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Mental Disorders

by Theodore Millon, Carrie M. Millon, Sarah Meagher, Seth Grossman, and Rowena Ramnath
John Wiley & Sons, 2004
Review by Roy Sugarman, Ph.D. on Dec 7th 2004

Personality Disorders in Modern Life

Millon, of the Mutiaxial Inventory fame, has said of personalities that they are like impressionist paintings in that each is at a distance easily accessed, but up close there is a bewildering complexity.  Jeff Magnavita, (a fitting name, given the analogy) in his foreword, notes that this book lays the groundwork for the construction of a working model of human personality dysfunction, as well as normal functioning.  If true, this would be a relief, given that mental health professionals are not regarded as terribly accurate when it comes to assessing normality, and perhaps we stand too close to the painting so to speak.  We certainly are capable of finding pathology in most circumstances, as for instance in the notorious Chelmsford Hospital matter in Australia, without always looking for the context markers that would say otherwise (see pg 72, with reference to interpersonal psychology).

Culture is another bedeviling factor, and only 6 pages of the 600-odd actually deal with this, always by using a window as a form of focusing on such issues throughout the book.  The DSM-IV is by its nature part of the Universalist school of thought, which holds that these described disorders may be thought of as universal.  Millon deals with this briefly, as others have done, without commenting on the eye of the diagnoser-beholder: the book's focus so often reverts to the evolutionary underpinnings of personality, related to survival, adaptation and replication, but never certainly from the perspective of an ideational Darwinism, where most of our interactions come to nothing, as Russ Barkley would have it.

Nowhere does one see a satisfactory discussion of the kind of perspective that the eye of the viewer of the painting might bring, and one might add to Millon that the eye of the beholder brings to the cumulative whole of the painting what the beholder wants to see, within the viewer's paradigm, not from a Universalist perspective, but culture specific.  One of my famous painter friends always responds to queries: "What do you want to see" or "What do you want it to be?"  As discussed by Millon, nosological categories have their value, not definitive, but guiding in what they tell us to look at, an epistemology of personality investigation, and that is what Millon sets out to do for us here, and well enough to make this a classic work for post-grads.

Millon's influence is thus, historically, quite large, and in the foreword anyway he is characterised as being a major driver in the quest for a 'personology', an epistemology of personality one imagines, defining what one should be looking at in a personality presentation.

To this end the book embarks by examining the historical foundations of the biology or psychodynamics of the putative disorders, and then the more contemporary views. This latter takes the form of an examination of the interpersonal, cognitive, traits/factors, and then the abovementioned evolutionary-neurodevelopmental perspectives.

Having 'romanced' all of these perspectives, Millon says somewhat cynically (and probably correctly) that psychology will always regard the latest 'fad' as the last word on the subject.  Perhaps it's not the latest fad, but the latest DSM, with some disorders coming and going, like masochism, sadism, and so on.

In keeping with the painting metaphor used above, Millon writes that we are left with a 'patchwork quilt' that fails to converge on an integrated view of personality (page 58).  The alternative to a more integrated view would be 'an uncomfortable eclecticism' of 'unassimilated partial views'. Later in this discussion we again see the emergence of the survival, adaptation and replication view taken in one of the early focused 'culture' windows referred to above.  This results then in a discussion of the domains of personality, which is clearly an attempt to converge the 'fads' of personality into a more usable format, or at least one that is more heuristically useful anyway, as the DSM's have set out to be.

The final format above leads Millon to hold that psychological health is dependent on the fit between the entire configuration of the person's characteristics and potentials with those of the environments in which the person functions (page 73), more than a passing reference to culture here. I note he goes on to say "Behaviors experienced as pleasurable are generally repeated…..while those experienced as painful….are not repeated" which of course ignores aspects of intrinsic motivation that are coming to the fore after Ryan and Deci's work for instance.  We may indeed embark on painful pathways if there is a reward inside us for pursuing such a course, with the fundamental attribution errors of others outside us making it clear they think there is something wrong with us in doing so.

For instance, why do men, the stereotype goes, resist asking others for instructions when they are clearly lost, with wifey and kids in tow, all demanding daddy stop and ask?  The answer really is that finding out where to go (extrinsic reward) is nowhere nearly as internally rewarding as toughing it out and emerging at your destination with only yourself and your amazing capacity for exploration and self-determination to blame (intrinsic reward), no matter how painful that might be to others, especially those sweating in the car who hate your latest Neil Young CD. Daddy is a PD! Daddy is a PD!  It really is all in the context both internally and externally….is it not?

If all behavior has a purpose, and this internal purpose, hidden from sight, may promote the idea that such behavior indicates that within this behavioral entity resides a 'horrible person', then the personality disorders as a whole would indicate a determined and collated set of fundamental attribution errors. For instance, a person with a sense of entitlement, always irritable, who cannot tolerate team approaches and touchy-feely committees, and who is adamant their way is probably correct, given their experience, full of rationalizations and disdainful of regulations which stunt creativity, is probably more likely to be from a certain country, or profession, rather than from a diagnostic category such as antisocial or narcissistic.  It depends where you stand, and these categories are thus predisposing professionals to label many characteristics as pathological. The above person however, in many societies that value such characteristics, would be seen as a creative leader with drive, ambition, single mindedness of purpose, and do well. In a more British and colonial system, they would have to have Royalty in their blood, or be sent to Coventry or simply sabotaged by the others (see Millon deal with this on pages 151-155). 

I cannot get away from the idea, at this stage, that only some must regard some concatenations of personality features as undesirable. My trainees then describe these characters as 'horrible people'.  Such attribution errors are common in responses to gender roles that are resistant to stereotypy, page 81: masquerading gender roles as madness may be to locate falsely (a fundamental attribution error, I think) within persons all of the ludicrous cognitive and behavioral limitations that actually reside in gender roles and stratification.

The development of the personality disorders section then proceeds with a discussion that, of course, these are not disorders in the medical sense: they are seen as theoretical constructs employed to represent varied styles or patterns in which the personality system functions in a maladaptive way in relation to its environment.  This by now is better language for me to evaluate and use in my paradigms:

When the alternative strategies employed to achieve goals, relate to others, and cope with stress are few in number and rigidly practiced (adaptive inflexibility); when habitual perceptions, needs, and behaviors perpetuate and intensify pre-existing difficulties (vicious circles); and when the person tends to lack resilience under conditions of stress (tenuous stability), we speak of a clinically maladaptive personality pattern (pages 77-78)

Another issue that arises then is that of my favorite hobbyhorse, namely that "a huge percentage of women diagnosed as personality disordered have histories of sexual and physical abuse" (page 82).  Given that the developing brain is exquisitely sensitive to stresses, and changes are noted in the limbic and other areas, with resultant changes in the hypothalamic-pituitary-adrenal axis in response to such abuse, this contention appears to have much merit, but is still neglected in history taking, or ignored, in some areas in which I work, as being part of the etiology; rather, there is a tendency to conform to the attribution error in its most fundamental guise, and label the person as horrible, and treat them accordingly. 

In my training since the '80's, there was the push-of-war between psychiatry and psychology as to who would treat the Axis II group, largely not regarded as suffering from a mental illness and hence not a deserved target of mental health intervention. Recent articles in the British Journal of Psychiatry have brought up just this issue, prompting my previous boss to close our hospital wards to anyone with Borderline Personality Disorder: a professor in psychiatry, he regarded such patients as not mentally ill.

Their anxiety, bipolarity, depressions etc were all felt to be secondary to the 'thing' of their personality disorder, a derangement of character rather than of mind or brain, whereas of course it is both of the latter that lead to the former derangement of character. Deciding on treatment, and then procuring it for them remains problematic. 

The window on gender notes:

Our conceptualizations are fuzzy, our samples are biased, our measures are biased, and our clinicians fall prey to their own biases.  The question of what to do is even more difficult to address (pg 83).

Perhaps then, my boss was right to deny access to a toxic environment…

Despite Millon's efforts, there is thus far to go in creating a science or a neuroepistemology for personology.  Chapter Four takes this on, but only after an exhaustive Chapter Three that examines the multitude of theories relating to how the disordered phenotype emerges.

Here one sees the emergence of the true genius of Millon and of his scholarly approach, and he and his colleagues are most thorough in examining the issues of testing, assessment and diagnosis in all their theoretical and practical vicissitudes.

The psychotherapy section of this chapter only begins thus after almost twenty pages, which tells you how thorough they have been.  A discussion around brief therapies, common factors of therapies, and technical eclecticism leads to the idea of synergistic therapy, one of Millon's own, with each intervention both targeted at a single aspect of the person, but also at the global outcome.  Personality is thus a functional-structural system, and targeted as such by synergistic therapies rather than a particular approach. In this way, one could use two approaches together where either in isolation would not work (a potentiation of pairing) or rather use a sequenced series of approaches chosen as a kind of filibuster.  Assessment and therapy are thus seen as continuous with personality in an integrated way, the theme of this book.

Chapter Five onwards focuses on individual disorders, beginning with the Antisocial.  Apart from the introductory discussions, the clinical aspects of normality versus abnormal in the eyes of the professional comprise the most important part of the discussion.  We all, I am sure, have a morbid fascination with the Hannibal Lector style of brilliant villain, there are many more amongst us who are less grossly abnormal, but who still do not represent the Judeo-Christian ideal of a human.  These former would include the adventurer and the dissenting personality, who I described above as the individual who goes their own path with resentment of the restraints of the 'pack', and who 'finesse' their way through life rather than slog, or follow the road most often travelled by others.  There are also variants on the antisocial, such as the covetous, or the humiliation-sensitive reputation-defender.  Again, various approaches, concluding with the environment neuro-developmental perspectives are described and evaluated.  As expected, the therapy section is slim.

The rest of the chapters follow the same extensive, intense framework

Finally, attention is given to the 'other' disorders in the backrooms of the DSM-IV.

Millon and colleagues have thus successfully updated the bible of personality disorder reference material, and there is nothing quite like it out there.  I remain with my reservations about his testing equipment, as using it with brain-injured populations or distinguishing those having gone through trauma from other groups leads to interesting formulations.

However, I do not have to estimate that this book will become a classic reference, mostly for those in the postgraduate zones of endeavor, since the first edition already is.

There is no real application for medication here, and that I suppose is correct, and the treatment side is thin, again, reflecting on sad reality.

However, with insights and research such as this from Millon and his colleagues, things are not looking that dim.


© 2004 Roy Sugarman


Roy Sugarman, PhD, Clinical Director: Clinical Therapies Programme, Principal Psychologist: South West Sydney Area Health Service, Conjoint Senior Lecturer in Psychiatry, University of New South Wales, Australia.

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