Book Review
Personality Disorders
Handbook of Personality Disorders: Theory, Research
and Treatment. W John Livesley, editor. New York: Guilford Press;
2001. 626 p. US$65.00.
Reviewer
rating*: Excellent
Review by Paul S Links, MD, FRCPC
Toronto, Ontario
This book was conceived to provide an “in-depth survey and
appraisal” of our current state of knowledge about personality
disorders. A handbook, thus named, indicates that the essence of
a field is found between the covers; it should be a resource for
both the novice and the expert. In this volume, John Livesley has
masterfully achieved this goal. He has probably created the reference
text for the study of personality disorders and, as well, an editorial
role that may extend through a series of future editions. Livesley’s
success is not surprising. He is already the editor of the Journal
of Personality Disorders, professor and former head of the Department
of Psychiatry, University of British Columbia, and an internationally
recognized researcher in the field. Livesley has assembled an extensive
array of academic expertise that includes leaders in developmental
psychology, behavioural genetics, psychometrics, neurobiology, cognitive
psychology, psychopharmacology, and psychoanalysis. The internationally
recognized experts contributing to this volume include Lorna Smith
Benjamin, Emil Coccaro, Glen Gabbard, John Gunderson, Marsha Linehan,
Theodore Millon, Tracie Shea, and Thomas Widiger.
The book is organized into 5 parts: Part I, “Theoretical and
Nosological Issues”; Part II, “Etiology and Development”;
Part III, “Diagnosis and Assessment”; Part IV, “Treatment”;
and Part V, “Treatment Modalities and Special Issues.”
Given the scope of this volume, it is important to acknowledge certain
topics that have not been included. Livesley explains that theoretical
positions such as classic psychoanalysis, objects relations theory,
and self-psychology have been purposely omitted because there is
a lack of systematic empirical research in these areas. The book
is not organized to discuss specific DSM-IV diagnostic entities,
primarily because Livesley strongly asserts that “current classifications
are arbitrary and temporary systems that have heuristic value in
stimulating and guiding research and in organizing clinical observations,
rather than definitive statements of the way that personality pathology
should be organized” (p x).
Part I, “Theoretical and Nosological Issues,” begins
with an introductory chapter in which Livesley challenges current
concepts used to define and classify personality and personality
disorders. Traditionally, “temperament” has been defined
as the biological substrate of personality, whereas character has
been defined as traits and behaviours that are environmentally determined.
Livesley notes, however, that all personality traits appear to be
heritable, and this distinction is therefore flawed. The categorical
approach to classification is carefully dismantled in favour of
a dimensional approach. According to Livesley, “Problems such
as overlap, high usage of personality disorders not otherwise specified
diagnosis, low reliability, and limited evidence of validity can
be attributed to failure to adopt a dimensional model” (p 18).
Livesley’s own research suggests that personality phenotypes
are made up of a large number of genetic building blocks, rather
than a few overarching traits. Therefore, the complexity of personality
likely arises from the multiple ways these blocks may be combined—a
model that discounts the possibility of discrete categories of personality
disorder.
In the third chapter of Part I, Thomas Widiger provides an enlightening
review of the history of the official classification systems and
their attempts to deal with personality disorders. Although Widiger
remains critical of current DSM approaches, he acknowledges that
criticizing our current systems has become “a rite of passage
for any leading investigators today” (p 77). He discusses the
issues that must be addressed in the development of the ICD-11 and
the DSM-V. One of the major challenges outlined by Widiger is to
set diagnostic thresholds for personality disorders, whether a categorical
or a dimensional method of classification is adopted. Widiger acknowledges
that this issue will only be resolved by reliably defining what
is meant by clinically significant impairment resulting from personality
disorders. As yet, little research exists to explain the relation
between social and occupational dysfunction and personality pathology.
Regina Dolan-Sewell, Robert Krueger, and Tracie Shea present an
excellent review of the literature examining the co-occurrence of
Axis I and Axis II disorders. They purposely avoid the use of the
term “comorbidity,” preferring instead the term “co-occurrence,”
because “comorbidity” traditionally refers to 2 or more
“distinct” disorders existing together. They indicate
that “our understanding of mental disorders has not yet reached
the level at which current nosological entities can be described
as truly ‘distinct’” (p 85). The authors conclude
that having an Axis II disorder increases the patient’s risk
for being diagnosed with an Axis I disorder. They observe that the
strongest relations exist between substance abuse disorders and
Cluster B personality disorders, and between somatoform disorders
and Cluster C personality disorders. There is little evidence for
other specific relations between Axis I and Axis II disorders.
Part II, “Etiology and Development,” addresses several
areas of inquiry that are seldom mentioned when discussing personality
disorders. Kim Bartholomew, Marilyn Kwong, and Stephen Hart offer
an excellent overview of attachment theory and the connections between
attachment problems and personality disorders. Although there is
no simple alignment of attachment pathology and specific personality
disorders, attachment theory provides an exciting and rather new
conceptual model that may enhance the targeting of therapies, the
prediction of initiation and completion of therapy, and the evaluation
of outcomes of certain intervention strategies. A seldom-discussed
issue in psychiatry is the question, Can personality change? Jennifer
Tickle and colleagues comprehensively address this question in Chapter
11. They review the basic arguments regarding the nature of personality—whether
“personality” refers to objective and observable traits;
whether it refers to holistic attributes including roles, attitudes,
goals, and behavioural tendencies; or whether, according to the
perspective of the situationalists, personality is inseparable from
social context.
Part III, “Diagnosis and Assessment,” has only 2 chapters
but demonstrates how relevant this work is to both researchers and
practitioners. Lee Anna Clark and Julie Harrison thoroughly review
all the instruments that assess personality disorders and discuss
both trait-based and diagnostically based self-report and interview
measures. In the second chapter of Part III, Roy MacKenzie discusses
the application of structured assessment measures to the clinical
care of patients with personality disorders. For example, he proposes
using symptom questionnaires to monitor the course of psychotherapy
much as you might monitor the course of antidepressant medication
therapy. The psychotherapy literature suggests that a sense of well-being
emerges early in therapy, followed by symptom reduction and, later,
by interpersonal and social change. Assessment measures allow clinicians
and patients to monitor the course of psychotherapy response objectively.
Mac-Kenzie discusses the value of sharing questionnaire results
with patients and gives specific examples of the merit of the feedback.
As with any large, edited volume, the chapter quality varies, although
the range is not dramatic. Two of the most disappointing chapters
are found in Part IV, “Treatment.” The chapter by William
Piper and Anthony Joyce gives an overview of psychosocial treatments
for personality disorders and reviews the literature targeting specific
problem behaviours and personality disorder–specific approaches.
Yet, under problematic behaviours, there is no mention of alcohol
or substance abuse. Indeed, the topic of alcohol or drug abuse does
not even appear in the subject index. This is the book’s only
major omission, especially considering that the book has been targeted
toward practising clinicians. This chapter is also missing some
key references. For example, the discussion of borderline personality
disorder (BPD) does not include the recent randomized controlled
trail by Bateman and Fonagy (1,2). Although residential and milieu
approaches to the management of BPD are included, assertive community
treatment of patients with this disorder is not even mentioned.
Paul Markovitz’s chapter on pharmacotherapy is also incomplete
and his conclusions idiosyncratic. For example, key references related
to lithium and valproate therapy in patients with BPD are missing.
In his review, Markovitz concludes that neuroleptics are not indicated
for controlling aggression, impulsivity, anxiety, and suicidality.
This conclusion is contrary to the consensus opinion of the working
group on BPD that recently developed treatment practice guidelines.
This group’s published algorithm for the treatment of impulsive-behavioural
symptoms in BPD includes low-dose neuroleptics as the second line
of intervention after selective serotonergic reuptake inhibitor
(SSRI) antidepressants (3). However, the section on treatment does
include some unique chapters. Anthony Ryle reviews the cognitive-analytic
therapies for personality disorders, a model that has attracted
more interest in Europe than in North America. Chapter 22 provides
a rare overview of psychoeducational approaches to managing personality
disorders. These approaches have reinforced the appropriateness
of psychiatric rehabilitation models for the care of patients with
severe personality pathology. Two promising models are discussed.
The McLean Psychoeducational and Multiple Family Group developed
by John Gunderson and colleagues is adapted from the programs developed
for the families of patients with schizophrenia. As well, Perry
Hoffman and others have developed a family program based on dialectical
behaviour therapy.
Part V, “Treatment Modalities and Special Issues,” indicates
the breadth of this volume. This section includes an extensive review
of group therapy, proceeding from general principles to specific
studies and along the way raising many questions for future examination.
Hassan Azim reviews the use of partial hospitalization for patients
with personality disorders. Stephen Hart discusses the forensic
issues related to these patients, yet makes the discussion relevant
to general practitioners. Livesley concludes with a presentation
of his framework for the integrated approach to the treatment of
patients with personality disorders.
This book is very reasonably priced, given that it has more than
600 pages. Although it pays attention to the latest research in
each area covered, the text is overall clear and understandable
for practising psychiatrists. The book is well laid out, includes
both an author and subject index, and is essentially free of production
errors.
In summary, the Handbook of Personality Disorders is a magnificent
achievement. This book is an important resource, and a space should
be made for it on the shelf of any individual studying or treating
individuals with personality disorders.
References
1. Bateman AW, Fonagy P. Effectiveness of partial hospitalization
in the treatment of borderline personality disorder: a randomized
controlled trial. Am J Psychiatry 1999;156:1563–9.
2. Bateman AW, Fonagy P. Treatment of borderline personality
disorder with psychoanalytically oriented partial hospitalization:
an 18-month follow-up. Am J Psychiatry 2001;158:36–42.
3. American Psychiatric Association. Practice
guidelines for the treatment of patients with borderline personality
disorder. Washington (DC): American Psychiatric Publishing Inc;
2001.
*Reviewer Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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