A Conceptualization of Personalityrelated Disorders of Interpersonal Behaviour With Implications For Treatment

Clinical Psychology and Psychotherapy
Clin. Psychol. Psychother. 6, 239260 (1999)
A Conceptualization of Personalityrelated Disorders of Interpersonal

Behaviour with Implications
for Treatment
Carlo Perris*
Umea University, Department of Psychiatry and WHO Collaborating Centre for

Research and Training in Mental Health, Umea, and The Swedish Institute of
Cognitive Psychotherapy, Stockholm, Sweden.
This article highlights the problematic aspects with current definitions
and classifications of personality disorders. Because of the acknowledged developmental nature of these disorders, a suggestion of an
alternative conceptualization derived from a comprehensive interactional model of psychopathology is proposed. Attachment theory
and its corollaries constitute the base for the reconceptualization of
personality disorders in terms of personality-related disorders of
interpersonal behaviour put forth in the article. Such a reconceptualization appears to be in line with current clinical practice. It counteracts
negative attitudes toward patients who are given a personality disorder
label, and has important implications for treatment as well as for
research. Copyright # 1999 John Wiley & Sons, Ltd.
INTRODUCTION
The scope of this article is to present a conceptualization of personality-related disorders of interpersonal behaviour that has implications for their
treatment. Due to understandable space limitations,
only the main issues of this approach can be highlighted, and even these in a constrained form. Also,
issues of treatment will be only hinted at this
juncture, whereas a more extensive presentation
will be made in a companion article now in
preparation. On the other hand, a thorough discussion of both the theoretical underpinnings, and the
practice of treatment, has been provided elsewhere
(Perris and Perris, 1998).
The term personality-related disorders of interpersonal behaviour is suggested as a more
*Correspondence to: Professor Carlo Perris, Swedish Institue
of Cognitive Psychotherapy, Sabbatsberg Hospital, Box 6401,
S-113 82 Stockholm, Sweden. Email address: carlo.perris@
mailbox.swipnet.se
CCC 10633995/99/04023922$17.50
Copyright # 1999 John Wiley & Sons, Ltd.
appropriate denomination of those psychopathological conditions that in current classification

systems are referred to as personality disorders
(PDs). The rationale for the proposed change in
terminology will emerge in the proceeding text.
There is not, however, any claim that the suggested
approach is unique. In its overall conception, it is
line with critical thoughts voiced by several authors
(Kiesler, 1996; Rutter, 1987; Holden, 1989;
Benjamin, 1993; Derksen, 1995; Kiesler, 1996;
Norton and Hinshelwood, 1996; van Velzen and
Emmekamp, 1996; Westen, 1997; Widiger and
Hagemoser, 1997), who have emphasized disorders
of interpersonal behaviour as one of the most
peculiar characteristics of PDs. Widiger and Hagemoser (1997), in particular, maintain that the
personality disorders could represent the interpersonal
disorders ( p. 299), whereas West and Keller (1994)
underscore that disturbed or impoverished interpersonal relationships are the hallmark of most personality
disorders ( p. 314). In discussing the PDs, finally,
240
Rutter (1987) emphasized that the characteristic that
seems to define them is a pervasive persistent abnormality in maintaining social relationships ( p. 453). Sim
and Romney (1990) pointed out that individuals
with PD are characterized by more intense and
more rigid interpersonal behaviour than normals.
Obviously, the theoretical conceptions of psychopathological behaviour propounded by Horney
(1945), Sullivan (1953), Leary (1957), Carson (1969)
and Kiesler (1996) have been relevant in the elaboration of the ideas put forth in this article. Bowlby's
(19691980) attachment theory and its derivates is,
however, the theoretical frame of reference on which
the proposal put forward in the following is mainly
based. Many of the opinions maintained in this
article have similarities with those offered by Safran
and Segal (1990), Young (1994), Holmes (1993),
Birtchnell (1993, 1997a, b), Horowitz (1996),
Horowitz et al. (1997), Romney and Bynner (1997),
Sperling and Berman (1994) and West and SheldonKeller (1994) even though there is not direct overlap.
The approach most closely related to the thesis
presented in this article, however, is that suggested
by Lorenzini and Sassaroli (1995). Pertinent also is
the path recently pursued by Brennan and Shaver
(1998). Congruence with similar approaches will be
emphasized.
A SUMMARY HISTORY OF PSYCHIATRIC

CLASSIFICATION
Psychiatry is a discipline strongly bound to
traditions. As Anderson and Goolishian (1988)
observed, the use of diagnostic categories enjoys a
long history in the field of mental health. It reached
its peak in the localizationist classifications of the
German psychiatrists at the turn of the century and
showed a decline in the period around the Second
World War. More recently, however, renewed
interests in more detailed classifications appear to
occur. The current dominance of a Linnean inspired
effort to categorize and delimit every possible
mental disturbance is evident in the almost
doubling of the diagnostic categories taken into
account in the successive editions of the American
Diagnostic and Statistical Manual (DSM). While the
DSM-II (American Psychiatric Association, 1968)
never enjoyed the popularity of its successors and
comprised just a few more than 180 diagnostic
categories, the number has risen to more than 400 in
the DSM-IV (American Psychiatric Association,
1994). On the other hand, whereas the number of
PDs taken into account in the DSM-I (American
C. Perris
Psychiatric Association, 1952) was 27, only ten
categories are included in DSM-IV, aside from a few
additional ones which have appeared and disappeared as an appendix in the successive editions
of the manual, from its third edition onward.
A difficulty in moving away from old and
cherished conceptions of mental disturbances as
discrete entities is reflected in the long standing
inability to relinquish the pursuing of even more
detailed classifications, as well as in the still
dominating tendency to polarize debate about
their occurrence and treatment in prominently
biological or psychosocial terms. In no other field
of psychiatric nosology are these two major
constraints hampering progress as evident as in
the categorization of personality disorders.
Allegedly, the approach followed in the DM
classification from its third edition onwards, is
atheoretical. Independently of how the proponents of
DSM prefer to qualify the term atheoretical, nothing
could be more illusory than this affirmation, first of
all, because the mere postulate of being `atheoretical' per se is a theoretical stance. Second, the
pursuit of a classification of mental disorders, both
in larger classes and in more detailed nosological
categorical, and their separation from PDs, is by
necessity the result of theoretical considerations
(Lopez-Ibor, 1997; Derksen, 1995). Third, the
principles used for categorization, also within a
major group, consistently reflect various theoretical
deliberations. The categories of personality disorders taken into account in the DSM represent a
mixture of theory, opinion and historical precedent
(Mulder and Joyce, 1997; Perris and Perris, 1998),
while at the same time reflecting a strong influence
of current societal values. On the other hand,
several authors maintain that the conception of
personality disorders in the current classification
systems not only has very poor validity and
reliability, but also ignores the fundamental
influence of cultural norms on human behaviour
(Nuckolls, 1992; Lewis-Fernandez and Kleinman,
1994; Derksen, 1995). The following problematic
examples illustrate this point.
Depressive and cyclothymic personality disorders
have disappeared from both the DSM and the
ICD classification of PDs (the former has, however,
made its comeback as an appendix to DSM-IV) on
the theoretical assumption that these psychopathological manifestations do not warrant as separate
entities from the affective disorders to which they
allegedly are genetically related. Despite evidence
suggesting that such a genetic relationship is
questionable (Hirschfeld, 1994; Hirschfeld and
Personality disorders
Holzer, 1994), the separation from the group of
personality disorders has been retained. Schizotypal
personality disorder, on the other hand, is subsumed
in the International Classification of Diseases
(ICD-10) of the World Health Organisation under
the heading schizophrenia, whereas it stands as a
distinct category of personality disorder in DSM,
obviously on some theoretical ground. Self-defeating
(masochistic) personality disorder has appeared and
disappeared from DSM classification on current
feminist theoretical assumptions and values, since it
seemed to reflect culturally determined ideas about
how women should behave. The boundaries
between schizoid and avoidant personality disorder,
on the one side, and social phobia, on the other, are
maintained on subtleties, inferences and historical
inaccuracies (Livesley et al., 1985; Livesley and West,
1986; Widiger, 1992). At the same time, proposals
have been advanced to define schizoid personality
disorder as Asperger's syndrome (Rutter, 1988), and to
consider Asperger's syndrome, schizoid and schizotypal
personality disorder as conditions only different in
degree rather than in kind (Tantam, 1988).
Kernberg (1984) has suggested that borderline and
histrionic personality disorder describe the same
diagnostic construct. Warner (1978), on the other
hand, contents that antisocial and histrionic personality disorders are essentially sex-typed forms of a
single condition, whereas Lauer et al. (1993) argue
for the fundamental similarity between borderline
personality disorder and multiple personality disorder
that is classified in axis I. Concerning narcissistic
personality disorder, finally, Livesley et al. (1994) have
argued for the occurrence of three different types
noting that placing them together into one category
does little justice to their uniqueness; Schore (1994),
however, takes into account two types, one egotistical and the other dissociative.
This morass is hardly newsworthy. It seems apt
to quote once again Anderson and Goolishian
(1988) who, albeit in a different context, maintained
that psychological problems seemingly appear, change
shape, and disappear as [therapists'] vocabularies and
descriptions change ( p. 375, brackets added). Furthermore, the suggested grouping of personality disorders in clusters, which has not received any
strong empirical support for its validity (Ekselius
et al., 1993; Blais et al., 1997; Plutchik, 1997), cannot
be anything less than the result of an unfounded
standpoint or the consequence of some theoretical
deliberations assumed to justify its proposal.
The continuing polarization between biological and psychosocial determinants of mental
disturbances in general, and the PDs in particular, is
241
evident in the intensive search for biological
(heredofamilial?) determinants of specific disorders
as contrasted to efforts aimed at purporting that
psychosocial factors might be the primary if not the
only determinants of these disorders. Dualism,
Lopez-Ibor (1997) suggests, is implicit also in the
separate classification of mental disorders from PDs.
In contrast with this tendency to polarize,
admittedly seldom brought to its extreme, is now
an ever-growing stream of thought, especially in the
fields of evolutionary psychology and psychiatry,
behaviour genetics and developmental psychology
and psychopathology where a great bulk of data is
rapidly accumulating. These data are paving the
way for a better understanding of the inseparatability of biological and psychosocial determinants
of both the normal and the deviant ( psychopathological) development of behaviour (Gilbert, 1992;
Plomin, 1994; Cicchetti and Cohen, 1995; Rutter and
Smith, 1995; Schore, 1994; Segal et al., 1997).
It is against this particular background that a
different conception of personality disorders in
terms of personality-related disorders of interpersonal behaviour should be considered.
In a sense, the nature of the approach to
be described in this article could be regarded
as deconstructionistic (Derrida, 1967). It attempts
to demystify and dismantle the reified belief
systems underlying the categorization of PDs,
while at the same time it proposes to grasp what
is confusing, and to utilize it in a creative way.
PROBLEMS WITH THE DEFINITION

OF PERSONALITY DISORDERS
The beginning of modern efforts aimed at a delimitation of abnormal personality characteristics of relevance for psychiatry can be traced back to Pritchard's
(1835) work on moral insanity, but achieved its
momentum early in this century. Already, at
an early stage, to define a personality as abnormal
was judged as heavily value laden. Debated issues at
the time were the extreme difficulty in deciding
when quantitative variations of characteristics,
which can be present in any individual, should be
regarded as abnormal without expressing value
judgements (Muller-Suur, 1950). In addition was
the fact that a deviation from statistical norm also
encompasses positive extremes which do not necessary imply psychopathology. Koch (1891/1893)
stands out as one of the most influential pioneers
in the definition and classification of psychopathic
personalities (the term psychopathic to be understood
242
as correspondent to the modern concept of psychopathological, and not as referring to any specific
group of personality disorder as it occurred later). In
defining the psychopathic personalities in successive
editions of his treatise, Koch proposed a devision
into those which implied a burden for the individual
and those which implied a burden for society. This
definition, to a large extent, still informs present
conceptions.
Kurt Schneider (1923/1950), an acknowledged
heir of the Kraepelinian tradition, laid the foundation on which all current classifications still
stand. He conceived the psychopathic personalities
as extreme deviations along a continuum,
thus adhering to a statistical realnorm criterion.
Schneider followed Koch in defining characterological dispositions as ( psychopathologically)
abnormal if they implied suffering either for the
individual or for others (inclusive of society). It is
evident, however, that while individual suffering
clearly reflects a (subjective) medical perspective,
the criterion suffering for others, instead, refers to a
value-laden social point of view. The distinction
between self and societal suffering has not been
devoid of consequences. The criterion suffering for
others, in fact, was regarded as debatable already by
Schneider, who warned for the risk of identifying
all antisocial behaviour with a psychopathic personality. The vicissitudes of the diagnostic criteria for
antisocial personality disorder in the successive
editions of the ICD and DSM confirm Schneider's
foresight and reflect the influence of evolving
societal values on psychopathological definitions.
The criterion of provoking an adverse effect upon the
individual, or on society that in fact was included in
the ICD-9 edition of the WHO's classification, was
excluded from the ICD-10 definition of personality
disorders. In addition, the label dissocial was
substituted to antisocial to categorize a type of PD
previously loaded by criminality.
Schneider, probably influenced by Jaspers (1913),
strongly emphasized that psychopathic personality
types should be regarded as distinguished from
other psychopathological disorders (especially the
psychotic ones) with which they could, however,
covary. From this point of view, the classification of
PDs in a separate axis in the DSM has to be
regarded as one of Schneider's heritages. Another is
Schneider's acknowledgement that various types of
psychopathic personality could be combined
(i.e., the current idea of comorbidity).
According to Schneider and other nosologists
of his time, abnormal personality dispositions
characterizing the psychopathic personalities were
C. Perris
constitutional in nature and highly influenced by
personal experiences. This opinion is better understood in the light of the distinction made by Jaspers
between development and process and aimed at
keeping separate those conditions which had to be
considered as the result of a deviant development
from those implying the occurrence of something
new for the individual, i.e. a disease. Also, the broad
conception of constitutional, held by Schneider and
many others, implied an assumption of probabilistic determinism which is fairly akin to modern
conceptions in behavioural genetics (cf. the concept
of quantitative trait loci: QTLs, Plomin et al., 1994;
Rende and Plomin, 1995). Schneider's influence,
however, is most evident in the ICD-10 definition of
PDs. In this definition it is maintained, in fact, that
PDs are . . . a severe disturbance in the characterological
constitution and behavioural tendencies of the individual
. . . and, later on: . . . Personality disorders . . . are
developmental conditions, which appear in childhood or
adolescence and continue into adulthood.
One major criticism against the concept of
personality disorders and their subdivision into
distinct categories, already voiced by Schneider,
is that it attempts to reify them as things, and, even
worse, to understand them as discrete diseases that
someone can have (Millon and Davis, 1996). Jaspers
(1913) maintained that a diagnosis of variations
of human nature is an impossibility, in part because
it is difficult to bring any diagnostic order of
practical value into shifting phenomena which
continually keep merging into each other. A similar
concern was recently expressed by Svrakic et al.
(1991), who maintain that the conception of PDs
as distinct units of mental disorders is neither
precise nor useful.
Even though the underscoring of constitutional
developmental
determinants
suggests
that
Schneider conceived the characterological abnormalities as enduring, he was keen, however, to
emphasize that many individuals may habitually
behave as abnormal personalities and only episodically as psychopathic personalities. Schneider, in
other words, wanted to emphasize the possible
occurrence of critical accentuations of abnormal
personality characteristics, which thus became
pathological. Millon and Davis (1996) seem to
agree with Schneider when in discussing personality prototypes, where they maintain that it is only
the unique manifestation or instantiation of the construct
or trait in the individual that is of immediate clinical
interest ( p. 6). The distinction between personality
styles and personality disorders reported by Sperry
(1995) is consistent with this line of thought, even
though Sperry does not discuss the possible
passage from style to disorder (see also Parker
et al., 1998, for further comments on this topic).
Schneider steered away from binding his description of psychopathic personalities to any special
theory as his contemporaries had done, and proposed a descriptive, asystemic classification based
on pointing out the most prominent features of each
group. This classification, comprising ten main
types with several subgroups, has since strongly
influenced all classificatory work concerning
personality disorders. Indeed, eight of the main
types identified by Schneider still occur in both the
ICD and the DSM classification system. Thus, it
seems that the allegation of being atheoretical by the
proponents of the DSM classification echoes
Schneider's standpoint concerning the description
of various types of psychopathic personality.
As de Girolamo and Reich (1993) point out,
modern definitions of PDs include three key
concepts: (i) An onset in childhood or adolescence;
(ii) a long-standing persistence over time coupled to
the pervasiveness of the abnormal behaviour
pattern across a broad range of personal and social
situations and (iii) the association with a substantial
degree of personal distress and/or problems in
occupational or social performance. Implicit in the
developmentalist conceptions of many authors
early in this century was the assumption that
psychopathic personalities were untreatable. It is
unclear to what extent a similar assumption is
concealed behind the attributes enduring, stable and
inflexible used to define the characteristics of PDs in
current diagnostic systems. On the other hand, all
these attributes have given risen to controversy
because they are too loosely defined (Widiger and
Frances, 1985; Derksen, 1995). Moreover, recent
overviews of the stability of the diagnosis of specific
PDs over time (Stone, 1993; Grilo et al., 1998)
suggest that personality disorders demonstrate only
moderate stability. Independently of the meaning
and validity of the attributes enduring, stable and
inflexible attached to PDs the idea of untreatability is
manifest in the still occurring questioning of
whether PDs should be of concern for psychiatry
at all (Cawthra and Gibb, 1998).
PROBLEMS WITH CLASSIFICATIONS

Since the seminal work of Koch and Schneider
mentioned above, categorical classifications of
personality disorders have been the dominating
approach. This is understandable because the use of
243
a categorical model fits in well with traditional
clinical conventions and procedures. On the other
hand, criticism has been levelled or several accounts
against the use of diagnostic categories from the
time in which they were first introduced. A few of
these criticisms are reported in the following.
A categorical model, that is a model based
on classes, implies a discontinuity whereas a
dimensional model (e.g. Schneider's) is based on
the assumption of continuity between normal,
abnormal and pathologically abnormal personality.
The categories included in the DSM classification,
on the other hand, are an admixture of both models,
without being either.
Another criticism concerns the use of the criteria
proposed for reaching a definite diagnosis. In
an ideal classificatory system, each (monothetic)
category should contain members that are identical
and meet all criteria. This is obviously not the case
with the ( polythetic) categories of personality
disorders, for which satisfying only a minimum
number of criteria is deemed sufficient for membership. The adoption of polythetic categories as in
DSM, however, implies several debatable consequences. First, the use of a polythetic system is
misleading as a single PD diagnosis is applied to
each example of a heterogeneous group of disorders
(Dowson, 1995). Second, the determination of an
appropriate threshold in relation to the number of
criteria for diagnosis is arbitrary. Third, the criteria
used in DSM, as Stone (1993) and Parker et al. (1998)
remark, are at different levels of generalization.
Some are trait levels, e.g., identity disturbance or
impulsivity, others are specific exemplars of traits,
e.g., has no close friends, whereas still others are
symptomatic acts, e.g., self-mutilating behaviour
lacking a unifying construct (Birtchnell, 1997b).
Fourth, some criteria occur in more than one PD
syndrome, and many patients fulfil criteria for two
or more PD diagnoses, at the same time as many of
the behaviours selected as exemplars could occur
independently of the presence of any PD at all.
Particularly disturbing in this context is that the
presence of one or more PDs (mean 3.4 in subjects
with any PD) was found in 35% of a population of
274 healthy university students investigated by
means of a diagnostic instrument (Dolan et al.,
1995). An even higher proportion (75%) was found
by Brennan and Shaver (1998) in a similar population.
Finally, analysis of axis II criteria indicates that
many do not cluster or factor with other criteria for
the same disorder (Schroeder and Livesley, 1991;
Livesley and Jackson, 1992; Blais and Norman,
244
1997; Blais et al., 1997) while many others do
overlap, hence becoming redundant. A serious
consequence of a high proportion of comorbidity
is that the interpretation of studies allegedly
focused on any single personality disorder becomes
dubious because of the possible simultaneous
occurrence in the same patients of other personality
disorders (i.e., comorbidity) (Dolan et al., 1995).
Besides these limitations, there are other disturbing issues to be taken into account. The first refers to
the relatively poor correspondence between the ICD
and DSM classification (Sara et al., 1996), which
might reflect the cultural influence on diagnostic
determinations. The second issue, instead, concerns
the change in number and content of criteria assigned
to the various PD from one edition of the DSM to
another. Such a change, well founded in many
instances, is now occurring at too short intervals and
reflects the uncertainties still surrounding the
definition of PDs at the same time as precluding
long-term studies. The change in number and
definition of criteria from DSM-III to DSM-III-R has
implied that, in the same sample, the number and
type of PD diagnoses assessed in accordance to the
two sets of criteria changed markedly (Vaglum et al.,
1989; Blashfield et al., 1992). A logical consequence of
rapidly changing criteria is that most research results
obtained on the basis of a however correct application of, for example, DSM-III criteria become
unreplicable (Romney and Bynner, 1997) and hence
doubtful in the light of DSM-III-R and even more so
in relation to DSM-IV. Finally, the narrowness of the
personality domain in the DSM and ICD classifications compared with the larger realm of maladaptive personalties recognizable within society as
a whole is most disturbing (Stone, 1993; Westen,
1997). Koch, Schneider and many others felt compelled to take into account several subgroups in their
typologies to emphasize the enormous variability of
psychopathic personalities. There is no theoretical
basis, Paris (1996) maintains, on which to decide
whether to have ten personality disorders as in
DSM-IV, or 300 (see also Westen, 1997). Finally, an
undue emphasis on diagnostic labels is likely to
contribute in the fostering of negative attitudes
toward the patients on whom they are applied.
ALTERNATIVES TO CATEGORICAL
CLASSIFICATIONS
Dimensional models, originally developed by
Gruhle (1922), and in line with Schneider's and
Plutchik's (1997) idea of a continuum from normality
C. Perris
to pathologically abnormal personalities, represent a
much debated alternative to the taxonomic approach
currently in use. The rationale behind favouring a
dimensional-trait approach is that PDs are nothing
but extreme variations of normally distributed
personality characteristics.
Besides the lack of universal consensus in
regarding PDs as extreme variations of normal
characteristics (Rutter, 1988), there are a number of
limitations to a generalized use of a dimensional
approach. One such limitation concerns the deliberation about which dimensions should be taken into
account, and the extent to which these dimensions
relate to the theoretical ground representing the
standpoint for their choice. Millon and Davis (1996),
in echoing what Schneider suggested, point out that
only a small fraction of all dimensions which could
be chosen in practice result in a clinically relevant
combination. Coolidge et al. (1994), for example,
voiced a number of reservations about the possible
relationship of the Five-Factor Personality Model to
personality disorders by showing that not all five
factors are relevant. Mulder and Joyce (1997)
question whether an empirical approach to taxonomy will ever be able to solve all the issues
imbedded in a dimensional approach.
A more severe limitation of dimensional conceptions is that they move from the assumption of
stability of personality traits and do not take into
account possible variations due to developmental
and contextual influences. Finally, the use of dimensional procedures is not in line with traditional
clinical everyday practice. Frances (1982) and
Livesley and Jackson (1992) acknowledge that
both psychiatrists and psychologists, in fact, prefer
categorical rather than dimensional diagnoses.
Another dimensional approach to describe
personality, and in extension PDs, is the Interpersonal Circle (IPC; Leary, 1957), constructed upon
two axes, usually dominancesubmission and love
hate. The IPC posits also that individual behaviours,
dispositions and problems can be arrayed in a circle
(circumplex) around the origin of the space marked
by these two axes. Both Gilbert (1992) and
Birtchnell (1993) point out that the lovehate
dimension may also be labelled in different ways
as, for example, linkingspacing, or distancecloseness. This proposal is clearly in line with the
conceptualization that will be suggested in a
subsequent section.
In principle, any two uncorrelated variables can
be used as axes and the relative location of all other
variables can be estimated. Factor analysis can be
used to determine two major independent axes and
then the factor loading of all other variables can be
plotted on these scales. The ICP thus, draws on the
factor analytic tradition of personality measurement
while giving greater attention of off-axis locations
that form combinations of the two primary
dimensions.
An extensive review of the state of art of
circumplex models has been recently reported by
Kiesler (1996), and in a book edited by Plutchik and
Conte (1997). The chapters clearly demonstrate that
during the last two decades there has been an
increasing number of publications that demonstrate
the application of the circumplex idea in research on
personality, in the development of assessment
instruments, in attempts to define personality disorders, and to inform psychotherapy and evaluate
outcome. Several authors have attempted to
demonstrate the application of the circumplex (or
variations of it) to personality disorders (Wiggins,
1982; Kiesler, 1996; Birtchnell, 1997a, b; Plutchik,
1997; Romney and Bynner, 1997; Stern et al., 1997;
Widiger and Hagemoser, 1997; Becker, 1998). Even
though the results obtained by the various authors
look promising, they remain, far from consistent.
Also, not all PDs can be accounted for in terms of
the interpersonal circumplex (Kiesler, 1996), and the
results obtained have been, at times, disappointing
(Birtchnell, 1997b). For example, Widiger and
Hagemoser (1997) point out the repeated failure in
accounting for borderline personality disorder.
Romney and Bynner (1997), who applied a technique (structural equation modeling: SEM) that they
loosely define as a combination of factor analysis
and path analysis, were able to demonstrate that
only five of the DSM personality disorders lie on a
circumplex.
A different kind of interpersonal circumplex
model (the Structural Analysis of Social Behavior,
SASB) was successively developed by Benjamin
(1974, 1993). Benjamin's model differs from other
models in two important respects. The first is
that she disagrees with the traditional interpersonal
stance that normality and abnormality are different
points on the same measurement continuum.
She assumes, in fact, that PD constructs refer to
discrete entities, distinct from each other and from
normal interpersonal functioning. A second divergence is that SASB contains three surfaces to include
a focus on self, focus on others and the introjection
of others' treatment of self. Benjamin (1993)
maintains that the more complex dimensionality of
the SASB permits adequate description of all the
personality disorders listed in DSM. Widiger
and Hagemoser (1997) point out, on the other
245
hand, that the SASB fails to include affective and
attitudinal components and is perhaps limited and
incomplete (see, also, Wiggins, 1994). Another
limitation is that all research work carried out thus
far has been apparently focused on the already well
established categories of PD, or on attempts at
refining already existing diagnostic criteria (e.g.
Benjamin, 1993).
More recently aspects of attachment also were
taken into account in studies with the circumplex
(e.g., Horowitz, 1996; Benjamin, 1996; Birtchnell,
1997b, c), also with regard to psychotherapy and its
outcome (Horowitz et al., 1993). Even though
research in this last mentioned field is still in an
early phase of development, it could be anticipated
that the results will be of great importance for a
closer refinement of the thesis maintained in this
article and for therapeutic interventions derived
from it. One probable severe limitation, however, is
that circumplex models, even more than other
traditional dimensional approaches, will encounter
difficulties in breaking through entering everyday
clinical practice.
AN INTEGRATED, INTERACTIONISTIC
AND HEURISTIC FRAMEWORK FOR
THE STUDY OF THE DEVELOPMENT
OF PSYCHOPATHOLOGICAL
MANIFESTATIONS
One point of agreement concerning the definition of
PDs seems to be that they should be regarded from a
developmental perspective in which both constitutional and experiential factors are taken into account.
It is in this context that the conceptual framework for
the definition of individual vulnerability and for the
study of its relationship to mental health that our
group has been developing for several years (Perris
and Perris, 1985; Perris, 1991a, b, 1998; Perris and
Perris, 1998) becomes relevant.
The model and its theoretical underpinnings have
been presented elsewhere with reference to various
kinds of mental disorders (e.g., depression, Perris,
1991b; schizophrenic disorders, Perris, 1989, 1998;
and the PDs, Perris and Perris, 1998). Thus only a
summary of its main characteristics will be provided
at this juncture. A schematic representation of the
model is shown in Figure 1. The focus of the
framework is on individual vulnerability, defined by
the individual's biological make-up and the
development of internal working models of self
and others, and the continuous interactions in
246
C. Perris
Figure 1. An overarching illustration of the model for the definition of individual vulnerability. According to this
model, individual vulnerability is defined by the continuous interactions between the individual's biological
characteristics and the internal working models that he has developed
between. The following are its distinguishing

characteristics:
(i) It is evolutionary, in that it takes into account
the importance of evolutionary relevant
motivation and affect systems.
(ii) It is constructivistic, in that it assumes that
every individual is born with potential
capacities to construe his own world.
(iii) It is developmental, in that it emphasizes life-span trajectories concerning the acquisition,
maintenance, transformation and extinction of
various behaviours, and the possible, phase-specific genetic influences on such processes.
(iv) It is interactionistic and integrative, in that
it clearly underscores the continuous occurrence of dialectical interactions among the
various factors which can contribute to the
development of psychopathological manifestations on the one side, and between the
various factors and the growing individual
with his developing level of vulnerability on
the other.
(v) Further, it takes into account cultural influences,

both across space and over time, a characteristic of particular importance for the delimitation and identification of PDs.
(iv) Finally, the framework is heuristic in that it
allows for various hypotheses to be derived for
empirical testing.
However, it is necessary to stress, at this juncture,
that the suggested framework should be understood as nothing more than a heuristic proposal of a
set of criteria for an integrated and holistic theory of
psychopathology.
The emphasis on the development of dysfunctional internal working models of self and others at
the core of individual vulnerability is crucial for the
conceptualization of psychopathological manifestations. It is with regard to the development of
these working models that the suggested framework, more explicitly than any other stress
diathesis model proposed by other authors, unifies
the constantly occurring interplay of biological and
psychosocial determinants of individual vulnerClin. Psychol. Psychother. 6, 239260 (1999)
ability. This is done while at the same time taking
into account the cultural context of development
and the phase specific influences on the latter.
Consideration of a time dimension, moreover,
emphasizes that vulnerability is not conceived as
an invariant trait, but rather as a life-long evolving
process susceptible to marked changes.
The approach which comes closest to the conceptualization of vulnerability advanced above is that
followed by Ciompi (1982) and focused on Affektlogik. Ciompi, however, has limited the application of
his model only to schizophrenic disorders.
EVOLUTIONARY RELEVANT
MOTIVATION SYSTEMS AND THE
DEVELOPMENT OF VULNERABILITY
For a move toward the understanding of psychopathological manifestations in general, and in
particular of personality-related disorders of interpersonal behaviour, a primary role is given to
evolutionary relevant behavioural motivation
systems and to basic affect systems, assumed to be
wired in in every individual. For some time now, a
focus on behavioural motivation systems has been
at the forefront of the interest from research workers
and clinicians alike (e.g., Lichtenberg, 1989; Gilbert,
1992; Liotti, 1994; Schore, 1994; Stevens and Prince,
1996). Also acknowledged is that no separation can
be made between behavioural systems and basic
affect systems and that both, however subjected to
environmental constraints, have to be regarded as
the core determinants of human behaviour.
The behavioural motivation systems considered
in the present framework include (i) the exploratory
system, (ii) the attachment system with its complementary (iii) caregiving system, (iv) the agonistic
system, (v) the sexual (reproductive) system and
(vi) the co-operation system. All of these are of
particular relevance for a closer understanding of
the development of personality-related disorders of
interpersonal behaviour, as well as for the understanding of what can occur in the context of the
therapeutic relationship when working with
patients suffering from any such disorder (Liotti,
1987; Perris and Perris, 1998).
Even though no universal agreement yet exists, as
to how many affects have to be regarded as primary
and which instead are to be understood as
derivative of the most basic ones requiring a more
complex functional differentiation of the central
nervous system, some concensus occurs in treating
the following as fundamental: (i) fear, (ii) disgust,
247
(iii) joy/happiness, (iv) anger and (v) sadness (see
Power and Dalgleish, 1997, for a recent account of
the identification of basic emotions, and their
physiological substrate). To this list, it might be
appropriate to add (vi) interest/excitement in view of
its putative relationship to the exploratory system
(Emde, 1989).
For a conceptualization of personality disorders
in terms of disorders of interpersonal behaviour, a
primary emphasis is put in this article on the
complementary systems of attachment and caregiving and their vicissitudes. Likewise emphasis is
put on the exploratory system as a necessary
prerequisite for the development of the phenomenon of the secure base postulated by Bowlby (1979),
from which the growing individual can operate.
The analysis of the relevance of the other systems,
unfortunately, has to be deferred to some later
occasion (see, however, Gilbert, 1992).
ATTACHMENT THEORY
In recent years, attachment theory and its corollaries
as originally propounded by Bowlby (19691980),
and successively elaborated and refined by several
authors, have come to be regarded as one of the
most challenging frameworks for a closer understanding of an individual's personality development. This also applies to the development of
psychopathological manifestations in children as in
adults and the aged. Bowlby (1978) already
envisaged this development and maintained that
in the fields of aetiology and psychopathology,
attachment theory can be used to frame specific
hypotheses which related different forms of family
experiences to different forms of psychiatric disorders.
Attachment is a potentially crucial determinant of
personality, both normal and disordered. As conceived by Bowlby, it is a long-lasting affective bond
characterized by the proneness to seek and maintain
proximity to a specific figure in order to obtain
protection and feel security. Accordingly, attachment behaviour is a goal-corrected behavioural
system, the goal of which is to attain or maintain a
sufficient degree of proximity or contact with the
caregiver. Activators and terminators of the behaviour can be emotionally appraised external stimulus
conditions, internal states ( feeling states) or a combination of the two (Bowlby, 1982). The primary
function of the caregiver, motivated by the complementary caregiving system, is to give physical or
emotional nurturance and support, thus promoting
248
the organization of emotional experiences and a
feeling of security. The use of the attachment figure
as a secure base is a necessary prerequisite for
exploration, hence for learning. Exploration concerns
not only the intriguing physical environment, but
also the emerging capabilities of the own body, as
well as the social world at large. Increased exploration and play, reduced wariness of strangers, and
increased sociability toward strangers, are all supported by the secure base, and are necessary
prerequisites of a development towards autonomy.
The caregiver's response to the child's attachment
signals (sensitivity) has been assumed to be one of the
principal determinants (others being temperamental
variables and contextual factors) of the type of
attachment that the child will develop. However, first
with the development of a particular strategy by
Ainsworth and her colleagues (the Strange Situation,
Ainsworth et al., 1978), the occurrence of different
attachment patterns in relation to caregiver's sensitivity could be empirically verified. Three main
patterns of attachment have consistently emerged in
studies of the strange situation: (i) type A: insecure
avoidant (defended); (ii) type B: secure, and (iii) type C:
insecureambivalent ( preoccupied, coercive). Later, an
additional pattern, (iv) type D: disorganized/disoriented attachment was identified and thoroughly
investigated by Mary Main and her group at
Berkeley (Main and Solomon, 1986; Main, 1995).
Main (1995) points out that because type D consists
in an interruption of organized behaviour, this
category is always assigned together with the bestfitting alternative (e.g., D/A, D/B or D/C).
Crittenden (1985), finally, has proposed the addition of (v) a type A/C: insecure avoidant/ambivalent,
which shares the characteristics of both type A and
C. The child presenting this pattern is expected in
the interactions with the caregiver to combine
defended and coercive strategies.
As mentioned above, the development of different attachment patterns is assumed to be contingent
on the quality of the main caregiver's response,
when the child's attachment behaviour is activated.
Roughly, the caregiver of a securely attached child
is characterized by the ability to appropriately and
empathetically respond to the child's signals, and to
favour exploration promoting autonomy. In contrast, the caregiver of an insecurely attached child
with an avoidant pattern is assumed to fail in
giving an appropriate response. Such failure,
reflecting empathic unavailability, can depend on
factual absence, or on a rejecting or intrusive
domineering behaviour, both of which are
inadequate in validating the child's emotions and
C. Perris
hurt the child's integrity. The main characteristic of
the caregiver of an insecureambivalent attached
child, on the other hand, is unpredictability. Most
often, response to signals is contingent on doing the
caregiver's bidding.
The developmental background of severely disoriented/disorganized attachment patterns, finally,
is characterized by unavailability of, and neglect
from the caregiver that can be contingent on
pathology, most frequently of a depressive type
(Radke-Yarrow et al., 1985; Liotti et al., 1991). Other
dysfunctional characteristics of the family environment leading to a disorganized/disoriented attachment pattern may include the occurrence of harsh
violence, severe neglect, and abuses of various kinds
(George and Main, 1979; Crittenden, 1988). Table 1
gives an overview of what has been said above.
All attachment theorists hypothesize that early
infantcaregiver interactions result in the development of internalized, affective/cognitive working
models of self and others (IWM) which are assumed
to be relatively stable and to influence the child's
organization of thoughts, affects and behaviour
related to current and future relationships. IWMs
consist of accumulated knowledge about the self,
attachment figures and attachment relationships.
IWMs, however, are not only crystallizations of past
interpersonal experiences but evolving (i.e., working) dynamic structures that forecast and guide the
formation of future attachments and relationships.
The concept of IWMs is particularly important
because it allows a conceptualization of the relative
stability of attachment experiences in a life-span
perspective and across generations.
A major breakthrough in the study of the stability
of IWMs, also across generations, was the development of a specific methodology: the Adult Attachment
Interview (AAI: George et al., 1985), for assessing
states of mind (Main et al., 1985) with respects to
attachment in adults. Application of the AAI has
allowed verification of many of the postulates of
attachment theory, and especially the assumption
concerning an intergenerational transmission of
attachment (Benoit and Parker, 1994; see, however,
Belsky and Isabella, 1988, for discordant findings).
Besides the AAI, several paper and pencil selfreport questionnaires have been developed recently
to assess attachment relationships in adults (see
Stein et al., 1998, and Brennan et al., 1998, for recent
reviews). Even though the majority of these selfreports focus on current relationships (e.g., of
romantic type), the classical tripartite typology of
secure, avoidant and ambivalent styles of attachment can easily be identified.
Table 1.
249
A summarizing overview of the main patterns of attachment in relation to caregiver's responsea
Children's main
attachment pattern
Caregiver's response to
attachment needs
Main consequence for the child
Ainsecure avoidant
Emotional unavailability. Lack of

validation of expressed feelings.
Rejection, or intrusive overprotection.
Bsecure
Secure base effect. Consistent empathic

attunement to the child's emotional
needs. Promoting exploration and
autonomy.
Unpredictability. Responses often
contingent on own needs. At times
intensively accepting and overprotective,
at times aloof and distant.
Erratic responsivity. Frightened/
frightening behaviour contingent on
pathology. Communication deviance.
Severe neglect. Abuse.b
Disavowal of the salience of feelings as

effective communication signals.
Withdrawal. Detachment in extreme
cases. Reliance on semantic memory.
Reliance on others' availability and on
own worth. Appropriate integration of
memory systems.
Cinsecure ambivalent
Ddisorganized/disoriented
aOnly
bThe
Reliance on the enhancement of

emotional expression to achieve desired
goals. Reliance on episodic memory.
Experience of fear. Pronounced lack of
adaptive affect regulation. Defensive
inhibition of the attachment system. Lack
of integration of memory systems.
the main patterns are shown. For the occurrence of subgroups see the text.
D-type mostly reflects a disorganization of the other main types. Hence elements proper to them may occur.
In the conceptualization of IWMs of self and

others taken into account by Lorenzini and Sassaroli
(1995) and by Perris and Perris (1998) in the model
reproduced in Figure 1, the core structure of the
IWM refers to the degree of conviction about the
expected outcome of attachment behaviour when
activated, probably recorded as a procedural
(implicit) memory. This conceptualization is consistent with the position taken by Main et al. (1985),
with the notion of presymbolic representation by
Beebe and Lachman (1988) and with the concept
of RIGs hypothesized by Stern (1985). Such implicit
core structure could be assumed to be responsible,
when unconsciously activated (Tulving, 1985), for
the automatic generation of emotions (and consequent behaviour) postulated by Power and
Dalgleish (1997).
The view of self, others and the social world at
large ingrained in IWMs, and coupled to episodic
or semantic memory or to an integration of both, as
Crittenden (1990, 1994) and many others maintain,
is hypothesized to be contingent on the content of
the core structure.
The securely attached child, who is able to
unconditionally trust in the availability and
empathic responsiveness of the attachment figure,
is assumed to develop an IWM of others as loving
and certainly available whenever needed, and a
complementary IWM of self as worthwhile and
loveable. Interactions are characterized by emphatic
responses (attunement, Stern, 1985; Haft and Slade,
1989; reflective function, Fonagy et al., 1991, 1997)
which validate the child's emotions and promote

the development of appropriate emotion regulation,
including tolerance of negative affects. Crittenden
(1990, 1995) points out that this type of outcome
allows for an integration of emotionally derived
and cognitively derived information, hence for the
integration of both episodic and semantic memory.
The insecureavoidant attached child, on the other
hand, is expected to develop an IWM of others as
rejecting or as coldly intrusive, and a complementary
IWM of self as unlovable, undeserving and undesirable. The caregiver fails in validating the child's
emotions which results in no help for the child to
arouse her attention and attain optimal proximity.
Since the child has no control on the activation of the
attachment behaviour, at the same time as being
unable to attain the desired degree of proximity, she
has to learn to regulate her distance from the
caregiver in order to avoid the risk of rejection. The
caregiver's responses are overall far from attuned,
but rather quite often of a double-bind type. As a
result of this kind of response, the child comes to
mistrust the value of emotions associated with
activation of the attachment systems, and learns to
minimize their meaning and dismiss them. Hence,
the child discards emotional experiences not congruent with the caregivers' semantic generalizations
(recorded as semantic memory) and adapts to
depend upon the latter rather than the former.
The insecureambivalent (coercive) attached
child, on the other hand, cannot rely on the
availability of the unpredictable caregiver (Bowlby,
250
1973; Cassidy and Berlin, 1994). Significant others
can at times behave as intensively accepting and
overprotective, at times aloof and distant, or they
can make availability contingent on performance.
This kind of IWM of uncertain availability of others,
determined by their inconstancy and unpredictability, can be additionally reinforced by recurrent
masked or open measures of abandonment or
desertion from home up to the prospect of suicide
or death. The complementary IWM of self, insecure
of love and worth, is characterized by vulnerability
and includes a new dimension of strength
weakness concerning the ability of attaining proximity and security. Consequently, behaviour will be
organized to gain coercively control over others'
behaviour through exaggerating one's own feelings
to gain attention. As Crittenden (1995) has aptly
pointed out, coercive individuals, unable to rely on
verbal information, have an affective organization
in episodic memory with limited ability to integrate
semantic with episodic memory. Worth noting is
that although the connections between attachment
classification and the child's temperament are
generally weak, this seems to not apply to the
ambivalent pattern. For this pattern, in fact, attachment quality and infant characteristics appear to be
directly related (Cassidy and Berlin, 1994).
Main and Hesse (1992; Main, 1995) and Liotti
(1992, 1993, 1999) maintain that neither rejection
of attachment behaviour nor unpredictable responsiveness is likely in itself to lead to a pattern of
disorganized/disoriented attachment, unless the
caregiver is also frightening or frightened. Complementary to IWMs of others as frightened/frightening, the disorganized/disoriented attached child also
develops multiple and contradictory IWMs of self.
Issues of self-worth or being lovable or not are no
longer at stake especially when abuse occurs. As a
consequence IWMs of self become characterized by
ambivalence, confusion and anger aligned along the
polarities of frighteningfrightened and strong
weak.
Thus, contingent on the characteristics of the
IWM in relation to the various attachment patterns
is the potential of developing more or less adaptive
behavioural strategies along the linkingspacing
dimension (Gardner, 1988; Gilbert, 1992) in order
to attain optimal distance (a term originally coined in
a different context by Bouvet, 1958) in relation to
the main attachment figure (Main, 1990). These
strategies have the aim of being able to feel as much
security as possible when attachment behaviour is
activated, without a too high risk of rejection,
abandonment or abuse.
C. Perris
A focus on the strategies aimed at optimizing
interpersonal distance, adopted by individuals with
different attachment patterns in their background
and ingrained in their IWMs, is at the base of the
conceptualization of personality-related disorders
of interpersonal behaviour proposed in this article.
Emphasis on the vicissitudes of attachment as the
organizing principle acting as a scaffold for the
development of personal knowledge (Guidano,
1987) underscores the inseparability of biological
and psychosocial determinants of the development
of interpersonal behaviour. In fact attachment and
its different patterns are contingent on the wired-in
and developmentally unfolding interactions of
proximity seeking and care-giving. These interactions, in turn, also depend as well on genetic
influences on parenting (Reiss et al., 1995; Kendler,
1996), which are probably mediated by inherited
temperamental characteristics (Belsky and Rovine,
1987; Goldsmith and Alansky, 1987) since they are
contingent on non-shared environmental and contextual influences (Plomin, 1994). The relevance of
memory processes, highlighted above, is also in line
with an integrated conception because of their well
explored contingency on biological factors other
than attachment.
ATTACHMENT AND AFFECT

REGULATION
Distress is unavoidable for humans. Hence, a
developmental task for infants involves acquiring
the ability to modulate, tolerate and endure experiences of negative affect (Kopp, 1989). There is a fair
agreement that the quality of attachment and the
strategies affected by the working models to gain
attention within optimal distance are closely linked
to emotion regulation (Cassidy, 1994; Crittenden,
1994; Schore, 1994; Amini et al., 1996), for example, to
the expression of anger (Mikulincer, 1998).
Main et al. (1985) suggest that working models
provide the individual with rules and rule systems
for the direction of behaviour and the felt appraisal
of experience ( p. 77). These rules are connected
with affect regulation (Kobak and Sceery, 1988;
Mikulincer et al., 1990; Cassidy, 1994; Schore, 1994;
Amini et al., 1996). Securely attached children
demonstrate an ability to tolerate negative affect
(self-soothing) and delay gratification (Jacobsen et al.,
1997), but they are also able to display positive
emotions (Farrar et al., 1997). Insecurely attached
children, on the other hand, are characterized by less
optimal styles of affect regulation, which are
different in relation to the different patterns of
insecure attachment and can markedly oscillate
(Kobak and Sceery, 1988; Cassidy, 1994; Collins,
1996; Mikulincer, 1998). Kobak and Sceery (1988) go
as far as to maintain that attachment theory is
ultimately a theory of affect regulation.
Beebe and Lachman (1988) and Amini et al. (1996)
suggest that critical episodes of caregiverinfant
misregulation become ingrained in non-verbal
implicit memory, largely outside conscious awareness, which in our model constitutes the core structure
of IWM. In line with the model proposed by Power
and Dalgleish (1997), mentioned above, it can be
assumed that the activation of this core structure, by
stimuli experienced as stressful, gives rise to
automated emotional and behavioural responses
characterized by incapacity of optimal internal selfregulation. Accordingly, almost automatic affective
explosions in some types of patient could be
assumed to be a result of the activation of core
structures occurring outside conscious awareness.
According to Schore (1994) and others (Amini
et al., 1996), the experience of being raised by a
psychobiologically dysregulating other, who
initiates but poorly repairs misattunement, is
incorporated into a working model of the self-
Figure 2.
251
misattuned-with-a-dysregulation other (Schore, 1994,
p. 446). These models are assumed to be imprinted
with painful and disorganizing negative affects that
can not be regulated either intra- or interpersonally.
Beebe and Lachman (1988) describe a stressinduced avoidance pattern of inhibition of responsivity associated with a total breakdown of the
dyadic interaction. As a result, the infant develops a
bias towards remaining in a state of unregulated
withdrawal. Main and Solomon (1986) refer to this
as a strategy of defensive independence, whereas
Gilbert and Trower (1990) describe this state as
one in which an organism remains continuously
ready to take defensive activity in case its behaviour
provokes hostility from a dominant conspecific.
Hence, from what has been stated above it seems
fair to maintain that a conceptualization of PDs as
disorders of interpersonal behaviour, traceable to
dysfunctional attachment patterns, would also
allow for accounting for the dysfunctional affect
regulation which is one main characteristic of these
disorders, at the same time as further underscoring
the inseparability of biological and psychosocial
determinants of this paramount regulatory process.
A graphic representation of the process assumed to
unfold is shown in Figure 2.
A schematic illustration of the process assumed to unfold when the attachment behaviour is activated
252
GROUPING OF PERSONALITY-RELATED
DISORDERS OF INTERPERSONAL
BEHAVIOUR IN RELATION TO
DYSFUNCTIONAL ATTACHMENT
PATTERNS
Against the background sketched so far, it seems
reasonable to assume that three main patterns of
disordered interpersonal behaviour traceable to
dysfunctional attachment patterns, can be identified:
(i) Personality-related behaviour disorders in interpersonal relationships characterized by withdrawal
from others (spacing), or intrusive control of others.
(ii) Personality-related behaviour disorders in interpersonal relationships characterized by active or
passive dependence on others (prominently linking).
(iii) Personality-related behaviour disorders in interpersonal relationships characterized by incapacity
to establish stable relationships and a chaotic, at
time oscillating, spacing/linking behaviour.
Patients with an interpersonal behaviour of type (i)
would be characterized by IWMs of which the core
structure is based on the conviction of failure
concerning attempts to achieve an optimal distance
to principal attachment figures which are able to
promote a feeling of security. These patients very
soon realize that emotional activation of the
attachment system is not enough to elicit an
empathic response from the attachment figure(s).
They ultimately dismiss the value of emotions as
communication signals, shutting them off. As a
result, it is assumed that insecurely attached
individuals of the avoidant type develop a bias
towards remaining in a state of unregulated
conservationwithdrawal (Schore, 1994).
In these subjects IWMs of others are comprised of
an experience of emotional unavailability, which
can be coupled to fear of rejection. Intrusive
experiences can also occur which, ultimately, are
also invalidating of emotional needs. The complementary IWM of self, postulated by Bowlby
(1973), is of unloveability and unworthiness. Strategies to optimize distance can take the form of any
of the subtypes of the A-pattern of insecure
attachment (e.g., withdrawal and detachment,
compulsive self-reliance, compulsive care-giving or
exaggerated compliance).
The core structure of the IWM of patients with an
interpersonal behaviour of type (ii) comprises a
conviction of uncertainty concerning the outcome
of attachment behaviour. IWMs of others are
characterized by the experience of inconsistency
and unpredictability of significant others, whose
C. Perris
response is often contingent on performance. Effect
regulation is also impaired because the primary
caregiver(s) are assumed to have been unable to
modulate the tempo and content of their stimulation
in response to a monitoring of the child's affective
state. Also, primary caregiver(s) have been more
responsive to protest than appeal and inefficient in
limit setting and aggression socialization.
The complementary IWM of self cannot be
structured along a dimension of loveability and
worthiness because of the unpredictability of the
caregiver's response. It could be assumed, instead,
that a more likely organization is along a dimension
weakstrong concerning the ability of eliciting
attention and a caring response. Strategies at
eliciting attention and provoking a caring response
consist of the various subtypes of the C-pattern of
attachment and may comprise, for example, a
threatening, flirtatious or helpless behaviour.
The core structure of the IWM of patients with an
interpersonal behaviour of type (iii) can obviously
share some of the characteristics of either type (i) or
(ii) because of the assumption that the D-pattern of
attachment most often represents a disorganization
of A (avoidant) or C (ambivalent) attachment
pattern (Main, 1995). The relationship with principal
caregiver(s), however, has been characterized by
more extreme experiences of neglect and/or by
experiences of violence and abuse. The IWM's core
structure, hence, also comprises a conviction of a
frightening outcome of the attachment behaviour.
IWMs of others are assumed to be most often
articulated along a dimension of frighteningfrightened (Liotti, 1993; see, also Perris and Perris, 1998,
for further detail). The IWM of self is assumed to be
poorly integrated and contradictory. It can share
characteristics of both the avoidant and the ambivalent subtype of insecure attachment. Patients with a
background of disorganized/disoriented attachment are, principally, unable to develop consistent,
however hardly functional strategies to optimize
distance in their interpersonal relationships. Rather
frequently, instead, their behaviour is characterized
by flightfighting oscillations. If a defensive exclusion
(Bowlby, 1973; Bretherton, 1991) has been adopted
to cope with severely traumatic experiences, dissociative symptoms can also occur (see Liotti, 1994,
for a thorough discussion of this topic).
A close perusal of what has been described so far
offer clear evidence that a conceptualization of
personality-related disorders of interpersonal
behaviour, based on the tenets of attachment theory,
can easily account for the various categories of PD
taken into account in the current classification
systems. This as well applies for other personalityrelated disorders of interpersonal behaviour
presently not included in current classifications.
Multiple personality disorder is one example of the
latter because its classification among axis I disorders
in DSM is deemed for several reasons to be less
appropriate (Kirsten, 1990; see also Lauer et al., 1993;
Marmer and Fink, 1994; Liotti, 1994; Perris and
Perris, 1998, and Liotti, 1999, for further discussion
of this issue). Another example could be the type A
personality. Gilbert (1992) has thoroughly commented on this type of PD and pointed out its possible
relationship to narcissism.
IS THERE EVIDENCE OF A POSSIBLE

LINKAGE BETWEEN DYSFUNCTIONAL
ATTACHMENT PATTERNS OF THE TYPE
DESCRIBED ABOVE AND THE VARIOUS
CATEGORIES OF PERSONALITY
DISORDERS CURRENTLY TAKEN INTO
ACCOUNT?
Before attempting to answer this question, a few
qualifications of the proposal presented above
needs to be emphasized.
(i) Focusing on only three main patterns of
relating should be understood as overarching
and primarily based upon a critical analysis of
the literature. All attachment theorists concur
in acknowledging that the main attachment
types (A, B, C) are comprised of several variations (e.g., A12, A3, A4, B2, B3, B4, C12,
C34, C56), each with its own peculiarities.
This especially concerns strategies for achieving and maintaining optimal distance, which
become evident as the child grows up.
Composite patterns have also been described
(e.g. the A/C, and the various combinations of
type D with A, B and C). Taking into account
such a variety, there is space for a closer
understanding of a larger range of variations
than those limited to the main patterns. Also,
the ever growing trend to assume a dimensional perspective in studies of attachment in
adults (Armsden and Greenberg, 1987; Collins,
1996; Collins and Read, 1990; Feeney and
Noller, 1996; Stein et al., 1998) attests to the
awareness of possible variations in degree of
dysfunction within each main pattern, and to
the necessity of taking them into account.
(ii) The development of the various IWMs of self
and others has been primarily conceptualized
253
on the basis of the child's interactions with its
main caregiver. Multiple, inconsistent and even
contradictory IWMs, however, can develop
contingent on the outcome of interactions with
different significant others when the individual
grows up. Even though basic IWMs are
assumed to develop very early and to be
relatively stable throughout life, the possibility
of substantial changes contingent to later
experiences is largely acknowledged. Hence,
the possibility that severe traumatic events
occurring, for example, in adolescence could
substantially shatter and transform IWM developed early in life is largely acknowledged.
(iii) Accordingly, the model proposed in this article
should not be understood as a masked attempt
to revitalize the obsolete concept of blaming the
mother who, most often, is the primary attachment figure. The emphasis on continuous
dialectic interactions of biological (genetics)
and psychosocial (shared and non-shared
environmental influences) factors as determinants of development in which the growing
child participate, emphasized in the model,
concurs in precluding such a reductionistic
interpretation.
(iv) Focus on IAMs allows for unifying the interpersonal and the intrapersonal sphere as well
as biological and psychosocial determinants of
behaviour, because IAMs are assumed to deal
with the recording and retrieving of emotional
memories and to deal with affect regulation.
Severe disturbances in attachment relationships have not only a psychological impact
on development, but they even exert a marked
influence on brain development and its related
biochemical mechanisms (see Schore, 1994, for
a thorough review).
(v) The occurrence of dysfunctional patterns of
attachment should not be regarded as an
ineluctable doom to the occurrence of psychopathological manifestations later in life, and
even less of specific ones. Similarly, an early
secure attachment does not necessarily protect,
as mentioned above, against mental breakdowns. Pathology always occurs as the result
of complex patterns of interaction among a
great number of risk and protective factors
with the concept of resilience (Rutter, 1987)
being paramount in this context. This standpoint should be evident from the fact that
dysfunctional IWMs, in the model in Figure 1,
are understood as a core feature of vulnerability
and thus assumed to influence to a large extent
254
C. Perris
the type and the degree of reactivity to
external events (Bowlby, 1979; West et al.,
1986), rather than being causal. As originally
suggested by Bowlby (1988), dysfunctional
attachment puts the child in movement,
through the life-span, on a unique pathway
probabilistically leading to disorder. The
particular pathway that is followed is always
determined by the interactions and transactions that are constantly occurring between
the developing individual, that is, its unique
ever developing personality and the ever
changing environment.
There is obviously no space at this juncture to provide

a thorough review of arguments put forward by
authors with a variety of theoretical perspectives
which suggest a linkage of the proposed conceptualization with various kinds of PD. Many of the
relevant considerations concerning the development
of PDs deductible from different theoretical orientations, and the available evidence as to the type
of childhood environment identified in this type
of patient, have been reviewed elsewhere (Perris and
Perris, 1998). Thorough information on the developmental background of patients with a PD has also
been made available in treatises by other authors
(Derksen, 1995; Dowson and Grounds, 1995; Paris,
1996; Millon and Davis, 1996), hence no further
repetition is deemed necessary at this juncture.
Recent overviews of attachment and psychopathology are also available (Holmes, 1993; Crittenden,
1995; Main, 1995; Atkinson and Zucker, 1997; Sroufe,
1997).
Information on the attachment pattern of patients
with a PD is in most instances inferential and based
on accumulated knowledge on the experiences of
parental rearing or on childhood environment
assessed in patients with a diagnosis of PD. The
major bulk of rather consistent evidence concerns
the childhood environment of patients with a
borderline or an antisocial personality disorder, or
patients with a multiple personality disorder
(Gunderson et al., 1980; Frank and Paris, 1981;
Meloy, 1988; Benjamin, 1993; Hayashi et al., 1995).
Also well documented is the occurrence of severe
neglect, violence and abuse in the childhood background of these patients (Kluft et al., 1985; van der
Kolk et al., 1991; Frankel, 1993).
A history of emotionally unavailable or rejecting
parents, unable to modulate affect regulation, is
well established in the childhood background of
patients with a disorder of a schizoid, paranoid or
avoidant type by authors of different ideological
orientations (Guntrip, 1969; Benjamin, 1993; Millon

and Davis, 1996).
Likewise lack of empathy, an inconsistent reward
of performance and harsh parenting are well
documented in the background of patients with a
dependent, anancastic, histrionic, narcissistic or
passiveaggressive personality disorder (Kohut,
1971; Kernberg, 1975; Magnavita, 1993).
Research more specifically focused on the occurrence and type of dysfunctional attachment patterns
in the background of the various categories of PDs
considered in current classification systems is,
however, of a more recent date and still scanty
(Livesley et al., 1990; Fagot and Kavanagh, 1990;
Sheldon and West, 1990; West et al., 1993; Williams
and Schill, 1994; van Ijzendorn et al., 1997). Most of
the findings reported so far, are congruent with the
thesis maintained in this article, but there are
several caveats concerning their interpretation.
First, any attentive reader of published reports
will easily notice that most authors have only taken
into the dichotomy between secure and insecure
(anxious) attachment without any further specification. Two main reasons have contributed to that.
First, the insecureambivalent attachment, as Cassidy
and Berlin (1994) remark, has longer been the least
understood. As a consequence, it has been often
combined with the avoidant type in the insecure
group. Second, the disorganized/disoriented pattern
has been identified only more recently. Moreover, because this pattern of attachment by
definition refers to a disorganization of behaviour,
it is often considered together with the best-fitting
alternative (e.g., A/D, or C/D), hence either the Aor C-pattern is emphasized. Indeed, the disorganized/disoriented attachment pattern is
seldom mentioned in practice except by the authors
who use the AAI as the main research strategy
(e.g., Liotti, 1993, 1994; Cotugno and Benedetto,
1995; Lorenzini and Sassaroli, 1995; Fonagy et al.,
1997).
Third, because of the unavoidable occurrence of
comorbidity, it is difficult to deduce from the results
reported so far to what extent specific attachment
patterns do relate to specific types of PD.
Finally, the results reported in the literature have
been obtained by means of a large array of
assessment instruments, some of which developed
ad hoc for the purpose of a particular research, while
others (e.g., those aimed at mapping rearing
experiences) only by inference allow the identification of dysfunctional attachment. Since the
constructs taken into account in the various instruments do not always overlap, it is difficult to tell
how comparable all these findings are. Rather
challenging, however, is that most results obtained
with different methods, in different quarters, tend
to concur despite methodological shortcomings.
One comprehensive (n 1407) investigation, in
which attachment patterns in all 13 categories of
PD classified in DSM (inclusive of self-defeating
and sadistic) were assessed, was recently published
by Brennan and Shaver (1998). The results show a
substantial overlap between attachment and
personality disorder measures. Because of a sizeable proportion of comorbidity in the investigated
series, it is difficult, however, to recognize specific
patterns for specific subtypes. On the other hand,
subjects classified as secure were nearly twice as
likely not to have a PD.
Obviously, carefully planned investigations
which take into account all different patterns of
attachment and all three main groups of personalityrelated disorder proposed in this article are still
warranted to evidentiate and refine distinguishing
characteristics among the different patients' groups.
CONCLUSION
Much of what has been emphasized in this article
reads as if it were assumed that the development of
personality-related disorder of interpersonal behaviour invariably and exclusively derives from early
attachment interactions. On the other hand, the
model in Figure 1 suggests otherwise, mostly
because the vicissitudes of attachment through the
life span can never fully be understood without due
attention being paid to their context (Bronfenbrenner,
1979) and to their multiple determinants. On the
other hand, because attachment patterns and their
variations are deeply intertwined with important
systems of the developing brain (Schore, 1994), there
is an opportunity for overcoming the dualism that
has hampered progress in psychiatry.
A conceptualization of PDs in terms of personality-related disorders of interpersonal behaviour
would probably influence in a positive direction the
attitudes of mental health workers toward these
types of patient at the same time suggesting clearer
guidelines as how to deal with them. Research
reported by authors who use a circumplex approach
(e.g., Benjamin, 1993; Horowitz et al., 1993) is
consistent with this expectation.
In a thought provoking article evidence was
presented by Westen (1997) that clinicians of a
variety of theoretical orientations who need to treat
personality disordered patients seldom rely, in the
255
conceptualization phase, on questioning based on
the criteria included in current classifications.
Rather, as Westen found out, they rely on listening
to the patients' accounts of interpersonal interactions and on the observation of their behaviour
with the interviewer. This apparently widespread
practice is undoubtedly congruent with the suggestion of a reconceptualization of PDs in terms of
disorders of interpersonal behaviour offered in this
article, and underscores its value in suggesting
guidelines for treatment.
Treatment of patients with a PD is a challenging
task. Long-term pharmacological treatment is
seldom of any advantage for patients with a PD,
and therefore should be limited to emergencies
(Dowson, 1995; Perris and Perris, 1998). As to
psychotherapy there is an increasing awareness that
appropriate modifications are necessary to the
conduct of therapy, independent of ideological
allegiances. At the base of such a growing
consensus, attachment theory has come to stand
out as the most important tool acting as a bridge
between the various schools of psychotherapy, and,
also, for informing in-patient treatment, e.g., training staff to assume the role of attachment figures
(Perris, 1992, 1993; Perris and Perris, 1998; Adshead,
1997). All these issues, unfortunately, cannot be
dealt with at this juncture. As mentioned in the
introduction to this article aspects of treatment will
be treated at some depth in a companion paper now
in preparation.
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A Conceptualization of Personalityrelated Disorders of Interpersonal Behaviour With Implications For Treatment

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Clinical Psychology and Psychotherapy

Clin. Psychol. Psychother. 6, 239260 (1999)