Social Factors in the Personality Disorders.

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Paris, Joel. Social Factors in the Personality Disorders. New York: Cambridge University Press, 1996. xxiii+231 pp. $54.95.This book aims to give credibility to the personality disorders, the "stepchildren of psychiatry," through a dispassionate, empirically based assessment of their features, etiology, and treatment. With one exception, this goal is accomplished. The author proposes a biopsychosocial model in which personality disorders are formed out of amplifications of temperaments. Noting that a person's temperamental traits have a strong hereditary basis, Paris nevertheless proposes that psychological and social factors are essential to their transformation into personality disorders.After a brief description of the disorders and various attempts to classify them, the author discusses biological, psychological, and then social factors in the development of the disorder. He next presents an integrated biopsychosocial model, and reviews each of the three subclusters (odd, impulsive, and anxious) from the viewpoint of this model, with clinical examples. The final two chapters describe treatment approaches and clinical guidelines. Paris emphasizes the importance of the family environment, amount of psychopathology in the parents, and social forces that may contribute to fragmentation. He also highlights the possible interactions among biological, psychological, and social factors, which form a self-reinforcing feedback loop that leads to a personality disorder (e.g., an overly aggressive child is more likely to receive severe punishments).Paris paints a sobering picture of the chronic course of these conditions and their untreatability, even suggesting that "psychodynamic psychotherapy is part of the problem, and not part of the solution," for many of these patients (p. 169). He notes that many personality disorders weaken in midlife as a result of natural recovery processes and that the most effective treatment approach may be to provide intermittent support. He thus advocates for working with rather than against the person's basic traits. He notes that adaptation is maximized when the personality disordered patient finds a place in society and a useful role for his particular traits and temperament.Quite in contrast with the unbiased presentation evident in much of the book, the author embraces a rather polemical stance regarding trauma theory (i.e., that personality disorders are caused by traumatic events in childhood). Believing that "the manufacture of false memories by well-meaning therapists, particularly in North America, has done much in recent years to bring psychiatry into disrepute" (p. 47), Paris sets out to minimize the role of trauma in the etiology of the personality disorders. Rather than remaining unbiased and noting the need for further research inquiry into the role of trauma, the author clearly attempts to dissuade the reader from entertaining it as a productive line of inquiry. In so doing, the author strays from a scientific attitude.For example, he summarizes a substantial literature on the role of combat in the development of posttraumatic stress disorder in one sentence, stating that "the measures of trauma were retrospective accounts" and are therefore suspect (p. 50). He asserts that trauma can only be considered a risk factor (though he presents data indicating that it is the number one risk factor), not a causal factor, because not everyone who is traumatized develops personality disorders. This argument is similar to the position of cigarette companies, who argue that smoking does not cause lung cancer because not everyone who smokes develops it.

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