cognition in political and legal decision making. Previously, he has presented research on and written about the role of autobiographical memory processes in personality and psychotherapy.
Annie M. Bollini, Ph.D., received her doctorate in clinical psychology from Emory University, completed her postdoctoral training at Emory School [Page 394]of Medicine, and is a licensed clinical psychologist in Georgia. Her main research areas have included schizophrenia and spectrum disorders, cognitive functioning, and stress. Currently, she is a behavioral scientist at the Centers for Disease Control & Prevention in Atlanta, Georgia. She conducts research and develops and evaluates programs on HIV/AIDS prevention in international projects, mainly in African countries.
Robert F. Bornstein, Ph.D., received his doctorate in clinical psychology from the State University of New York at Buffalo and is professor of psychology at Adelphi University. Dr. Bornstein has published widely on personality dynamics, assessment, and treatment. He wrote The Dependent Personality (Guilford Press, 1993) and The Dependent Patient: A Practitioner's Guide (American Psychological Association, 2005). Dr. Bornstein's research has been funded by the National Institute of Mental Health and the National Science Foundation; he received the Society for Personality Assessment's 1995, 1999, and 2002 awards for Distinguished Contributions to the Personality Assessment Literature, and the American Psychological Foundation 2005 Theodore Millon Award for Excellence in Personality Research.
Rebekah Bradley, Ph.D., is an assistant professor in the Department of Psychiatry and Behavioral Sciences at Emory University in Atlanta, Georgia. She is also the director of the Trauma Recovery Program and the Atlanta Veterans Medical Center. Her current areas of research include the impact of traumatic experiences, particularly childhood abuse; the etiology and treatment of posttraumatic stress disorder; and the etiology, classification, and treatment of personality disorders, particularly borderline personality disorder. She received her master's degree in psychology from Wesleyan University and her doctorate in clinical community psychology from the University of South Carolina.
John F. Clarkin, Ph.D., is codirector of the Personality Disorder Institute at New York Presbyterian Hospital, Westchester Division, and clinical professor of psychology in Psychiatry at the Joan and Sanford I. Weill Medical College and Graduate School of Medical Sciences of Cornell University in New York City. He is the author and coauthor of several books on the treatment of severe personality disorders and has written over 100 articles and chapters focusing on the symptoms and treatment of personality-disordered patients. He is past president of the International Society for Psychotherapy Research.
Carolyn Zittel Conklin, Ph.D., is a staff psychologist in the Harvard Medical School psychiatry program. She was awarded the 2006 Scientific Paper Award from the American Psychoanalytic Association; her paper, “Countertransference Phenomena and Personality Pathology in Clinical Practices: An Empirical Investigation” (published in the American Journal of Psychiatry, 2005), was deemed the best published empirical paper on a psychoanalytic topic. Dr. Conklin is interested in the areas of adult ambulatory service, psychodynamic psychotherapy, and treatment of borderline personality disorder.
[Page 395]James D. Herbert, Ph.D., is a professor of psychology at Drexel University, where he serves as director of clinical training of the Ph.D. program in clinical psychology as well as associate dean of the College of Arts and Sciences. He received his doctorate from the University of North Carolina at Greensboro in 1989. He serves as the director of the Anxiety Treatment and Research Program at Drexel and has an active research program on the assessment and treatment of social anxiety disorder. He has published widely on the behavioral treatment of anxiety disorders as well as on quackery and pseudoscience in mental health.
Eric Hollander, M.D., is the principal investigator for a number of current federal grants, including a grant from the NIH Greater New York Autism Center of Excellence, the NIMH Research Training Grant in Psychopharmacology and Outcomes Research, and a grant from an FDA-funded multicenter treatment trial of pediatric body dysmorphic disorder. He is the principal investigator of the autism Clinical Trials Network and chair of the eight-center NIH STAART Autism Steering Committee. During his career, Dr. Hollander has published more than 450 scientific reports in the psychiatric field. He has edited 19 books, including Autism Spectrum Disorder (2003), the American Psychiatric Publishing Textbook of Anxiety Disorders (2002), and The Clinical Manual of Impulse Control Disorders (2006). Dr. Hollander also serves as a reviewer for eight medical journals.
Christopher J. Hopwood, M.S., is a doctoral candidate at Texas A&M University. He received a master's degree from Eastern Michigan University. His research interests include personality assessment, personality pathology, and interpersonal process.
Oren Kalus, M.D., is a Board Certified psychiatrist in private practice and on staff at a community mental health clinic in Kingston, N.Y. Dr. Kalus's interest in schizoid P.D. dates from his tenure as an assistant professor at Mount Sinai School of Medicine and a member of a research group headed by Dr. Larry Siever on personality disorders. Since leaving Mount Sinai in 1993 he has pursued a largely clinical career both providing direct care and lecturing and providing workshops to clinicians on cognitive neuroscience. Dr. Kalus's most recent area of interest entails the convergence between psychopathology and art. Dr. Kalus recently presented a poster on an aesthetic form of derealization in the artist Alberto Giacommeti at the 2006 Toward Science of Consciousness Conference in Tucson, Ariz.
Alicia Kaplan, M.D., is affiliated with the Department of Psychiatry, Mount Sinai School of Medicine. She has published on the classification and treatment of obsessive-compulsive disorder and related conditions.
Daniel N. Klein, Ph.D., received his doctorate in clinical psychology from the State University of New York at Buffalo. He is currently professor of psychology and psychiatry and behavioral science at Stony Brook University. Dr. Klein's research focuses on the mood and personality disorders and on [Page 396]the role of temperament and personality in psychopathology. He has been an associate editor of the Journal of Abnormal Psychology, is past president of the Society for Research in Psychopathology, and is president-elect of the Society for a Science of Clinical Psychology.
Kenneth N. Levy, Ph.D., is an assistant professor in the Department of Psychology at Pennsylvania State University and directs the Laboratory for Personality, Psychopathology, and Psychotherapy Research. Dr. Levy teaches graduate seminars in psychotherapy research and personality theory and supervises a clinical training practicum emphasizing contemporary psychodynamic psychotherapy for personality disorders. He is also an adjunct assistant professor of Psychology in Psychiatry at the Joan and Sanford I. Weill Medical College of Cornell University, where he is a faculty fellow at the Personality Disorders Institute (PDI). Dr. Levy has authored more than 50 articles and chapters in the areas of developmental psychopathology, attachment theory, personality disorders, and psychotherapy research.
Vijay A. Mittal, M.A., is a doctoral candidate affiliated with the Clinical Psychology Department at Emory University. He studies longitudinal development of adolescents at risk for psychotic disorders. More specifically, he focuses on investigating neural, endocrine, and behavioral markers associated with the schizophrenia prodrome and high risk for psychopathology. He is particularly interested in examining the potential of movement abnormalities to inform neural diathesis–stress conceptualizations of schizophrenia.
Leslie C. Morey, Ph.D., is department head and professor of psychology at Texas A&M University. He received his doctorate in clinical psychology from the University of Florida and has served on the faculties at Vanderbilt University, Harvard Medical School, the Yale University School of Medicine, and the University of Tulsa. He has served as associate editor of Assessment and Journal of Personality Assessment and as consulting editor for a number of journals, including Journal of Personality Disorders and Psychological Bulletin.
Christopher J. Patrick, Ph.D., is Starke R. Hathaway Distinguished Professor and director of clinical training in the Department of Psychology at the University of Minnesota. He graduated from the University of British Columbia in 1987, where he completed his dissertation entitled “The Validity of Lie Detection With Criminal Psychopaths.” He has published extensively in the areas of psychopathy, antisocial behavior, and substance use/abuse; his other research interests include emotion, personality, psychophysiology, and cognitive neuroscience. He is the recipient of Distinguished Early Career Contribution awards from the American Psychological Association (1995) and the Society for Psychophysiological Research (1993). He is a consulting editor for Psychological Assessment and Journal of Abnormal Psychology as well as a former associate editor of Psychophysiology.
[Page 397]Joseph S. Reynoso, M.Phil., is an advanced doctoral candidate in clinical psychology at the City College of New York and the Graduate School and University Center of the City University of New York. He completed his internship in clinical psychology at Kings County Hospital Center in Brooklyn, New York, concentrating on adult inpatient and emergency psychiatry. Mr. Reynoso is currently a psychology fellow training at Columbia University's Counseling and Psychological Services. His professional interests include the measurement of romantic love, treatment of severe psychopathology, and psychoanalytic therapy with underserved populations. He has coauthored chapters and articles on attention deficit hyperactivity disorder assessment, personality disorders, and psychotherapy research.
Larry J. Siever, M.D., is professor of psychiatry and vice chair for VA Affairs at Mount Sinai School of Medicine in New York City. He also serves as executive director of the Mental Illness Research, Education and Clinical Center (MIRECC) and chief of the psychiatry program at the Bronx VA Medical Center in the Bronx, New York. Dr. Siever has published over 350 peer-reviewed articles. He earned his Bachelor of Arts degree from Harvard College in Cambridge, Massachusetts, and his doctorate from Stanford University School of Medicine in Stanford, California. He directs the Mood and Personality Disorders program at Mount Sinai, a federally funded research program that investigates the neurobiology of the schizophrenic spectrum personality disorders, such as schizotypal personality disorder, and impulsive/affectively unstable personality disorders, such as borderline personality disorder. He is a member of the American College of Neuropsychopharmacology (ACNP) and past president of the Society of Biologic Psychiatry, from which he received the A. E. Bennett Award for clinical research.
J. David Useda, Ph.D., attained a doctorate in clinical psychology at the University of Missouri-Columbia and a postdoctorate at the University of Rochester School of Medicine and Dentistry's Center for the Study and Prevention of Suicide. Dr. Useda has conducted research and published in his area of expertise: personality and its disorders. He remains an adjunct faculty member at the University of Rochester's Department of Psychiatry and is in private practice. Together, Dr. Useda and his wife are happily raising a son.
Elaine Walker, Ph.D., is a professor of psychology and neuroscience in the Department of Psychology at Emory University. She leads a research laboratory funded by the National Institute of Mental Health to study the development of adolescents at risk for mental illness. Her research focuses on child and adolescent development and brain changes associated with adolescence. She has published over 150 scientific articles and six books dealing with mental health and neuroscience.
[Page 398]Rachel H. Wasserman, B.A., is a doctoral student in clinical psychology at Pennsylvania State University. Her research and professional interests include mechanisms of change in the treatment of borderline personality disorder, longitudinal approaches to the assessment of outcome, the role of therapeutic alliance in the treatment of patients with severe psychopathology, and psychoanalytic psychotherapy. Ms. Wasserman has coauthored articles on expectancy effects, meditation, cortical plasticity, and mechanisms of change in psychotherapy.
Drew Westen, Ph.D., is a professor in the Department of Psychology and the Department of Psychiatry at Emory University. He received his doctorate in clinical psychology from the University of Michigan and subsequently taught at the University of Michigan, Harvard Medical School, and Boston University. Professor Westen is both a clinician and a researcher; he has written over 150 scientific papers and three books, and his work on the classification of personality pathology in adolescents and adults has been funded by the National Institute of Mental Health. He is currently completing a book on politics entitled The Political Brain: The Science of the Mind and the Article of Getting Elected.
Thomas A. Widiger, Ph.D., is the T. Marshall Hahn Professor of Psychology at the University of Kentucky. He received his doctorate in clinical psychology in 1981 from Miami University in Ohio and completed his internship at Cornell University Medical College, Westchester Division. He has published over 200 articles and chapters in scientific, clinical, and academic journals and texts in the area of the diagnosis and classification of personality disorders. He currently serves as associate editor for the Journal of Abnormal Psychology, Journal of Personality and Social Psychology, Journal of Personality Disorders, and Annual Review of Clinical Psychology, as well as consulting editor for a few additional journals. He was the research coordinator for DSM-IV and served as cochair of the DSM-V Research Planning Conference for Personality Disorders.