Differentiating Normal, Abnormal, and Disordered Personality

Transcription

1 European Journal of Personality Eur. J. Pers. 19: (2005) Published online in Wiley InterScience ( DOI: /per.559 Differentiating Normal, Abnormal, and Disordered Personality W. JOHN LIVESLEY* and KERRY L. JANG Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC V6T 2A1, Canada Abstract Interest in the interface between normality and psychopathology was renewed with the publication of DSM-III more than 20 years ago. The use of a separate axis to classify disorders of personality brought increased attention to these conditions. At the same time, the definition of personality disorder as inflexible and maladaptive traits stimulated interest in the relationship between normal and disordered personality structure and functioning. The evidence suggests that the traits delineating personality disorder are continuous with normal variation and that the structural relationships among these traits resemble the structures described by normative trait theories. Recognition that personality disorder represents the extremes of trait dimensions emphasizes the importance of differentiating normal, abnormal, and disordered personality. It is argued that while abnormal personality may be considered extreme variation, personality disorder is more than statistical variation. A definition of personality disorder is suggested based on accounts of the adaptive functions of personality. Copyright # 2005 John Wiley & Sons, Ltd. A puzzling feature of the study of normal and disordered personality is that psychology and psychiatry have until recently pursued their studies independently using different conceptual models. Psychiatry has followed a more medical model that assumes discrete categories of disorder whereas personality psychology has tended to pursue trait models. Recently, however, interest in the relationship between normality and the psychopathology of personality has increased due to the publication of the Diagnostic and Statistical Manual (DSM-III) more than 20 years ago (APA, 1980). The DSM defined personality disorder as an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, and is stable over time. The most recent edition (DSM-IV) lists ten disorders: paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, and *Correspondence to: W. J. Livesley, Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC V6T 2A1, Canada. livesley@interchange.ubc.ca Received 7 January 2005 Copyright # 2005 John Wiley & Sons, Ltd. Accepted 30 March 2005

2 258 W. J. Livesley and K. L. Jang obsessive compulsive. Each diagnosis is defined by a cluster of traits. For example, the criterion set for borderline personality disorder includes behaviours indicative of affective lability, impulsivity, and insecure attachment. Traits are defined as enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts (APA, 1994, p. 630). By emphasizing traits, the DSM encouraged exploration of the interface between normal and abnormal while implying a qualitative distinction between the two. The evidence does not support this distinction. Researchers have been remarkably unsuccessful in identifying any point of separation between normality and disorder (Widiger, 1993; Livesley, Schroeder, Jackson, & Jang, 1994). This failure along with accumulating evidence that individual differences in personality disorder are continuously distributed has increased the importance of defining the relationship between normal and disordered personality and the features that distinguish them. In this paper, these issues will be considered in terms of two broad questions: (1) Can normal and disordered personality be conceptualized using the same constructs, and is the structure of personality the same in general population subjects and patients with personality disorder? and (2) What do we mean by abnormal personality and personality disorder, and what features differentiate normal from disordered personality? We begin by considering alternative conceptualizations of the distinction between normal and disordered personality. CONCEPTUAL DISTINCTIONS BETWEEN NORMAL AND DISORDERED PERSONALITY Most students of personality disorder hold one of four conceptions of the relationship between normal and disordered personality (Strack & Lorr, 1994). The first assumes that normal and disordered personalities are distinct categories with a clear distinction between normality and pathology and between different forms of disorder. This view is asserted by categorical models of personality disorder such as the DSM-IV and ICD-10. The second conception asserts the opposite position that normal and disordered personality merge. Although these are the main models, Strack and Lorr noted that some approaches combine elements of these positions. A third model asserts that although there are only quantitative differences between normal and disordered personality, certain combinations of traits can lead to qualitative differences in the constellations of features defining disordered personality. Evidence for this position would be provided by studies indicating that the covariation among traits differed in clinical and non-clinical groups. A fourth viewpoint is a modification of this position that asserts that the traits that constitute normal personality can lead to distinct disorders due to the influence of specific aetiological processes. The critical issue for differentiating normal and disordered personality raised by these models is whether there are qualitative differences between clinical and normal groups. Theoretically, several forms of qualitative difference may be envisioned (Livesley et al., 1994). First, the clearest qualitative difference would be discontinuity in a distribution of features of personality disorder in the form of either bimodality or a point of rarity (Kendell, 1975). Although DSM diagnoses are said to be categorical in nature, the distribution of the diagnostic criteria appears continuous. Ratings of these criteria in patients with personality disorder (Frances, Clarkin, Gilmore, Hurt, & Brown, 1984; Kass, Skodol, Charles, Spitzer, & Williams, 1985) and first degree relatives of psychiatric

3 Normal, abnormal, and disordered personality 259 patients (Zimmerman & Coryell, 1990) are continuously distributed. Similarly, the distribution of the criteria for specific disorders in community samples shows evidence of continuity (Nestadt et al., 1990). Also, little evidence of discontinuity has been found in the distributions of personality disorder traits. Livesley, Jackson, and Schroeder (1992) found no evidence of discontinuity in the distributions of 100 traits selected to provide a systematic representation of personality disorder. However, it should also be noted that bimodality seems to be a necessary but not sufficient indicator of qualitative differences (see Grayson, 1987). The strongest evidence of discontinuity comes from taxometric analyses (Meehl, 1973, 1992; Meehl & Golden, 1982; Waller & Meehl, 1998) of schizotypy which suggest the occurrence of a discrete taxon. There is also some suggestion of a taxon for psychopathy (Harris, Rice, & Quinsey, 1994) and possibly borderline personality disorder, but studies of other forms of personality disorder have not provided strong evidence of discontinuity (see Haslam, 2003a, 2003b). A second form of qualitative difference could occur when the features of personality disorder are continuous with normal variation but the dysfunction associated with the disorder shows a threshold effect when a given level of a trait occurs. The evidence does not support this model. Functional impairment assessed with the Global Assessment of Functioning Scale is continuously distributed and increases progressively with the number of criteria exhibited with little evidence of a major increase in dysfunction when diagnostic thresholds are reached (Nakao et al., 1992). A third view is that a qualitative difference would occur if patients with personality disorder exhibited traits that are not found in healthy individuals. There is little evidence, however, that there are traits specific to personality disorder. Perusal of the clinical literature, including the DSM-IV diagnostic criteria for personality disorder, indicates that the terms used to describe personality pathology are identical to those used to describe normal personality. An extensive content analysis of the clinical literature of personality disorder failed to identify traits that are specific to personality disorder (Livesley, 1986). Moreover, scales developed to assess personality disorder traits appear to be equally applicable to the assessment of personality in healthy individuals (Clark, 1990; Livesley et al., 1992; Helmes & Jackson, 1994). Evaluation of the means, standard deviations, distributional plots, and internal consistency supports the view that the scales of personality disorder traits retain their coherence when administered to non-clinical samples. Finally, the same traits could characterize normal and disordered personality but the configuration of these traits could differ in clinical groups. The evidence on this point will be considered in the following section. THE STRUCTURE OF PERSONALITY DISORDER If trait organization differs in clinical and non-clinical groups, the constellation of traits selected to represent personality disorder should be more crystallized in a group of patients with clear evidence of personality disorder and trait structure should vary across groups. Comparisons of normal and clinical groups show differences in the magnitude of scores on trait scales but not in the structure of their principal component loadings. Comparisons across normal and clinical groups Studies of the structure of personality disorder traits consistently report that a few major dimensions (usually four) underlie personality disorder diagnoses (Mulder & Joyce,

4 260 W. J. Livesley and K. L. Jang 1997). The first empirical investigations of the structure of personality disorder traits were reported in the 1970s (Presly & Walton, 1973; Tyrer & Alexander, 1979). Since then the structure has been confirmed across studies in which the items examined were DSM personality disorder criteria (Austin & Deary, 2000; Mulder & Joyce, 1997), more extensive criteria that included personality features of Axis I disorders (Clark, 1990), and extensive lists of traits identified by systematic literature review (Livesley, 1991; Livesley, Jang, & Vernon, 1998). The structure is independent of method of measurement: it is identified in studies using structured interviews (Tyrer & Alexander, 1979; Austin & Deary, 2000) and self-report measures (Clark, 1993; Livesley et al., 1998). Tyrer and Alexander (1979) found that the four factor structure underlying 24 traits descriptive of personality disorder was similar in patients with personality disorder and those with other psychiatric disorders. Livesley (1986, 1987) used a modification of the lexical approach that led to the five factor approach to normal personality to identify the terms used to represent personality disorder. Items identified through a content analysis of the clinical literature were reduced to 100 traits using a combination of clinician ratings and rational methods. Self-report scales were developed for each trait (Livesley, Jackson, & Schroeder, 1989) and the structure underlying these scales was explored in general population subjects and a sample of patients with personality disorder (Livesley et al., 1992). Data from the two samples were examined in separate principal component analyses. The important question for conceptualizing normal and disordered personality is whether the two samples yielded important differences in the structure of their principal component loadings. In each case, a 15 component solution was optimal. Examination of the similarity of the component loadings in the two samples indicated considerable congruence. These results were used to develop a self-report inventory the Dimensional Assessment of Personality Pathology Basic Questionnaire (DAPP-BQ; Livesley & Jackson, in press). The similarity in primary factor structure in clinical and non-clinical samples is also found in analyses of higher order structure. Livesley and colleagues (1998) compared the factor structure underlying 18 dimensions of personality disorder assessed using the DAPP-BQ in a general population sample, a clinical sample consisting of patients with a primary diagnosis of personality disorder, and a general population twin sample. Decomposition of the phenotypic correlation matrices for the three samples separately yielded four components that were labelled Emotional Dysregulation, Dissocial, Inhibition, and Compulsivity. Congruence coefficients among the phenotypic components ranged from 0.94 to 0.99, indicating remarkable similarity in the clinical and general population components. This structure is robust across cultures, being reported in studies from North America (Livesley et al., 1998), Germany (Pukrop et al., 2001), Holland (van Kampen, 2002), and China (Zheng et al., 2002). Comparisons of normal and disordered personality traits The similarity in the structure of personality disorder traits across samples differing with respect to the presence of personality disorder and evidence that the same constructs may be used to represent normal and disordered personality (Helmes & Jackson, 1994) raises the question of whether personality disorder may be represented by models of normal personality. This question has been examined in two ways: (1) evaluating the degree to which DSM personality diagnoses can be accommodated within models of normal

5 Normal, abnormal, and disordered personality 261 personality and (2) exploring the relationship between descriptions of personality disorder traits (as opposed to disorders) and models of normal personality. Multiple studies suggest that several models of normal personality can accommodate DSM personality disorder diagnoses, including the five-factor model, Eysenck s three component structure, and the interpersonal circumplex. The evidence suggests that the five factor model provides a notably better fit than the interpersonal circumplex (Soldz, Budman, Demby, & Merry, 1993). However, there seems little difference in fit between three and five factor models. The relationship between the five factor approach and DSM diagnoses has, however, received most attention. DSM personality disorders fit the five factor framework well (Ball, Tennen, Poling, Krazler, & Rounsaville, 1997; Blais, 1997; Dyce & Connor, 1998; McCrae et al., 2000; Reynolds & Clark, 2001; Trull, Widiger, & Burr, 2001). However, the results of these correlational studies are difficult to interpret. The global nature of DSM diagnostic constructs most disorders consist of multiple traits (Shea, 1995) makes it difficult to determine the constructs responsible for observed relationships. More pertinent to the distinction between normal and disordered personality are studies that explore the relationship between models of normal and disordered personality. The four higher order or secondary factors of personality disorder closely resemble four of the five factors assessed by the NEO-PI-R (Costa & McCrae, 1992). Emotional Dysregulation, Dissocial, Inhibition, and Compulsivity resemble neuroticism, (dis)agreeableness, introversion, and conscientiousness, respectively (Widiger, 1998; Livesley, 1998). Consistent with other analyses of clinical scales, a factor resembling openness was not obtained (Clark, 1993). The apparent convergence between the DAPP-BQ and the Neuroticism, Extraversion, and Openness Personality Inventory (NEO-PI) was confirmed when both measures were administered to a sample of 300 subjects (Schroeder et al., 1992). Principal components analysis of the 18 scales and five NEO-PI domains yielded five factors resembling the five factor structure. The systematic relationships between the five factor model and personality disorder diagnoses and traits led to the suggestion that the five factor model provides a suitable framework for classifying personality disorder (Costa & Widiger, 1994, 2002). However, the five factors do not appear to capture all aspects of personality pathology. Despite the convergence between the five factor model and the DAPP-BQ, clinically important traits such as DAPP-BQ insecure attachment and cognitive dysregulation are poorly represented by the NEO-PI-R (Schroeder et al., 1992). The Schedule for Non-Adaptive and Adaptive Personality (SNAP) also seems to capture clinically relevant behaviours not included in the NEO-PI-R (Reynolds & Clark, 2001). This suggests caution in accepting the suggestion that the five factor model might provide an integrating framework for personality disorder. The five factor model as operationalized by the NEO-PI-R does not appear to cover the range of traits relevant to assessment. The primary or facet structure in particular needs further development before it captures clinical concepts (Livesley, 2001). NORMAL, ABNORMAL, AND DISORDERED PERSONALITY Evidence that personality disorder may be described by using graded continua that are continuous with dimensions of normal personality promises to integrate the study of normal and disordered personality and to bring coherence to the study of personality disorder a field that currently lacks an integrative framework. Unfortunately it also contributes to the problem of differentiating normal and disordered personality variants a conceptual

6 262 W. J. Livesley and K. L. Jang problem with considerable practical implications. The continuity observed between normality and pathology suggests that the extreme variants that constitute personality disorder can only be differentiated from normal personality variants using thresholds that must to some extent be artifactual. This does not, however, mean that they must be arbitrary empirically determined thresholds could be established based on an understanding of liability or risk associated with different levels of trait expression. This raises questions about what we mean by personality disorder, what it is about extreme variation of adaptive traits that makes them disorders, and whether extreme variation alone is sufficient to warrant a diagnosis of personality disorder. Personality disorder as extreme trait variation The simplest distinction between normal and disordered personality is quantitative personality disorder represents an extreme position on a trait dimension, that is, it involves either too much or too little of a given characteristic (Eysenck, 1987; Kiesler, 1986; Leary, 1957, Wiggins & Pincus, 1989). The justification for this approach is that extremeness is assumed to indicate inflexibility in interpersonal behaviour and many conceptions of personality disorder, including that adopted by the DSM-IV, consider inflexibility to be a hallmark of personality disorder. Unfortunately, this idea confuses extreme scores on a personality trait with disordered functioning (Parker & Barrett, 2000). As Wakefield (1992) pointed out, statistical deviance alone is neither a necessary nor sufficient criterion for disorder. With personality disorder, it is difficult to see how an extreme score on dimensions such as conscientiousness, extraversion, or agreeableness is necessarily pathological. Some additional factor needs be present to justify the diagnosis. The DSM suggests two characteristics inflexibility and subjective distress. Presumably inflexibility is a function of extremeness (McCrae, 1994). However, an extreme position on a trait dimension does not necessarily indicate inflexibility. One could imagine an individual who acts in an extremely extraverted way most of the time but is able to refrain from these behaviours at critical moments when they would be inappropriate. Extremeness and inflexibility are probably highly correlated but they are not the same. Extremity appears to be a necessary condition for personality disorder but it is not sufficient. Disorder implies something else. But what is this something else? At this point, it is useful to recall distinctions made by Kurt Schneider (1922/1950) more than 80 years ago in his classical work on personality disorders, which he referred to as psychopathic personalities. Schneider distinguished personality, abnormal personality, and personality disorder. The term abnormal personality was used in the statistical sense to refer to extremes of normal variation. Schneider recognized, however, that extremity alone was not sufficient to justify a clinical diagnosis. He asserted that personality disorders were forms of abnormal personality that either cause personal suffering or cause society to suffer. Although the conceptual distinction between personality, abnormal personality, and personality disorder continues to be useful, the criteria that Schneider proposed to differentiate abnormal and disordered personality are less helpful. The problem is that both personal and community suffering are continuous variables and it is unclear how much personal suffering is needed to justify a diagnosis of personality disorder. Shyness may causesomediscomfortinsome situations but clearly not all shy individuals have personality disorder: disorder implies something more profound. Even more problematic is that both personal and community suffering are dependent on social context. Traits such as being outspoken or highly

7 Normal, abnormal, and disordered personality 263 independent may cause problems for the community in some contexts but one would not consider them an indication of disorder. For good reasons, psychiatric classifications are cautious about including disorders that are culturally bound or found only in certain cultures. Despite these problems, little conceptual progress has been made beyond Schneider s formulation. The DSM-IV definition of personality disorder as maladaptive and inflexible traits that are associated with functional impairment or distress is not an improvement it merely restates the definition in a different form. An extension of the extreme trait definition of personality disorder is Widiger s (1994) proposal, based on the five-factor model, that personality disorders could be diagnosed at that point along the continuum of personality functioning that is associated with clinically significant impairment involving dyscontrolled impairment or maladaptivity in psychological functioning (Widiger & Trull, 1991; Widiger & Sankis, 2000). The idea is interesting but it creates the problem of the criteria that could be used to diagnose dyscontrolled maladapativity reliably. Without a general definition, one would have to catalogue the various maladaptive manifestations of each trait. The proposal also seems to embody an ideal concept of normality since, as Widiger (1994) noted, everyone shows some degree of maladaptive expressions of basic traits. Perhaps the difficulty in arriving at a definition of personality disorder that relies largely on trait expression occurs because the construct of trait does not readily lend itself to this task. Trait constructs represent proclivities tendencies to act in certain ways and exhibit a particular class of behaviours. They do not describe competencies. Thus extreme levels of a trait may increase the risk of psychopathology but they are not necessarily maladaptive. A definition of personality disorder needs to incorporate features of disorder that are separate from, although possibly correlated with, extreme trait variation. Such an approach is also needed because traits are not all there is to personality, and the clinical concept of personality disorder refers to more than maladaptive traits (Livesley & Jang, 2000). It is useful in this context to think of personality as a system of interrelated structures and processes (Costa & McCrae, 1994; Mischel, 1999; Vernon, 1964) that includes dispositional traits, personal concerns including motives, roles, goals, and coping strategies, and the life narrative and self system that provides an integrated account of past, present, and future (McAdams, 1994). The psychopathology of personality disorder covers all components of this system: symptoms, problems with affect and impulse regulation, maladaptive expressions of traits, interpersonal problems, and self-pathology (Livesley, 2003). Disorder is seen not only in the contents of the system but also in its structure and functioning. Indeed, the notion of disorder implies a disturbance of functioning. As Wakefield (1992) suggested, mental disorders generally could be defined as harmful dysfunctions. That is, they involve a harmful failure of internal mechanisms to perform their naturally selected functions. By extension, personality disorder involves a harmful dysfunction in the normal adaptive functions of the personality system. Personality disorder as adaptive failure Some years ago, Cantor (1990) recalled Allport s comment that personality is something and personality does something to draw attention to how personality psychology (and psychiatric nosology) has focused largely on what personality is that is, on the description of individual differences in normal and disordered personality. In the process, they neglected what personality does and how personality functioning is disturbed in personality disorder. Cantor described the functions of personality in terms of the personal

8 264 W. J. Livesley and K. L. Jang tasks that individuals face and set for themselves, the schemata used to construe these tasks, the self, and life situations, and the strategies used to achieve personal tasks. This functional analysis provides the beginnings of a definition of personality disorder. The functions described, however, involve mechanisms that differ in breadth and scope. Some involve dysfunctions in specific adaptive mechanisms. Although a description of these dysfunctions would contribute to our understanding of psychopathology, the concept of personality disorder implies something more pervasive than circumscribed dysfunction. This suggests that a definition of personality disorder should be focused on the more abstract level of life task. Life tasks are the problems individuals face as a consequence of cultural expectations of social living and underlying biology. Tasks vary with culture and stage of development. Especially important for understanding personality disorder are universal life tasks that have evolutionary significance. Personality may be viewed as the product of adaptive mechanisms that evolved to solve problems of survival and reproduction that confronted our remote ancestors in the ancestral environment of hunter-gatherers on the African savanna. Universal tasks were common problems to be solved for effective functioning and survival in the ancestral environment. The problem of course is to establish an agreed set of universal tasks. Plutchik (1980) suggested one approach that has the merit of being similar to clinical concepts of personality disorder. He identified four universal challenges: the development of identity; the solution to the problems of dominance and submissiveness created by hierarchy that is characteristic of primate social hierarchies; development of a sense of territoriality or belongingness; and solution to the problems of temporality, that is, problems of loss and separation. These ideas lead to the suggestion that personality disorder occurs when the structure of personality prevents the person from achieving adaptive solutions to universal life tasks (Livesley, 1998, p. 141). This is a deficit definition, which considers personality disorder to be a harmful dysfunction involving the failure to acquire the structures required for adaptive functioning. The life tasks involved could be expressed in traditional clinical language while still retaining an evolutionary perspective by defining personality disorder as the failure to achieve one or more of the following: (1) stable and integrated representations of self and others; (2) the capacity for intimacy, to function adaptively as an attachment figure, and/or to establish affiliative relationships; and (3) adaptive functioning in the social group as indicated by the failure to develop the capacity for prosocial behaviour and/or cooperative relationships. To differentiate personality disorder from other mental disorders, one or more of these failures should be enduring and traceable to adolescence or at least early adulthood and they should be due to extreme personality variation rather than another pervasive and chronic mental disorder such as a cognitive or schizophrenic disorder. Failure to achieve adaptive solutions to these tasks was probably maladaptive in an evolutionary sense. A cohesive sense of self or identity would help to ensure the adaptive social behaviour needed to gain access to the resources needed for reproduction and survival. It would also contribute to the establishment and attainment of the longer term goals that are part of effective adaptation. The ability to function effectively in close familial relationships would contribute to effective reproduction and child-rearing that would help to guarantee that genes were passed on. Finally, cooperative and prosocial behaviour would facilitate access to resources and the protection of the social group. These tasks are probably equally pertinent to effective adaptation in the contemporary situation. In a continually changing world, a coherent

9 Normal, abnormal, and disordered personality 265 sense of self provides a stable frame of reference that gives stability to relationships, provides direction and purpose to action, and contributes to self-regulation. The capacity for intimacy, attachment and cooperative behaviour are no less important now than for our remote ancestors. Although this definition is derived from normal personality theory and evolutionary psychology, it incorporates clinical concepts of personality disorder. Most clinical conceptions of disordered personality reference either chronic interpersonal difficulties or problems with self or identity. Rutter (1987), for example, concluded that personality disorder is characterized by a persistent, pervasive abnormality in social relationships and social functioning generally (p. 454). In contrast, psychoanalytic thinkers such as Kohut and Kernberg tend to emphasize self pathology. Kohut (1971), for example, considered narcissistic personality in terms of the failure to develop a cohesive sense of self. Similarly, Kernberg (1984) considered identity diffusion to be a central feature of borderline personality organization. Identity diffusion was said to involve a poorly integrated concept of the self and of significant others...reflected in the subjective experience of chronic emptiness, contradictory self-perceptions, contradictory behavior that cannot be integrated in an emotionally meaningful way, and shallow, flat, impoverished perceptions of others (1984, p. 12). Several advantages accrue from defining personality as the failure to achieve adaptive solutions to universal life tasks. First, it separates the diagnosis of personality disorder from the assessment of individual differences in personality dimensions such as traits, thereby avoiding the problems created by defining disorder only in terms of extreme levels of a given characteristic. Second, it emphasizes the severity of personality disorder and clarifies the distinction between disordered personality and dysfunctions in relatively discrete aspects of personality such as an isolated trait. Such dysfunctions may cause distress but they do not always lead to the level of difficulties usually seen in patients considered to have personality disorder. Finally, the definition of disorder is based on an understanding of the functions of normal personality rather than an arbitrary set of characteristics. CONCLUDING COMMENTS Ideas about the nature of personality disorder and its relationship to normal personality have changed considerably in recent years. Far from being the separate domains assumed by contemporary psychiatric nosologies, they are merely seen to reflect different levels of the same continua. We are only just beginning the task of describing and explaining the various ways in which personality pathology is manifested and there are major challenges, both conceptual and empirical, in understanding disordered personality and its relationship to normal personality structure and functioning. Nevertheless, we think that there is considerable merit in differentiating the assessment of extreme levels of individual differences in personality characteristics from the evaluation and diagnosis of disorder. The distinction brings a measure of clarity to the assessment process and places emphasis on dysfunction at the overall level of the organization and functioning of the personality system. We also think that it is apparent from the progress that has been made in understanding the similarity in trait structure across clinical and non-clinical groups that much is likely to be gained from integrating personality disorder with theories of personality and its development.

10 266 W. J. Livesley and K. L. Jang REFERENCES American Psychiatric Association (APA). (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: American Psychiatric Association. American Psychiatric Association (APA). (1994). Diagnostic and statistical manual of mental disorders (4th edn). Washington, DC: American Psychiatric Association. Austin, E. J., & Deary, I. J. (2000). The four As : A common framework for normal and abnormal personality? Personality and Individual Differences, 28, Ball, S. A., Tennen, H., Poling, J. C., Krazler, H. R., Rounsaville, B. J. (1997). Personality, temperament, and character dimensions and the DSM-IV personality disorders in substance abusers. Journal of Abnormal Psychology, 106, Blais, M. A. (1997). Clinician ratings of the five-factor model of personality and the DSM-IV personality disorders. Journal of Mental and Nervous Disease, 185, Cantor, N. (1990). From thought to behavior: Having and doing in the study of personality and cognition. American Psychologist, 45, Clark, L. A. (1990). Toward a consensual set of symptom clusters for assessment of personality disorder. In J. Butcher, & C. Spielberger (Eds.), Advances in personality assessment (Vol. 8, pp ). Hillsdale, NJ: Erlbaum. Clark, L. A. (1993). Personality disorder diagnosis: Limitations of the five-factor model. Psychological Inquiry, 4, Costa, P. T., & McCrae, R. R. (1992). Revised NEO Personality Inventory (NEO-PI-R) and the NEO Five-Factor Inventory (NEO-FFI) Professional Manual. Odessa, FL: Psychological Assessment Resources. Costa, P. T., & McCrae, R. R. (1994). Can personality change? In T. F. Heatherton, & J. L. Weinberger (Eds.), Can personality change? (pp ). Washington, DC: American Psychological Association. Costa, P. T., & Widiger, T. A. (Eds.). (2002). Personality disorders and the five-factor model of personality (2nd edn). Washington DC: American Psychological Association Books. Dyce, J. A., & Connor, B. P. (1998). Personality disorders and the five-factor model: A test of facetlevel predictions. Journal of Personality Disorders, 12, Eysenck, H. (1987). The definition of personality disorders and the criteria appropriate to their definition. Journal of Personality Disorders, 1, Frances, A. J., Clarkin, J., Gilmore, M., Hurt, S., & Brown, S. (1984). Reliability of criteria for borderline personality disorder: A comparison of DSM-III and the diagnostic interview for borderline patients. American Journal of Psychiatry, 42, Grayson, D. A. (1987). Can categorical and dimensional views of psychiatric illness be distinguished? British Journal of Psychiatry, 151, Harris, H. T., Rice, M. E., & Quinsey, V. L. (1994). Psychology as a taxon: Evidence that psychopaths are a discrete class. Journal of Consulting and Clinical Psychology, 62, Haslam, N. (2003a). Categorical versus dimensional models of mental disorder: The taxometric evidence. Australian and New Zealand Journal of Psychiatry, 37, Haslam, N. (2003b). The dimensional view of personality disorders: A review of the taxometric evidence. Clinical Psychology Review, 23, Helmes, E., & Jackson, D. N. (1994). Evaluating normal and abnormal personality using the same set of constructs. In S. Strack, & M. Lorr (Eds.), Differentiating normal and abnormal personality (pp ). New York: Springer. Kass, F., Skodol, A., Charles, E., Spitzer, R. L., & Williams, J. B. W. (1985). Scaled ratings of DSM- III personality disorders. American Journal of Psychiatry, 142, Kendell, R. E. (1975). The role of diagnosis in psychiatry. Oxford: Blackwell. Kernberg, O. F. (1984). Severe personality disorders. New Haven, CT: Yale University Press. Kiesler, D. J. (1986). The 1982 interpersonal circle: An analysis of DSM-III personality disorders. In T. Millon, & G. L. Klerman (Eds.), Contemporary directions in psychopathology: Toward the DSM-IV. (pp ). New York: Guilford. Kohut, H. (1971). The analysis of the self. New York: International Universities Press. Leary, T. (1957). Interpersonal diagnosis of personality: A functional theory and methodology for personality evaluation. New York: Ronald.

11 Normal, abnormal, and disordered personality 267 Livesley, W. J. (1986). Trait and behavioral prototypes of personality disorder. American Journal of Psychiatry, 143, Livesley, W. J. (1987). A systematic approach to the delineation of personality disorders. American Journal of Psychiatry, 144, Livesley, W. J. (1991). Classifying personality disorders: Ideal types, prototypes, or dimensions? Journal of Personality Disorders, 5, Livesley, W. J. (1998). Suggestions for a framework for an empirically based classification of personality disorder. Canadian Journal of Psychiatry, 43, Livesley, W. J. (2001). Commentary on reconceptualizing personality disorder categories using trait dimensions. Journal of Personality, 69, Livesley, W. J. (2003). Practical management of personality disorder. New York: Guilford Press. Livesley, W J., & Jackson, D. N. (in press). Manual for the Dimensional Assessment of Personality Pathology (DAPP-BQ). Port Huron, MI: Sigma Assessment Systems. Livesley, W. J., Jackson, D. N., & Schroeder, M. L. (1989). A study of the factorial structure of personality pathology. Journal of Personality Disorders, 3, Livesley, W. J., Jackson, D. N., & Schroeder, M. L. (1992). Factorial structure of traits delineating personality disorders in clinical and general population samples. Journal of Abnormal Psychology, 101, Livesley, W. J., & Jang, K. L. (2000). Toward an empirically based classification of personality disorder. Journal of Personality Disorders, 14, Livesley, W. J., Jang, K. L., & Vernon, P. A. (1998). The phenotypic and genetic architecture of traits delineating personality disorder. Archives of General Psychiatry, 55, Livesley, W. J., Schroeder, M. L., Jackson, D. N., & Jang, K. L. (1994). Categorical distinctions in the study of personality disorder: Implication for classification. Journal of Abnormal Psychology, McAdams, D. P. (1994). Can personality change? Levels of stability and growth in personality across the life span. In T. F. Heatherton, & J. L. Weinberger (Eds.), Can personality change? (pp ). Washington, DC: American Psychological Association Press. McCrae, R. R. (1994). A reformulation of Axis II: Personality and personality-related problems. In P. T. Costa, & T. A. Widiger (Eds.), Personality disorders and the five-factor model of personality (pp ). Washington, DC: American Psychological Association. McCrae, R. R., Yiang, J., Costa, P. T., Dai, X., Yao, S., Cai, T., & Gao, B. (2000). Personality profiles and the prediction of categorical personality disorders. Journal of Personality, 69, Meehl, P. E. (1973). MAXCOV HITMAX: A taxonomic search method for loose genetic syndromes. In P. E. Meehl (Ed.), Psychodiagnosis: Selected papers (pp ). New York: Norton. Meehl, P. E. (1992). Factors and taxa, traits and types, differences of degree and differences of kind. Journal of Personality, 60, Meehl, P. E., & Golden, R. R. (1982). Taxometric methods. In J. N. Butcher, & C. C. Kendall (Eds.), The handbook of research methods in clinical psychology (pp ). New York: Wiley. Mischel, W. (1999). Personality coherence and dispositions in a Cognitive Affective Personality System (CAPS) approach. In D. Cervone, & Y. Shoda (Eds.), The coherence of personality (pp ). New York: Guilford. Mulder, R. T., & Joyce, P. R. (1997). Temperament and the structure of personality disorder symptoms. Psychological Medicine, 27, Nakao, F., Gunderson, J. G., Phillips, K. A., Tanaka, N., Yorifuji, K., Takaishi, J., & Nashimura, N. (1992). Functional impairment in personality disorders. Journal of Personality Disorders, 6, Nestadt, G., Romanoski, A., Chahal, R., Merchant, A., Folstein, M., Gruenberg, E., & McHugh, R. (1990). An epidemiological study of histrionic personality disorder. Psychological Medicine, 20, Parker, G., & Barrett, E. (2000). Personality and personality disorder: current issues and directions. Psychological Medicine, 30, 1 9. Plutchik, R. (1980). A general psychoevolutionary theory of emotion. In R. Plutchik, & H. Kellerman (Eds.), Emotion: Theory, research, and experience (pp. 3 33). San Diego, CA: Academic. Presly, A. J., & Walton, H. J. (1973). Dimensions of abnormal personality. British Journal of Psychiatry, 122,

12 268 W. J. Livesley and K. L. Jang Pukrop, R., Gentil, I., Steinbring, I., & Steinmeyer, E. (2001). Factorial structure of the German version of the Dimensional Assessment of Personality Pathology-Basic Questionnaire in clinical and nonclinical samples. Journal of Personality Disorders, 15, Reynolds, S. K., & Clark, L. A. (2001). Predicting dimensions of personality disorder from domains and facets of the five-factor model. Journal of Personality, 69, Rutter, M. (1987). Temperament, personality and personality disorder. British Journal of Psychiatry, 150, Schneider, K. (1950). Psychopathic Personalities (9th ed., English trans.). London: Cassell. (Original work published in 1922). Schroeder, M. L., Wormworth, J. A., & Livesley, W. J. (1992). Dimensions of personality disorder and their relationships to the big five dimensions of personality. Psychological Assessment, 4, Shea, M. T. (1995). Interrelationships among categories of personality disorders. In W. J. Livesley (Ed.), The DSM-IV Personality Disorders (pp ). New York: Guilford. Soldz, S., Budman, S., Demby, A., & Merry, J. (1993). Representation of personality disorders in circumplex and five factor space: Explorations with a clinical sample. Psychological Assessment, 5, Strack S., Lorr, M. (1994). Introduction. In S. Strack, & M. Lorr (Eds.), Differentiating normal and abnormal personality (pp. xiii xviii). New York: Springer. Trull, T. J., Widiger, T. A., & Burr, R. (2001). A structured interview for the assessment of the Five- Factor Model of Personality: Facet-level relations to the Axis II personality disorders. Journal of Personality, 69, Tyrer, P., & Alexander, M. S. (1979). Classification of personality disorder. British Journal of Psychiatry, 135, van Kampen, D. (2002). The DAPP-BQ in the Netherlands: Factor structure and relationship with basic personality dimensions. Journal of Personality Disorders, 16, Vernon, P. E. (1964). Personality assessment: A critical survey. London: Methuen. Wakefield, J. C. (1992). Disorder as harmful dysfunction: A conceptual critique of DSM-III-R s definition of mental disorder. Psychological Review, 99, Waller, N. G., & Meehl, P. E. (1998). Multivariate Taxonomic Procedures. Thousand Oaks, CA: Sage. Widiger, T. A. (1993). The DSM-III-R categorical personality disorder diagnoses: A critique and alternative. Psychological Inquiry, Widiger, T. A. (1994). Conceptualizing a disorder of personality from the five-factor model. In P. T. Costa, & T. A. Widiger (Eds.), Personality disorders and the five-factor model of personality (pp ). Washington, DC: American Psychological Association Press. Widiger, T. A. (1998). Four out of five ain t bad. Archives of General Psychiatry, 55, Widiger, T. A., & Sankis, L. M. (2000). Adult psychopathology: Issues and controversies. Annual Review of Psychology, 51, Widiger, T. A., & Trull, T. J. (1991). Diagnosis and clinical assessment. Annual Review of Psychology, 42, Wiggins, J. S., & Pincus, A. L. (1989). Conceptions of personality disorder and dimensions of personality. Psychological Assessment, 1, Zheng, W., Wang, W., Huang, Z., Sun, C., Zhu, S., & Livesley, W. J. (2002). The structure of traits delineating personality disorder in China. Journal of Personality Disorders, 16(6), Zimmerman, M., & Coryell, W. (1990). Diagnosing personality disorder in the community: A comparison of self-report and interview measures. Archives of General Psychiatry, 47,