A Tower Unto Heaven: Toward an Expanded Framework for Psychopathology

I respond to commentaries on my target article “An Evolutionary Life History Framework for Psychopathology.” I start by addressing criticism of my basic assumptions about life history strategies and their implications for individual differences in human behavior. Next, I examine the theoretical structure of the proposed framework and respond to the commentators’ challenges to its generality and flexibility. I show how the framework can be expanded to include multiple levels of analysis and to integrate behavioral control with neurological functionality; I also reinterpret the recent finding of a general factor of psychopathology in the context of the expanded framework. In the last section I discuss specific psychopathological conditions, namely attention deficit/hyperactivity disorder, borderline personality disorder, substance abuse, autism spectrum disorders, schizophrenia spectrum disorders, obsessive-compulsive disorder, eating disorders, and depression. For each condition, I reply to the commentators’ criticism of my life history analysis, integrate their suggestions and insights, highlight the present weaknesses of the theory, and indicate promising directions for future research.     

Discontinuities,side steps,and finding a proper place: an autobiographical account

In this invited autobiography, I present an account of some influential events and experiences in my life that led me eventually, after some false starts, to a career in personality assessment psychology. The psychological research and applied areas (self-report personality assessment and cross-cultural research) with which I have been identified for over 40 years can, however, be seen in early interests, although their impact and their direction were not always apparent at the time of occurrence. Several people who were influential in my career development are noted and a number of important collaborators who helped sustain my efforts in personality assessment research and practice over the years are highlighted.     

Over half a century of playing with inkblots and other wondrous pursuits

This invited autobiography focuses on the highlights in the career of a psychologist who has devoted over a half century to personality assessment, among other lifetime pursuits. Beginning with an introduction to my early years growing up in Chicago, the story continues through World War II when, as a naval officer, I developed a late-blooming interest in coping behavior and reactions to stress. As with many other post-war graduate students, inkblots held a particular fascination for me as an indirect means of assessing personality and psychopathology through perception. A successful dissertation followed by fellowships and grants over several decades made possible the development of the Holtzman Inkblot Technique (HIT). Published in 1961 by the Psychological Corporation, the HIT consists of two parallel forms containing 45 test blots each. It has been used in hundreds of research studies and in clinical practice as an alternative to the Rorschach throughout the world. In addition to work on the HIT, I describe my efforts to expand personality assessment and psychological research into the international arena and provide a summary of activities in administration and public service.     

The interpersonal circle as a heuristic model for interpersonal research

In this article, I review major advances in the development of the interpersonal circle and its measurement, as delineated by Timothy Leafy (1957) and his colleagues. In my early work (Lorr & McNair, 1963, 1965), an interpersonal Behavior Inventory consisting of manifest behavioral statements was constructed. The 14 categories were found to fit a circular order in several samples. Studies using LaForge and Suczek's (1955) Interpersonal Check List, and Wiggins's (1979) Interpersonal Adjective Scales further established the value of Leary's conceptions and extended them. Several major theorists, researchers, and clinicians including Benjamin, Carson, Horowitz, Kiesler, and Wiggins have been inspired by Leary and, in many cases, have extended his ideas in ways not originally envisioned. Recent research (e.g., Hofstee, de Raad, & Goldberg, 1992; Millon, 1987) demonstrated the pertinence of the interpersonal conception of personality to the 5-factor model and personality disorders.     

The shaping of personality: genes, environments, and chance encounters

I started my career as a clinical psychologist with an interest in personality assessment. But a loss of faith in psychoanalytic theory, projective tests, and clinical case studies in general led to a shift in my interests to personality research. Subsequent jobs at research institutes and universities allowed me to indulge in science. I developed the trait-state concept and its application in tests for affect measurement. For 10 years I did experimental research in the field of sensory deprivation. The sensation seeking idea and tests evolved from this work but soon expanded to many other areas. Research in the biological basis of sensation seeking started with genetic and psychophysiological research, but research conducted in other laboratories also pointed to a psychopharmacological basis for the trait. Over the last several decades, I have formulated a psychobiological model for personality. I have used factor analysis and the biosocial model to develop an "alternative-five" factorial trait structure for personality.     

Transforming Our Understanding of Theories, Paradigms, & Mental Disorders: The Legacy of Donald Capps in the Field of Pastoral Care and Counseling

The life and work of Donald Capps has transformed my thinking and practice as a teacher, minister, and counselor. Incorporating his research into my clinical practice has led me to greater compassion and grace toward those clients who present with personality disorders and characterological disturbances.     

The relationship between childhood abuse and adult personality disorder symptoms

This study assessed personality disorder symptomatology in a community sample of healthy adults without diagnosable DSM-IV-TR Axis I psychiatric disorders who reported a history of childhood abuse. Twenty-eight subjects with a history of moderate to severe physical, sexual, and/or emotional abuse according to the Childhood Trauma Questionnaire were compared to 33 subjects without an abuse history on symptoms of personality disorders. Subjects in the Abuse group were more likely to report subclinical symptoms of paranoid, narcissistic, borderline, antisocial, obsessive compulsive, passive-aggressive, and depressive personality disorders. These findings link reports of childhood abuse with symptoms of personality disorders in the absence of Axis I psychiatric disorders in a community sample of healthy adults.     

Psychology,Pedagogy, and Creative Expression in a Course on Evil

In this article, I describe my Psychology of Evil course, in which a majority of students chose to do creative projects rather than research papers or reports on readings. I explore the impact of the interdisciplinarity demanded by the topic and the texts, modeled by the professor, and brought to the course by the students. In addition, I discuss the effects of classroom environment, personality, intelligence, and especially shadow work (the repressed, feared, unwanted part of our personalities) on students' creative productions.     

Three boys and their stories: Atypical eating and primitive relations1

Eating disorders of whatever category, especially the most severe ones such as anorexia or bulimia, are often considered typical of the female sex. While this is correct concerning these two disorders, I suggest that there are other eating disorders that are more frequent among boys, especially the ones concerning atypical relations to food, notwithstanding the evidence that the already very well‐known syndromes of bulimia and anorexia are also gaining ground among males. However, similar, unspecified eating disorders do not seem to occur so often among girls. Clinical data from my private practice should be taken for granted considering these matters, since I do not yet have statistical data to back up my thesis. In examples from three clinical cases involving boys and one female vignette, I shall attempt to establish a relation between eating disorders and primitive relations with men and women. This relation goes well beyond the oft‐cited ‘contemporary’ causes of eating disorders. In addition, I shall situate these differences among symptoms of both sexes and relate them to impasses in different stages of emotional development, as well as to the extent to which girls’ identification with their mother’s sex can influence their acquisition of eating disorders.     

The burden of disease among adolescents with personality pathology: quality of life and costs

In adults, personality disorders are associated with a low quality of life and high societal costs. To explore whether these findings also apply to adolescents, 131 adolescent patients were recruited from a mental health care institute in The Netherlands. Axis I and Axis II disorders were diagnosed using semi-structured interviews. The EuroQol EQ-5D was used to measure quality of life and costs were measured by the Trimbos and Institute for Medical Technology Assessment Questionnaire on Costs Associated with Psychiatric Illness. The mean EQ-5D index value was 0.55. The mean direct medical cost in the year prior to treatment was €14,032 per patient. The co-occurrence of Axis I and Axis II disorders was a significant predictor of a low quality of life. Direct medical costs were higher for the depressive personality disorder. This study shows that the burden of disease among adolescents with personality pathology is high. This high burden provides evidence to suggest that further research and development of (cost-)effective treatment strategies for this population may be worthwhile.     

Now and Then

I describe my development as a psychoanalyst from my dream of psychoanalysis as a revolutionary movement battling against ignorance and fixed beliefs to finding in Freud's theoretical framework a reliable, scientific base from which I could pursue my own thinking. I trace the evolution of my thinking through my experiences on the training and at my first post-training job in an antenatal department. I give an account of the culmination of my analytic development in my work at Brent Adolescent Centre where my husband, Moe Laufer, and I developed our theory of developmental breakdown in adolescence. Here we pioneered work and research with adolescents in analysis and at the walk-in center.     

Negative life experiences and the development of cluster C personality disorders: a cognitive perspective

Early negative experiences have long been thought to play an important role in the development of personality disorders. Most of the literature regarding these early life experiences has focused on borderline personality disorder, with only occasional focus on other personality disorders. Utilizing cognitive theory of personality disorders (Beck et al., 2004), the authors conceptualize cluster C personality disorders (avoidant, dependent, and obsessive-compulsive). They then critically review the relevant literature on early negative life experiences and later development of these disorders to determine whether the theory is supported by the empirical data. The theory regarding avoidant and dependent personality disorders has limited support, whereas data relating to obsessive-compulsive personality disorder are much weaker. Implications and future research suggestions are discussed.     

Personality and the psychology of learning

The aim of this article is to examine the interaction between personality and learning in order to find clues to the role that a student's personality plays in the process of adaptation and learning. To scrutinize such an expansive area requires that I cover a lot of territory in a small space, condensing many components and processes. Wherever meaningful, I will direct readers to sources that provide greater depth of coverage. The article is divided into four sections. The first section covers personality theories and models based on a structure-oriented view of personality. The second section addresses personality from a process-oriented viewpoint. Current research findings that relate personality characteristics explicitly to learning processes, strategy use, and metacognition are briefly reviewed. The third section goes one step further and discusses second-generation process-oriented personality models. These models are applied to student behaviour during actual learning episodes. A general outline of my model of the adaptable learning process is given and it is argued that the quality of subjective experience is not just an outcome of personality characteristics. It is influenced by student * situation transactions. In the fourth section, conclusions and suggestions for future research are given.     

Emotions and interpersonal relationships: toward a person-centered conceptualization of emotions and coping

ABSTRACT This essay describes my theory of emotions. I make a case for studying discrete emotions in the context of four processes that represent the central features of my theoretical system: appraising, coping, flow of actions and reactions, and relational meaning. I explain why coping is a key feature of the emotion process, and I discuss issues related to the measurement of coping and the importance of understanding coping processes in the context of personality and situational demands. I make the argument that emotions are best studied as narratives, and I offer one such narrative in the form of a case study to demonstrate how emotions can best be understood in the context of an interpersonal relationship and by considering individual differences, interpersonal transactions, and relational meaning. I conclude this essay with a caution that field specialization may interfere with our understanding of emotions and other psychological phenomena, and I underscore the virtues of ipsative-normative research designs as a way to move closer to a person-centered personality psychology.     

Negative Life Experiences and the Development of Cluster C Personality Disorders: A Cognitive Perspective

Early negative experiences have long been thought to play an important role in the development of personality disorders. Most of the literature regarding these early life experiences has focused on borderline personality disorder, with only occasional focus on other personality disorders. Utilizing cognitive theory of personality disorders (Beck et al., 2004), the authors conceptualize cluster C personality disorders (avoidant, dependent, and obsessive–compulsive). They then critically review the relevant literature on early negative life experiences and later development of these disorders to determine whether the theory is supported by the empirical data. The theory regarding avoidant and dependent personality disorders has limited support, whereas data relating to obsessive–compulsive personality disorder are much weaker. Implications and future research suggestions are discussed.     

Personality and Psychopathology: An Application of the Five-Factor Model

Our review is concerned with the relationship of the five-factor model of personality to psychopathology, focusing in particular on Axis II personality disorders and depression. The five factors provide a particularly compelling model for interpreting the Axis II personality disorders as maladaptive variants of normal personality traits. However, we also discuss methodological and conceptual limitations of this application. There has been little research on the relationship of Openness, Agreeableness, and Conscientiousness to Axis I mental disorders, but considerable attention has been given to Neuroticism and Extraversion. We focus in particular on the difficulty in distinguishing between the various ways in which personality can relate to depression, either as a predisposition to, a complication of, a pathoplastic effect upon, or a spectrum variant of the mental disorder. We conclude with recommendations for future research.     

The effect of Axis II disorders on the outcome of treatment of anxiety and unipolar depressive disorders: a review

Psychiatric and other clinicians have often speculated on whether the presence of a personality disorder would indicate a poorer course of treatment for an Axis I disorder. Starting around 1990, the standardized criteria of the DSM increased interest in examining this area empirically. This report updates my previous reviews and examines other writing in this area. There is still a considerable body of evidence indicating that personality may cause a poorer treatment outcome of an Axis I disorder; however, there are also intriguing new developments. The introduction of new drug treatments that may be helpful with some dysfunctional personality traits changes some of the findings and may suggest that there may be preferential treatments for some Axis I patients with certain comorbid personality traits. (In certain cases this may apply to some specific psychotherapy techniques as well.) In addition, at times, personality traits may predict a positive outcome to treatment. This review is an attempt to bring together this diverse area and suggest where fruitful areas of research and intervention may possibly be found.     

Personality variables, psychopathological alterations and personality disorders in alcohol-dependent patients according to Cloninger's typology of alcohol abuse

In this paper, an evaluation of Cloninger's typology of alcohol abuse in personality, psychopathology and personality disorders is carried out. The sample consisted of 158 alcoholics in treatment (56 Type I alcohol-dependent patients and 102 Type II alcohol-dependent patients). All subjects were assessed with diverse assessment tools related to personality (Impulsiveness Scale, Sensation Seeking Scale and STAI), psychopathology (SCL-90-R, BDI and Inadaptation Scale) and personality disorders (IPDE). The main findings were that Type II alcohol-dependent patients were more impulsive and sensation-seeking and they displayed more hostility and emotional distress than Type I alcohol-dependent patients. Personality disorders were not so prevalent in the case of Type I alcohol-dependent patients. The most specific personality disorders for Type II alcohol-dependent patients were narcissistic and paranoid. The implications of this study for further research are commented on.     

More than one way to change: a study of course heterogeneity during and after short-term psychiatric in-patient treatment

This study describes differences in course and outcome, defined by GSI (SCL-90) at admission, discharge, and one‐year follow‐up, in 458 patients receiving in‐patient treatment for long‐standing symptom and/or personality disorders.
A K-mean cluster analysis identified seven subgroups of patients, representing four clinical distinct, meaningful patterns of change: early improvement, late improvement, relapsing after discharge, and a severe chronic course.
Main findings: the subgroups had unique correlates among socio-demographic, diagnostic, and treatment-related characteristics. One of the relapsing groups had a high rate of Cluster C personality disorders, whereas the other had low participation in the anxiety programme. The group with severe chronic course showed occupational maladjustment and high number of both Axis I and II disorders.
Implications: anxiety patients should participate in anxiety-treatment programmes, Cluster C patients should be followed and monitored for relapse, and severe chronic patients should be offered specialised treatment for their co‐existing substance abuse and/or eating disorders.     

A personal odyssey

In this autobiography, I tried to capture important aspects of my personal and professional development from my childhood in the ethnic ghettos of South Philadelphia to Pennsylvania State University and the University of Chicago and eventually to over 45 years on faculty at Yale. It has been a journey that I could never have anticipated and that has given me a sense of the unpredictability of psychological development. We all evolve in an open system and a significant portion of the variance of the outcome is determined by fate. But much is also determined by the ability to recognize opportunities and the willingness to take chances and to work hard when opportunities arise. As I reflect on my career of over 50 years, I have been delighted that I opted for a career as a clinical psychologist because it has provided me with opportunity to develop clinical skills and to combine these skills with scholarship and research. While I take considerable satisfaction in the recognition that my contributions have received, the most important aspect of my career has been my relationship with students and colleagues. These collaborations have clearly enriched my work; but more important, they have enriched my life.