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Theodore Millon’s Disorders of Personality: Introducting a DSM/ICD Spectrum from Normal to Abnormal  (available here: https://www.amazon.com/Disorders-Personality-Introducing-Spectrum-Abnormal/dp/0470040939) builds a personological taxonomy in accord with his earlier theory in Toward a New Personology. Being the more recent, it includes expansions upon the taxonomy offered previously. It extends the understanding of clincal personality disorders toward normalcy, It also suggests new personality types and disorders not covered by the DSM or ICD.

Millon begins the Preface with a justification of the guiding principles of the book:

“Guiding the principles and content of this book is Darwin’s concept of natural selection. In line with this ‘‘law’’, personology and personality disorder are conceived as varieties of successful and failed natural selection efforts by humans as they attempt to achieve an optimal balance among the three essential elements comprising life: (1) existential survival (avoiding death/pain and enhancing life/pleasure); (2) ecological adaptation (environmental accommodation/passive and environmental modification/active); and species replication (maximizing reproduction/ self and nurturing progeny/others).” (Millon 2011 ix)

The interplay of these three elements, as described in the preceding sections, will serve as the foundations of this model. Our first task then is to clarify and justify these three elements. 

Millon is regarded as an expert on personality, and this description of the text I think justifies its use:

“The task of authoring and improving the most successful professional-level book in the field (the first two editions sold some 70,000 copies in 27 printings) is not merely to tweak prior editions or to transmit recently established knowledge, but to introduce substantive and innovative ideas that will further guide developments in the subject. I have sought to fulfill this latter role by providing a strong theoretical base for allying and integrating normal and abnormal personality spectrum concepts in accord with Darwinian evolutionary ideas, as well as to elaborate a dimensional schema of traits for therapeutic planning.” (Millon 2011 ix)

There are two major clinical manuals the book companions:

“This book may be seen as an introduction and companion volume to the forthcoming Diagnostic and Statistical Manual of Mental Disorders (DSM-5), scheduled for publication by the American Psychiatric Association in 2013.” (Millon 2011 ix)

These two manuals were early obvious considerations for structuring this chapter around. Unfortunately, both manuals use poorly-grounded categorizations of the personality disorders, and neither considers the spectrum from abnormal to normal. Note, however:

“Not only has the DSM-5 committee altered its name to that of the Personality and Personality Disorders Work Group, but there has been an increasing recognition in the field that normal and abnormal personality conceptions be organized within a single conceptual framework” (Millon 2011 x)

The professional community is coming to understand personality as existing in this multi-spectral framework, as opposed to the older conceptions of personality disorders as discrete pathologies. 

Millon describes his book as satisfying this need:

“It is in this book where I have moved vigorously forward with the novel proposal that a coordinated structural model based on Darwinian theory can provide the overarching framework for identifying and articulating normal and clinical personality styles, types, and disorders spectra. “ (Millon 2011 x)

Why base the model on Darwinian theory? Because the personology field has exhibited no coherent, shared conceptions until now, nor possessing a synthesizing framework to guide the field, so it needs an overarching substantive framework to galvanize its different part. A system based on evolutionary principles can do this. (Millon 2011 x)

Millon has long been proposing personality categories. (Millon 2011 xi). He  began with a ‘‘biosocial framework’’, later developing the one called an ‘‘evolutionary model.’’ Even though they appear to diverge, the two conceptual schemas are consistent and complementary. “The former derives its constructs largely from learning theory and undergirds developmental ontogenesis; the latter includes constructs derived from evolutionary theory that are applicable both to phylogenesis and human adaptive styles” (Millon 2011 xi)  See also Toward a New Personology: An Evolutionary Model by Theodore Millon.

A note regarding the uses of key concepts in the DSM-5 and Millon’s model:

“The DSM-5 will propose that a central role be given to the concepts of positive and negative emotionality; these correspond directly to the theory’s survival bipolarity of pleasure (life enhancement) and pain (death avoidance). Similarly, the externalizing and internalizing DSM concepts parallel in most regards the theory’s adaptation bipolarity of active (ecologic modification) and passive (ecologic accommodation). And the DSM’s self- and interpersonal functioning dimension matches fully the theory’s replication bipolarity of self (reproductive maximization) and other (reproductive nurturance). However, whereas the DSM lists these imaginative bipolar formulations as separate and uncoordinated proposals, our Darwinian-based theory shows how they interrelate and thereby generate deductively not only the classical group of DSM personality disorders, but clarify and innovate novel normal styles and historically overlooked ones as well.” (Millon 2011 xii) (See also the work of Seth Grossman, Roger Davis, Bob Meagher, Addi Geist Agar, Michael Antoni, Robert Tringone, Neil Bockian, George Everly, Flo Grabel, Rose Wilansky, Audrey Melamed, Naomi Grossman, Sally Perlis, Jean Jones, Mary-Lou McGinnis, Leila Foster, JoAnn Lederman, Jeffrey Magnavita, Joseph Zubin, Paul Meehl, Allen Frances, Don Klein, Jean Endicott, Nancy Andreasen, Bob Spitzer, Larry Siever, Kathy Phillips, Tracie Shea, Tom Widiger, Bob Hirschfield, Bruce Pfohl, Roger Blashfield, John Gunderson, Elsa Ronningstam, Mary Zanarini, Ed Murray, Paul Blaney, Bob McMahon, Otto Kernberg, Michael Stone, Lorna Benjamin, Aaron (Tim) Beck, Gerry Klerman,  Erik Simonsen, Gunilla Øberg, Morten Birket-Smith, Bent Rosenbaum, Fini Schulsinger, Niels Strandbygaard,  Jan Derksen, Wim van den Brink, Franz Luteyn, Herman Groen, Theo Bouman, David Bernstein, Robert Abraham, Hedwig Sloore, Gina Rossi, Robert Weinryb, Marie Asberg, Svenn Torgersen, Per and Sonya Vaglum, Bjørn Østberg, Alv Dahl, W. John Livesley, Joel Paris,  Steve Strack, Darwin Dorr, Frank Dyer, Joseph McCann, Jim Choca, Carol Watson, Joe Grosdidier, Theo Jolosky, Christine Carlson, Kristie Thoenen, Christine Thompson, John Kamp, Larry Weiss, Aurelio Profitera, Herb Reich, Peggy Alexander, Tisha Rossi, Kelly Franklin, Jo Ann Miller, Isabel Pratt, Judi Knott, Linda Indig, Tracey Belmont, Donna Meagher, Alyssa Boice,  Gardner Murphy, Kurt Goldstein, Ernst Kris,  Mel Sabshin,  Drew Westen, Robert Bornstein, Robert Krueger, Aaron Pincus, Mark Lenzenweger, Mark Blais, Brent Roberts, Mike Antoni, Caryl Bloom, Neil Bockian, Roger Davis, Seth Grossman, Carrie Millon, Sarah Minor, Steve Strack, and Robert Tringone.)

Historical, Theoretical, and Methodological Foundations

“That the incidence of both mild and severe mental disorders is strikingly high in contemporary society cannot be denied.” (Millon 2011 3)

What is a mental disorder? The concept mental disorder is, at its most basic, that of an incongruence between normal mental processes and those that are dysfunctional, personally or socially. Because normalcy and function are value-laden, so is mental disorder. Once the bounds of normalcy are set, then whether mental processes are normal can be factually determined. Once the bounds of functionality are set, then whether mental processes are functional can be factually determined. Among the value-laden concepts, mental disorder is especially important to our lives. While there are many ways to understand it, most people believe in the medical model in the contemporary United States. By “medical model” I here mean an understanding of mental disorder as a kind of illness, and thus the proper object of treatment of Western medicine. I say “believe in” because most people do not think theoretically, and for most people only seldom even explicitly, about mental disorder, but they do assent to statements they understand to be the opinion of those deemed authorities by medical institutions and behave as such. In other words, most Americans believe in the medical model (for mental disorder) like most Americans believe in Christianity, rather than how a theorist understands the medical model or a theologian Christianity. This isn’t to disparage the public, but to warn that to many readers, such a model may just seem to be the way things obviously are and must be.

The concept is also important practically because our institutions do in fact follow a medical model, in research and treatment. While I find the medical model to be deeply inadequate for psychiatry, not to mention medicine, it must be understood to make sense of the ongoing research on mental disorders. Moreover, to be conversant with an existing audience, I must use existing language, and so I will at least start with the terms in academic and professional use. I’m saying this early to be upfront about the fact that I am not always saying what I take to be the most correct, but rather the most correct given the conceptual and lexical framework we have to work with at whatever point in this text we’re at.

Gregory Zilboorg writes (1941) that “detachment suggests a certain lack of feeling, reviewing the events of the past with the cold eye of an unconcerned and unaroused observer.” (Millon 2011 3) Millon suggests instead that “To look on our subject’s history as if it could be portrayed as a series of dots on a statistical table will miss an essential aspect of its vitality.” (Millon 2011 3) ( See also Lytton Strachey 1931 and Millon 2004a, 1969, 1990, 1996, 2010b.)

A brief discussion is warranted here about Personology’s place in the sciences as Millon uses Kuhn’s concept of paradigm to understand the competing theories in the field:

“As is evident throughout this book, Thomas Kuhn’s brilliant, if controversial, concept of ‘‘paradigm’’ characterizes the divergent patterns of thought regarding the subject of the mind and mental science (1962). Kuhn’s concept recognizes that an articulated set of assumptions are posited by theorists and investigators concerning the fundamental entities of which a subject is composed; also, it identifies questions that may legitimately be asked about such entities and the techniques that may be employed in seeking answers to relevant questions. Once a paradigm is established it becomes the given groundwork for ‘‘puzzle solving,’’ that is, the rules that scientists and clinicians may employ to further elaborate their subject.

Although Kuhn has described how new paradigms replace previous paradigms, he does acknowledge that competing paradigms can coexist, each posing its own set of propositions, rules, and questions that followers may seek to answer” (Millon 2011 4)

By using Millon’s model, I do not intend to say that the other models are wrong or useless. It is in fact from those other models that Millon synthesizes his theory. Due to the environment the mental health sciences are produced in, they  “are largely the result of an evolutionary process of haphazard variation and natural selection” (Millon 2011 4) (See also Gardner Murphy 1930.)

Consider several of the competing schools of Psychology and Personality:

“To Kretschmer (1925), body morphology was a significant variable in conceptualizing pathological types; for Cattell (1957, 1965), statistically derived trait dimensions were given preeminence; for Horney (1950), it was the interpersonal orientation developed to resolve unconscious conflicts that received emphasis.” (Millon 2011 5)

Again, though, there’s reason for optimism regarding Millon’s project:

“What should be especially heartening is that theorists and classifiers have been convinced that the complexities and intricacies of personality can, in fact, be studied systematically and will, it is hoped, yield to efforts at scientific comprehension. “ (Millon 2011 5)

With my use of Millon’s evolutionary theory of personality justified, we move to the historical antecedents. Millon’s book describes these in much greater detail, but I will reconstruct and quote some key points in the following section. Because we’ve covered a lot in this section, let’s take a moment to review before getting into the history.

Review

Millon defines a personality as a set of “styles of adaptive functioning”. I chose to synthesize Millon’s book because of the many historical sources he synthesizes. I will later contrast my Millonian model with other models. My hypothesis is that they will generally be able to be incorporated or explained. The disputes may arise over the accuracy of Darwinian theories of evolution or the connection‌ ‌ between‌ ‌personality‌ ‌and‌ ‌natural‌ ‌selection. On the first point, there is enough consensus in the field of Biology for us to accept such theories. Regarding the latter, we should consider the ways the relationship might be different. According to Millon, we should expect this evolutionary model of personality to be accurate because each facet of personality developed through evolution. 

Being requires distinction (from non-being). Life is seen from the point of view of personality as having length, circumstances, and activities.

Millon’s justification for the model uses the relatively high level of unity and evidentiary support in Biology to justify its use in priority over psychological, sociological, and other possibilities that are not yet in a state of theoretical unity. Personality can be understood from the perspective of social, practical, and cultural understanding, but we must choose from these perspectives to comprehend personality, whereas the biologies have already reached a consensus of sorts that we can work with. the personology field has exhibited no shared conceptions nor synthesizing framework to guide the field, so it needs an overarching framework to galvanize its different parts.

The concept mental disorder is  that of an incongruence between normal mental processes and those that are dysfunctional, personally or socially. Because normalcy and function are value-laden, so is mental disorder. Most people believe in the medical model in the contemporary United States. By “medical model” I mean an understanding of mental disorder as a kind of illness, and thus the proper object of treatment of Western medicine.The concept is also important practically because our institutions do in fact follow a medical model, in research and treatment.