Book Review

Abnormalities of Personality: Within and Beyond the Realm of Treatment

N Engl J Med 1994; 330:1243-1244April 28, 1994

Article

Abnormalities of Personality: Within and Beyond the Realm of Treatment
By Michael H. Stone. 546 pp. New York, W.W. Norton, 1993. $50. ISBN: 0-393-70127-1

This book reflects the enormous and exciting growth in knowledge about personality disorders during the past decade and sets this growth within the context of the dramatic changes that are transforming psychiatry. Its author, Michael Stone, is one of the few people with the intellectual breadth and the clinical experience required to undertake such a book. When, to these qualifications, you add the author's gift for writing clearly and his knack for choosing recognizable examples from our popular culture, the results are excellent.

Most clinicians will find Stone's chapters on treatment stimulating and informative, but I believe this book's central contribution is in the chapters in which he explicates the intellectual ferment that surrounds the psychopathology of personality disorders. Stone is at his best when he forges links between the growing body of research on psychopathology with the largely independent bodies of research on the structure of normal personality and the more distant but equally relevant bodies of research on ethology (animal behavior) and human ecology (especially genetics). Behind these efforts to reach out and apply these new bodies of knowledge to the understanding of personality disorders is psychiatry's growing impatience with the current nosology of personality disorders and the desire to have it revised in accord with more scientifically and biogenetically based data.

Of particular importance to readers will be Stone's chapter on the so-called five-factor model. Briefly, this model asserts that normal personalities consist of five dimensions, each of which is more or less present in everyone and each of which is largely heritable and stable. These five dimensions are neuroticism (how worried or anxious one is), extraversion (as compared with how introverted one is), openness (how flexible and creative one's mind is), agreeableness (how interpersonally agreeable one is), and conscientiousness (as compared with how undisciplined one is).

Stone traces the discovery of these dimensions and describes his efforts to catalogue maladaptive variants of the traits. He concludes by adapting the five dimensions to provide the foundations on which disorders of personality are superimposed. For readers who are unfamiliar with this model, Stone offers a valuable introduction. But readers who hope that Stone will build bridges from these five dimensions to abnormal personality structures will be disappointed. Indeed, many readers will find Stone's introduction to other efforts to identify the substructures of personality disorders, such as Cloninger's or Siever's biologic systems, equally compelling and intellectually stimulating. All readers will leave these chapters with informed perspectives on the frontiers that now excite personality-disorder mavens.

Stone's discussion of the treatment of personality disorders is eclectic, evenhanded, and filled with lively vignettes and controversial opinions. His book reflects the shift away from the emphasis on individual psychodynamic psychotherapy, which earlier books have accepted as the primary, if not only, therapy for all personality disorders. Now, psychodynamic psychotherapy takes its place beside many other therapies, each contending for prominence. His discussion of the competing treatments (such as cognitive-behavioral, pharmaceutical, supportive, and group therapies) demonstrates admirable scholarship and a wish to be respectful and fair. A careful reading of these chapters illustrates why there is now a need for an overarching theory that would guide the selection of treatment for different phases of the personality disorders. Even in the absence of such a guide, Stone's descriptions of treatment generally reflect the growing optimism that the social-adaptation problems of people with personality disorders can and should be broken into components that are amenable to discrete time-limited interventions.

Of particular interest is the effort to integrate the advances in cognitive-behavioral strategies with psychodynamic concepts and to give them due importance. Stone skillfully illustrates how cognitive strategies can be applied. In so doing, with typical irony, he compliments the venerable leader of cognitive therapies, Aaron Beck, by saying he has succeeded in pouring “old wine into new bottles.”

Though I could have hoped that Stone would give more attention to the clinical and ethical importance of the advances in pharmacotherapy -- advances that have recently made Peter Kramer's Listening to Prozac (New York: Viking, 1993) a national bestseller -- this is not his primary interest, and it is probably scientifically premature to draw broad conclusions. As such, the limitations of his attention to this subject are justified by the limitations in our knowledge.

This book is a virtuoso performance by one of our most intellectually gifted contemporaries. Mental health professionals from all disciplines will find it educational and readable. Readers looking for answers will find that they are rarely available. Readers who want to broaden their perspectives and enjoy the process will be rewarded. I doubt that anyone could do this job better than Stone has.

John G. Gunderson, M.D.
McLean Hospital, Belmont, MA 02178