Theodore Millon (2000).
Reflections on the future of DSM Axis II
Journal of Personality Disorders
, 14, 1, 30-41.
ISSN:
0885579X
Headnote
Several proposals are enumerated in this article: (a) the need to employ a coherent classification-guiding theory; (b) the wisdom of conceptualizing personality patterns as prototypes; (c) a proposed shift away from the Aids I-Axis II distinction to a three-part continuum; (d) the utility of specifying relationships among the various classification categories of the nosology; (e) a proposal for refining and differentiating personality disorder subtypes; and (fl the utility of expanding the range and comparability of the diagnostic criteria.
Several Axis II suggestions will be enumerated in this article; some are more radical than others in that they have significant implications for DSM-V beyond those related to the personality disorders.
EMPLOYING A COHERENT CLASSIFICATION THEORY
As with its DSM-III and -III-R forerunners, the DSM-IV classification was not only derived intentionally in an atheoretical manner, but no coherent theoretical system was seriously explored to provide a consistent framework for coordinating the various syndromes. Such a conceptual schema would be helpful, even if the established nosology were reliably anchored to empirical research, which it is not. If all of the principal clinical syndromes or personality disorders could be logically derived from a systematic theoretical foundation, this would greatly facilitate an understanding of psychopathology, organize this knowledge in an orderly and consistent fashion, and connect the data it provides to other realms of psychological theory and research, where they could then be subjected to empirical verification or falsification. Especially promising in this regard are a number of dimensional schemas, such as those proposed by Cloninger, Benjamin, Millon, Costa, and Tellegen. From such sources, psychopathology might advance much in the way as has physics. In describing the features that have given physics much of its success as a scientific discipline, Meehl ( 1978) has noted that, "The physicist's scientific power comes from...the immense deductive fertility of the formalism" (p. 825).
CONCEPTUALIZING PERSONALITY PATTERNS AS PROTOTYPES
There is a need to explicitly recognize the intrinsic heterogeneity of each of the disorders comprising DSM-IV Axis II; this argues for the wisdom of formalzing a paradigm shift from a "disease entity" to a "prototypal" diagnostic model. The Personality Disorders Work Group moved implicitly in the direction of what Cronbach and Meehl (1955) termed "bandwidth fidelity" in which a balance is struck between conceptual breadth and identification precision. Cantor et al. (1980) addressed this issue two decades ago.
The recent revisions in the standard diagnostic manual have brought the system even closer to the prototype view than before. Diagnostic criteria are not presented as prototypes-larger sets of correlated features rather than selected defining ones; guidelines for diagnosis also emphasize the potential heterogeneity of the symptoms of like-diagnosed patients. Moreover, a potential for overlap in clinical features across different diagnostic categories is underscored. They help to emphasize, rather than obscure, the probabilistic nature of diagnostic categorization.
REPLACING THE AXIS I AXIS II DISTINCTION WITH A THREE-PART CONTINUUM
Among the most important steps taken in forming the DSM-III multiaxial system was the partition of the personality disorders from the main body of clinical syndromes and their placement in a separate axis. In the past, clinicians were often faced with the task of deciding whether a patient was best diagnosed as possessing a personality or a symptom syndrome; that choice is no longer necessary. Now, clinicians can record not only the current clinical picture, but also those characteristics that make the patient vulnerable and typify his/her behaviors over extended periods, both prior to and concurrent with the presenting Axis I complaint. The differentiated multiaxial format has enabled practitioners to place the clinical syndromes of Axis I within the context of the individual's susceptibilities and pervasive style of functioning.
This two-part distinction is, in my judgment, no longer as significant as first thought. Because of space limitations, I cannot elaborate the alternative as fully as I would like (see Millon 1999). Essentially, the proposal is designed to reflect a three-point continuum of pathology: simple reactions (SRs), which are relatively free of "contaminating" personality traits; complex syndromes (CSs), which are relatively distinct symptom constellations that are enmeshed in part in various personality patterns (PPs), the latter composed primarily of a cohesive group of personality traits and features. These patterns may be further differentiated into personality "styles," signifying a relatively normal pattern of adaptive functioning, and "pathologies" (not "disorders"), signifying the failure of the pattern to function adaptively in the patient's psychosocial life.
Let me elaborate briefly: simple reactions, complex syndromes, and personality patterns (styles/ disorders) lie on a continuum such that the former is essentially a straightforward singular symptom, unaffected by other clinical characteristics of which the person-as-a-whole is composed (Millon, 1969). At the other extreme are personality patterns composed of an interrelated mix of cognitive attitudes, interpersonal styles, as well as biological temperaments and intrapsychic processes. Complex syndromes lie in between, manifestly akin to simple reactions, but interwoven and mediated by pervasive personality traits and vulnerabilities.
Clinical signs in PPs reflect the operation of a system of deeply embedded characteristics of functioning, that is, a constellation of traits that systematically "support" one another and color and manifest themselves automatically in most facets of the individual's life. By contrast, SRs are relatively discrete responses that derive from specific neurochemical dysfunctions or are prompted by rather distinctive stimulus experiences. Simple reactions operate somewhat independently of the patient's overall personality pattern; their form and content are determined largely by the character of a biologic vulnerability or the specifics of an external precipitant, that is, they are not contaminated by the intrusion of other psychic domains or forces. Simple reactions are best understood, then, not as a function of the intricate convolutions between intrapsychic mechanisms, interpersonal behaviors, cognitive misperceptions, and the like, but as simple and straightforward responses to an endogenous liability or to adverse and circumscribed stimulus conditions.
precipitating source the pathology, but also to many secondary elements that reflect the patient's complex of mediating processes.
CSs often arise in response to what objectively is often an insignificant or innocuous event. Despite the trivial and specific character of the precipitant, the patient exhibits a mix of complicated responses that have minimal relationship to how normal persons respond in these circumstances. Thus, CSs often do not "make sense" in terms of actual present realities; they signify an unusual vulnerability and an overreaction on the part of the patient, a tendency for objectively neutral stimuli to touch off and activate cognitive misperceptions, unconscious memories, and pathological interpersonal responses. CSs usually signify the activation of several traits that comprise the varied facets of a personality style or disorder; they are seen in individuals who are encumbered with the residues of deeply embedded biological vulnerabilities or adverse life events that have led to the acquisition of problematic intrapsychic defenses, cognitive beliefs, and interpersonal habits.
A precipitating stimulus, biologic or psychologic, will stir up in these patients a wide array of intervening emotions and thoughts which "take over" as determinants of the patient's response; reality stimuli serve merely as catalysts that set into motion a complex chain of intermediary processes that transform what might otherwise have been a fairly simple and straightforward response. Because of the "contaminating" intrusion of these transformations, complex syndromes acquire an irrational and often "symbolic" quality. For example, in a complex phobic syndrome the object that is feared may come to represent something else; thus, a phobia of elevators may symbolize a more generalized and unconscious anxiety about being closed in and trapped by others.
Intrusions of this complex nature do not occur in simple reactions. The patient's responses are neither deep nor widespread, but restricted to a delimited class of biological vulnerabilities or environmental conditions. These pathological responses do not "pass through" a chain of complicated and circuitous intrapsychic and cognitive transformations before they emerge in manifest form. Thus, in addition to the restricted number of precipitants that give rise to them, simple reactions are distinguished from complex syndromes in the more-or-less direct route through which they are channeled and expressed clinically.
SPECIFYING RELATIONSHIPS AMONG REACTIONS, SYNDROMES, AND PERSONALITY PATTERNS
Although the DSM-IV provides a multiaxial schema in which relationships that exist among clinical categories can be noted, each category is still organized as if it were a discrete entity of clustered clinical signs independent and distinct from other categories. A framework that would spell out the inevitable overlap occurring among diagnostic groups would enable the clinician to identify immediately the intrinsic covariations that do exist among clinical groups. Especially valuable would be the illumination of relationships between personality vulnerabilities and coping styles, on the one hand, and specific complex syndromes on the other. What is likely to be needed to achieve this end is more than a format that merely organizes the fragmented nature of the current nosology, but one, as noted previously, that is based on theoretical principles which furnish a logic for organizing the clinical world.
REFINING AND DIFFERENTIATING PERSONALITY STYLE/DISORDER SUBTYPES
DSM-III, -III-R, and -IV. What is presented, in great part, is a series of "ideal" or pure textbook conceptions of each ostensibly discrete and boundaried disorder.
There are, in clinical fact, numerous variations of the "textbook" personality disorders, divergences from the published prototype that reflect both the results of empirical research and the observations of clinical work. It is my personal belief that the universal laws from which the personality prototypes may be derived are best understood in terms of theory, but we should recognize that there are other fruitful and nontheoretical sources from which such information can be derived.
Moreover, given the interpenetrant and multidetermined nature of any personality construct, we must resist the ever-present linguistic compulsion to simplify and separate constructs from their objective reality, and then to treat them as if their clinical manifestations were achieved through some abstruse form of causality. Constructs (e.g., personality prototypes) are to be used heuristically, as guidelines to be replaced and reformulated as necessary; it is only the unique way in which the construct is seen in specific patients that is of clinical interest. The DSM personality disorders are essentially nomothetic in that they comprise hypothetical or abstract constructs derived from general clinical or theoretical sources (biochemical, intrapsychic). Given the "fixed" characterization of each of these constructs in the DSM, it would not seem unwise to generate a range of personality subtypes to represent trait-constellation variants that come close to corresponding to the distinctive character of many of our patients.
Not only is the Axis II of DSM-IV not an exhaustive listing of personality trait configurations that may closely correspond to many of our patients, but it does not even begin to scratch the surface of human variability. A DSM-IV diagnosis alone, unsupplemented by information from additional descriptive domains, constitutes an insufficient basis by which to articulate the trait dynamics of a person. Nomothetic propositions and diagnostic labels are mere superficialities to be overcome as understanding is gained. They are necessary, but not sufficient and, in fact, if left on their own, may be regarded as prescientific.
Experienced clinicians know that there is no single schizoid (or avoidant, or depressive, or histrionic) type. Rather, there are several variations, different forms in which the core or prototypal personality expresses itself. Some reflect the workings of constitutional dispositions that life experience subsequently impacts and reshapes in different ways, taking divergent turns and producing shadings of different psychological characteristics. The course and character of life experiences may be marginally different, yet complexly interwoven; moreover, divergent influences may have simultaneous or sequential effects, often producing a recombinant mixture of different personality patterns in the same person, such as those that might stem from parents who are strikingly different in their child-relating styles, one conducive to the formation of an avoidant pattern, the other to an obsessive-compulsive one.
taxons begin to be broken down into multiple, narrow taxons of greater specificity and individually descriptive value, as we should begin to do when describing the several subtypes of each broader-based personality disorder category.
The idea of subtypes recognizes two fundamental facts. The first derives from the long descriptive traditions of psychology and psychiatry, as perhaps best expressed in the works of the turn of the century nosologist Emil Kraepelin. In the ordinary course of clinical work, we find that every formal disorder sorts itself over time into ever finer subcategories; these rest initially on an a priori theoretical basis, but ultimately flow from observable social factors and their interaction with biological influences such as constitution, temperament, or perhaps even systemic neurological defects. Accordingly, if society were different, or if the neurotransmitters chosen by evolution to bathe the human brain were different, subtypes also would be different. However, at this point in time, subtype entities are the pristine product of clinical theory and observation, fundamentally no different, however, than the prototypes they refine; boundaries between them are usually "soft." The taxonomic controversy between the "splitters" and the "lumpers" reflects arguments regarding disorders of no known inevitability. All we may ask is that we begin to generate "subtypes" that reflect the particularities of human nature and pathology.
To summarize, clinicians and students should learn not only the pure prototypal personalities, but also the alternates and mixtures that are seen in clinical reality. In three of my recent books (Milton, 1999; Milton & Davis, 1996, 2000) I have sought to describe a number of these subtype variations; they reflect mixtures, pure and mixed patterns of learning and experience, consistent inclinations of several types, and conflict resolutions in which overt appearances are different from that which is covert. The DSM-V should demonstrate a greater awareness of the diversity of each of the DSM-IV's personality prototypes.
Let me illustrate several subtype variants of one of the "standard" personality prototypes, the dependent pattern (abbreviated from Millon & Davis, 1996).
THE DISQUIETED DEPENDENT
A mixture of the dependent and avoidant patterns, the disquieted dependent is of ten found in an extreme form in institutional settings that minister to chronic ambulatory patients. Most live a parasitic existence sustained by institutional rewards and requirements. Whereas all dependents are submissive and self-effacing, relying on others for guidance and security, the disquieted dependent possesses an underlying apprehensiveness that overlies a lack of initiative and an anxious avoidance of autonomy. They seem easily disconcerted and experience a general sense of dread and foreboding. They are particularly vulnerable to separation anxiety, and greatly fear loss of support and nurturance. Unlike most dependents, these fears are sometimes expressed through outbursts of anger directed at those who fail to appreciate their needs for security and safety.
THE ACCOMMODATING DEPENDENT
Accommodating dependents are more submissive, agreeable, and hungry for affection, nurturance, and security than other subtypes. Fears of abandonment lead them to be overly compliant and obliging. Some become socially gregarious and charming, and seek to become the center of attention through self-dramatizing behaviors. As such, they are similar to the appeasing histrionic. Both are gracious, neighborly, benevolent, and compliant in their relationships with others, preferring to avoid conflict and seek harmony even at the expense of their internal values and beliefs. Further, both are preoccupied with external approval, so that both may be left without any real inner identity, valuing themselves not so much for their intrinsic traits, but only in terms of their relationships with others. By submerging or allying themselves with the abilities and virtues of others, they bolster themselves through an illusion of shared competence, and are comforted by the belief that the bond achieved thereby is firm and unbreakable. Both evidence a naive attitude toward life's problems. Maintaining an air of pleasantry and good spirits, they deny disturbing emotions and cover inner conflicts through self distraction. Critical thinking is not their strong point. Having had others do for them most of their lives, most areas of knowledge are underdeveloped or immature.
Unlike "appeasing histrionics," however, accommodating dependents tend to be self-sacrificing, and readily adopt the role of inferior or subordinate. They are sympathetic toward the needs of their partners, who almost always feel stronger and more competent as a result. They avoid self-assertion and leave responsibilities in the hands of others. In contrast, the histrionic takes a more active posture, maneuvering and manipulating their life circumstances, rather than passively sitting by. The self-sacrificing and inferior posture of the accommodating dependent somewhat resembles the masochistic personality. All that matters is that others like them, are pleased by them, and are willing to accept their smiles and goodwill as sufficient.
Unfortunately, most accommodating dependents are accommodating for a reason: Agreeableness is designed to encourage others to take control, thereby compensating for their incompetency. They always have a smile and a friendly word, but rarely follow through on adult responsibilities. In fact, they usually feel helpless whenever autonomy or initiative is required. The loss of a significant source of support or identification may prompt severe depression. Open displays of guilt, illness, anxiety, and depression are common, but serve a purpose. These deflect criticism and transform threats of disapproval or abandonment into support and sympathy.
THE IMMATURE DEPENDENT
Different individuals mature at different rates. Moreover, even within a single person mathematical or musical abilities may mature relatively early, with language abilities maturing later, or vice versa. Some individuals, however, never achieve even a modest level of accomplishment at any point in life. Instead, they remain childlike throughout their existence, prefer childhood activities, fmd satisfaction relating mainly to children, and thoroughly dislike all adult activity and responsibility. Not only are such persons dependent through their childlike outlook and level of achievement, they seem satisfied in doing so.
difficult, however, when others begin to expect more, or demand that they mature and get down to the business of life. To their troubled parents or spouses they often seem irresponsible and neglectful. Eventually, their failure to develop the abilities necessary to survive on their own leaves them completely incapable of ever maturing to an adultlike level.
THE INEFFECTUAL DEPENDENT
The ineffectual dependent represents a combination of the dependent and schizoid patterns. Both patterns exhibit a general lack of vitality, low energy level, fatigability, and weakness in expressiveness and spontaneity. Schizoids usually possess an anhedonic temperament, meaning that they are unable to experience pleasurable emotions in great depth. Moreover, they shun social relationships, including being part of a family, and almost always choose solitary activities. The ineffectual dependent, however, is more able to empathize and understand the basic emotions of others. Moreover, the thought processes of schizoids often seem more unfocused, tangential, or even absent, especially with regard to human relationships. Interpersonal subtleties escape the understanding of most schizoids, but are understood by most ineffectual dependents, who do not shun close personal relationships. Like the immature dependent, the ineffectual variety seeks an untroubled life completely free of responsibility, though mainly because of their lack of drive rather than their childish nature. Through their schizoid characteristics, they often simply tune out life's demands. Not wanting to deal with reality, they resist all external pressures, sleepwalk through life, half disengaged and half dependent. Not wanting to engage anything or think too hard, they often exhibit a certain fatalism that allows them to ignore difficulties by becoming resigned to their own ineffectual destiny. Nothing ever changes, and they have neither the drive nor desire to act on their own behalf.
THE SELFLESS DEPENDENT
For the selfless dependent, idealization and total identification are the major themes. Like all dependents, they subordinate themselves to others, but in a much more extreme fashion. Attachment concerns take on a new meaning for these individuals, who totally merge themselves with others, forfeiting their own identity in the process. Their own unique personal potentials are denied and left to atrophy as the residuals of an unwanted independence. Through fusion, they secure a sense of significance, emotional stability, and purpose in life. Eventually, everything they do is performed in service of extending the status and significance of another, be it a person or an institutional entity. In extreme cases they are completely defined through their relationships, existing as an extension of their significant other, with no sense of themselves as an independent beings at all. Because of this fusion, they may adopt values and attitudes that are quite different from their ordinary preferences. Sometimes they seem confident and self-assured, but only by assuming for themselves the qualities of the persons or institutions with whom they have identified.
Despite the loss of their own identity, many selfless dependents do seem fulfilled by their self-sacrificing lifestyle. Whereas all dependents are submissive, adopting the values and beliefs of more powerful others to whom they attach themselves, the very essence of the selfless dependent rests on those to whom they sacrifice themselves. The more they fuse with their idealized others, the more they become emotionally attached, and the more they feel themselves to have significance in the world. Stereotyped examples include mothers who live for and through their children, and wives who submerge themselves totally within the lives and careers of their husbands.
through external sources, they make themselves extremely vulnerable to loss. When relationships run into difficulties, selfless dependents experience episodes of anxiety and depression, which fluctuate in intensity depending on the quality of the attachment. All dependents are devastated when relationships end, but the selfless dependent is almost completely destroyed, having essentially been voided of themselves. Sometimes the anticipation of loss is sufficient to leave them with a chronic hopelessness, a characteristic of the depressive personality.
EXPAND THE RANGE AND COMPARABILITY OF DIAGNOSTIC CRITERIA
Although it may be difficult to identify and "carve those joints" which meaningfully divide the raw behaviors and traits that comprise clinical symptoms, we should, at the very least, utilize similar descriptive clinical domains throughout the diagnostic criteria of the DSM. Inconsistencies in the clinical phenomena which embody the diagnostic criteria will result only in a lack of comparability and a lack of parallelism among clinical assessments. Certain commonalities must be routinely addressed to ensure that different syndromes can be compared and differentiated. Although the domains included to assess personality patterns may include a wide range of clinical phenomena, it would make good scientific and practical sense if certain specific realms were consistently addressed, for example, mood/affect, cognitive style, interpersonal conduct, and self image (see Milton, 1969, 1981; Millon & Davis, 1996).
No doubt greater clarity in clinical communications, as well as greater research reliability, has followed the systematic use of diagnostic criteria. However, most of the criteria (even in the data-based DSM-IV) lack adequate empirical support. Some criteria are insufficiently explicit or, conversely, are overly concrete in their operational referents. Many are redundant both within themselves as well as with other diagnostic classes. Others are insufficiently comprehensive in syndromal scope or display a lack of parallelism and symmetry among corresponding personality categories.
Despite the inherent limitations that are built into syndromic and prototypic categories, several shortcomings among the DSM-IV diagnostic criteria should and can be remedied. There are a number of factors that undermine the homogeneity of Axis II class membership requirements. As noted, these difficulties arise in part from a lack of comparability among diagnostic criteria; for example some categories require all defining features to be present whereas others allow choice among the criteria. I believe that this heterogeneity in diagnostic requirements will bear directly on the efficiency and utility of each definitional feature, as well as possibly compromise the validity of the covariates that ostensibly comprise each syndrome, reaction, or personality. The DSM-V still needs to clarify the "fuzziness" between boundaries so as to eliminate excessive numbers of unclassifiable cases.
One step toward the goal of sharpening diagnostic discriminations is to spell out a distinctive criterion for every diagnostically relevant clinical attribute aligned with every prototypal category (see Milton & Davis, 1996). For example, if the attribute "interpersonal conduct" is deemed of clinical value in assessing personality, then singular diagnostic criteria should be specified to represent the characteristic or distinctive manner in which each personality "conducts its interpersonal life" (see Table 1).
prototypal covariates. Moreover, clinicians would be able to appraise both typical and unusual personality patterns, as well as establish the coherence, if not the "validity" of both recently developed (e.g., subtypes) and classically established diagnostic (e.g., prototypes) entities.
CONCLUDING COMMENTS
Reflecting on his labors while serving as chairman of the Task Force for the DSM-II, Gruenberg noted that the instability of mental health diagnostic schemas over the centuries led him to wonder whether the excitement concerning the appropriateness of one or another classification might not actually reflect a deep need on the part of its contributors to obscure their lack of knowledge. Engaging in fruitless and labored debates over new terms and clever categories may be a simple displacement of effort in which one pretends the "correct" labels and taxonomies are themselves the knowledge gaps that exist. I would like to think that the suggestions proposed herein will be seen by my colleagues as more substantive than cosmetic, as well as more readily implemented than impractical and idealistic.
Tabla 1.
Tabla 2.
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