13c
Charles A. Sanislow and Anna Darre Hector
Commentaries on our chapter by Cain and Arntz raise compelling questions about the status quo as related to the Cluster C personality disorders. In response, we have taken the opportunity to clarify our perspective and elaborate our central thesis suggesting that an integration of mechanisms would open possibilities for new kinds of progress.
Cain (this volume) provided a persuasive argument for the validity and utility of interpersonal theory to enhance our understanding – and treatment – of anxious fearful pathology, and made a compelling case for interpersonal theory as vital to understand and treat anxious-fearful personality disorders. We agree. Cain illustrated the value of interpersonal theory for identifying pathognomonic patterns of maladaptive behavior, and for implementing treatment strategies. In our chapter, we made an appeal to integrate internal (psychological and biological) mechanisms into the study of personality pathology, elaborated ways that this might be done, and argued that this would move the field farther than another reorganization of symptoms. While we embrace Cain’s argument for interpersonal processes, we also want to draw attention to elements of the person in the interpersonal situation. We do so with a focus on both interpersonal theory and mechanisms.
Cain traced the roots of interpersonal theory back to Sullivan (1953). Sullivan championed the idea of understanding human behavior and its aberrations through the lens of interpersonal process, and he realized the resulting empirical advantage towards efforts to identify pathologies and to change them for the better. In the predominant psychoanalytic thinking of his era, his focus on overt behavior was a radical departure from the then contemporary object relations theory. Sullivan was also a pragmatist because he targeted the treatment of pathology where it was manifested, in life and the therapy context. Moreover, he was ahead of his time because he connected interpersonal transactions to the internal mechanisms that humans brought to interaction. Key among the concepts introduced by Sullivan was his notion of parataxic distortions that served to minimize anxiety and facilitate development – for better or worse – by creating expectancies and instances of selective inattention (Sullivan, 1953). Essentially, he was tapping mental operations that would decades later be elaborated by mainstream concepts in cognitive psychology (Carson, 1982).
Arntz (this volume) marshaled evidence based on structural models that challenged the structural organization of Cluster C, assembling evidence that obsessive-compulsive personality disorder (OCPD) is a misfit. We generally agree with this distinction, and findings from the Collaborative Longitudinal Personality Study including factor analysis (Sanislow et al., 2002) and comorbidities across clusters (McGlashan et al., 2000), support Arntz’s contention. We hasten to add, however, that limiting focus to the symptom level to improve diagnosis is likely to have the unintended consequence of keeping us in the weeds. Structural models of psychopathology symptoms have value for identifying compelling symptom clusters, but validation requires spelling out connections to internal mechanisms (Sanislow, 2016).
Arntz does move on to make connections to internal mechanisms by reporting features of cognitive schemas that distinguish OCPD from other Cluster C personality disorders. Namely, OCPD patients tend to overcompensate to defend against vulnerable feelings, in contrast to other Cluster C sufferers who tend to rely on avoidance strategies. It may be matters of grain size or focus that there is lack of agreement in the extent to which different sorts of maladaptive behaviors share in common the avoidance (i.e., defense) of some form of anxiety. OCPD may appear to be adaptable because overcompensation can be functional for some individuals. Regardless, our goal is not to defend the cluster structure of the DSM. Rather, we emphasize the importance of developmental processes in determining how a common dysfunctional internal mechanism may give rise to varied outcomes (Cichetti & Rogosch, 1996).
In this light, we reiterate our assertion that there is considerable promise in expanding focus to transdiagnostic constructs and processes that have utility for anchors of personality that relate to maladaptive behavior. For example, Downey and Feldman (1996) suggest that rejection sensitive (RS) individuals are more likely to perceive rejection and ill intent in ambiguous social situations, both with strangers and romantic partners. This assumption of malicious intent by others may help explain why some RS individuals exhibit aggressive behaviors. Downey describes the process as a self-fulfilling prophecy to ensure rejection by romantic partners (Downey, Freitas, Michaelis, & Khouri, 1998). Further, interpersonal mechanisms (external, as opposed to internal) provide an opportunity to capitalize on the power of the interpersonal approach for better understand and treating Cluster C personality disorders. Critchfield, Benjamin & Levenick (2015) remind us that multiple diagnoses are the rule and not the exception for personality disordered patients, and thus present complications for treatment. Using Benjamin’s (2003) Interpersonal Reconstructive Therapy (IRT) approach, they identified interpersonal prototypes that cut across multiple personality disorders, including obsessive compulsive, passive aggressive, and borderline, and demonstrated specificity and sensitivity of cross-cutting interpersonal processes that transcended DSM diagnoses.
All things considered, we do not view the higher order organization of Cluster C as an ultimate truth, nor do we view personality disorder diagnoses themselves as natural kinds. We do think that the frequency of diagnostic co-occurrence among personality disturbed individuals complicates matters. The reality that successful forms of psychotherapeutic treatment are not targeted at a personality disorder diagnoses per se but rather at maladaptive patterns of behavior, as suggested by Cain, or at dysfunctional cognitive schemas, as suggested by Arntz, support the utility of valid, cross-cutting mechanisms. Our chapter argued that incorporating basic internal mechanisms and their dysfunction into research – whether with RDoC or with other approaches – will be necessary to move beyond another rearrangement of symptoms and traits and to allow us to live meaningfully outside the cluster. Our rejoinder reiterates our view, and, motivated by our commentators, we add that person (mechanism) and situation (interpersonal processes) are inseparable (Cain), and that an awareness and articulation of grain size will serve us well as we go forward (Arntz).
References
Benjamin, L. S. (2003). Interpersonal Reconstructive Therapy. New York: Guilford Press.
Carson, R. C. (1982). Self-fulfilling prophecy, maladaptive behavior, and psychotherapy. In J. C. Anchin and D. J. Kiesler (Eds.), Handbook of Interpersonal Psychotherapy (pp. 64–77). New York: Pergamon.
Cicchetti, D., & Rogosch, F. A. (1996). Equifinality and multifinality in developmental psychopathology. Development and Psychopathology, 8, 597–600.
Critchfield, K. L., Benjamin, L. S., & Levenick, K. (2015). Reliability, sensitivity, and specificity of case formulations for comorbid profiles in interpersonal reconstructive therapy: Addressing mechanisms of psychopathology. Journal of Personality Disorders, 29, 547–573.
Downey, G., & Feldman, S. I. (1996). Implications of rejection sensitivity for intimate relationships. Journal of Personality and Social Psychology, 70(6), 1327–1343.
Downey, G., Freitas, A. L., Michaelis, B., & Khouri, H. (1998). The self-fulfilling prophecy in close relationships: Rejection sensitivity and rejection by romantic partners. Journal of Personality and Social Psychology, 75(2), 545–560.
McGlashan, T. H., Grilo, C. M., Skodol, A. E., Gunderson, J. G., Shea, M. T., Morey, L. C., … Stout, R. L. (2000). The Collaborative Longitudinal Personality Disorders Study: Baseline Axis I/II and II/II diagnostic co-occurrence. Acta Psychiatrica Scandinavica, 102, 256–264.
Sanislow, C. A. (2016). Connecting psychopathology meta-structure and mechanisms. Journal of Abnormal Psychology, 125, 1158–1165.
Sanislow, C. A., Morey, L. C., Grilo, C. M., Gunderson, J. G., Shea, M. T., Skodol, A. E., … McGlashan, T. H. (2002). Confirmatory factor analysis of DSM-IV schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders: Findings from the Collaborative Longitudinal Study of Personality Disorders. Acta Psychiatrica Scandinavica, 105, 28–36.
Sullivan, H. S. (1953). The Interpersonal Theory of Psychiatry. New York: W. W. Norton.