Handbook of Personality Disorders; Theory, Research, and Treatment

Canadian Psychology, Nov 2002 by Coles, E Michael

W. JOHN LIVESLEY (Ed.) Handbook of Personality Disorders: Theory, Research, and Treatment New York: TheGuilford Press, 2001, 640 pages (ISBN 1-57230-629-7, US$65, Hardcover) Reviewed by E. MICHAEL COLES The title of this book leads one to expect it to be the usual chronicling of DSM personality disorders, (i.e., a revision of Livesley's 1995 book The DSM-IV Personality Disorders), with each of the disorders given its own chapter. It consequently comes as a pleasant surprise to see a table of contents in which none of the 28 chapters is devoted to a DSM-IV-TR disorder: A text that is free from the tyranny of the APA is a rarity today. Its objective, as stated in the Preface, is the provision of "an overview and evaluation of current ideas," in the hope that "systematic accounts of the major empirical findings and succinct statements of the core issues as they pertain to the various topics central to understanding personality disorders will lay the foundation for theoretic integration in the future".

The key term for this book is "empirical." It occurs 13 times in the two-and-one-half page Preface, with the opening paragraph making it clear that, in the eyes of the editor, "theoretical speculations based on observations made in the course of clinical practice and the in-depth treatment of small numbers of patients" (p. ix) are bad, while "empirical scrutiny" (p. ix) and "empirical evaluations" (p. ix) are good. This idea is repeated in the first chapter, authored by the editor, where the opening paragraph concludes with the statement that "clinical developments have been paralleled by similar progress in research that has transformed the field from one that was dominated by clinical observation and impression into an active arena for empirical analysis" (p. 3). Gordon Allport (1938) may not have approved of such a development, but it is consistent with the standards of contemporary psychology, to say nothing of the criteria for inclusion of disorders in the latest of the American Psychiatric Association's diagnostic and statistical manuals, DSM-IV-TR (APA, 2000).

The coverage of this book is comprehensive. Its 21 chapters are organized into five parts: Theoretical and Nosological Issues, Etiology and Development, Diagnosis and Assessment, Treatment, and Treatment Modalities and Special Issues. But for the last section, this is similar to the organization adopted 20 years ago by Coles (1982) and 21 years earlier than that by Eysenck (1961), and establishes a logical sequence of major topics. Livesley, himself, writes the first and last chapters, but there is a total of 46 contributors listed, including such notable authorities as Lee Anna Clark, Theodore Milton, and Thomas A. Widiger.

Compiling as comprehensive a text as this is not an easy task. As might be expected when such a broad area is covered by so many contributors, the quality is variable. Some chapters are clearly written by recognized authorities, and are on topics that are fundamental to a comprehensive consideration of personality disorders. The early chapters by Milton, Meagher and Grossman on "Theoretical Perspectives," and by Widiger on "Official Classification Systems" are good examples. Unfortunately, other chapters illustrate the limitations resulting from the neglect of traditional theories and a selection procedure that gives the greatest weight to empirical research. The chapter by Bartholomew et al. on attachment, for example, stands alone insofar as, of the numerous references to Bartholomew in the text, only one occurs outside Bartholomew's own chapter, and that is Benjamin and Pugh's reference to a specific assessment instrument, the Adult Attachment Questionnaire, in their chapter on "Using Interpersonal Theory to Select Effective Treatment Interventions." However, this instrument does not merit mention in Clark and Harrison's chapter on "Assessment Instruments." Furthermore, the only references to attachment and attachment theory are those that occur in the chapter by Bartholomew et al. One looks in vain for explanations of such obvious clinical examples as Clerembault Syndrome and Folie a deux in terms of attachment theory, although speculation about possible relationships between attachment styles and DSMIV personality disorders tends to substitute for the empirical demonstrations the text promised to consider. The authors' suggested implications for intervention (pp. 222-224) are particularly short of empirical support, but this is a comment that could be made about a number of chapters, where, despite the editor's stated intentions, speculative suggestions substitute for empirical research.

A more basic issue when reviewing an attempt to use the results of academic empirical research to shed light on clinical concepts is the data base (see Carlson, 1971). As Paris notes on p. 231, "data from clinical and community populations can lead to very different conclusions." Academics like to use college and university students as subjects in their research populations of greatest convenience - but do not always advertise this fact when citing other studies. The selection process that results in a college and/or university student taking part in an experiment is very different from the selection process that results in an individual becoming a psychiatric patient. It is, therefore, not surprising that, despite comments such as "preoccupied individuals would be expected to exhibit histrionic and borderline tendencies" (p. 204), "fearful attachment has much in common with the avoidant and dependent personality disorders" (p. 204), and "based on previous research and theoretical analysis, we can speculate about the attachment components of some personality disorders" (p. 215), the empirical personality research of academics has had limited impact on clinical theories and practice.