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Book Review   |    
Social Factors in the Personality Disorders: A Biopsychosocial Approach to Etiology and Treatment
David Brizer, M.D.
Psychiatric Services 1998; doi:
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by Joel Paris; New York City, Cambridge University Press, 1996, 231 pages, $54.95

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Character nosology extends back to the ancient Greeks, and to Galen's choleric, sanguine, phlegmatic, and melancholic temperaments. (Or should we say dopaminergic, serotonergic, noradregeneric, and cholinergic temperaments?) Current research targeted at the identification of biologic and social determinants of personality disorders continuously refines and occasionally eclipses earlier models. "Moral insanity" and Wilhelm Reich's notion of "character armor" have been superceded by sophisticated attempts to locate these disorders in an epidemiologic, heritable, and biopsychosocial universe.

Professor Paris' volume draws on his own extensive work (he has published prolifically on developmental antecedents of the borderline personality, among other areas) as well as on that of dozens if not hundreds of others who have broadened our understanding of this complex area.

Clearly, Dr. Paris has done his homework. The material is presented thoughtfully and in an articulate manner, offering the reader a comprehensive review of current knowledge of social determinants of DSM axis II pathology.

To the author's credit, relevant but not necessarily social (read "environmental") underpinnings of these disorders are also covered.

What do we really know about personality disorders? We know that the trait-state dichotomy doesn't always hold—for example, those with active substance use or mood disorders or both "look like" they have character disorders but often shed their pathologic-appearing personas as their axis I disorders remit. We discuss the possibility of a heritable continuum of "schizotypy," variably expressed as eccentricity and magical thinking on the one hand and as frank schizophrenia on the other. We know that childhood abuse and early exposure to other toxic family interactions are predictive of antisocial and borderline personality in later life.

Some consensus exists on the utility of clustering these disorders, making bedfellows, for example, of histrionic, borderline, and antisocial personality disorders under an "impulsive" canopy. We know that some may disagree with such clusterings and lumpings. For all we know, personality disorders may be dimensional rather than discrete categorical entities. Dr. Paris illuminates these controversies in a forthright, intellectually honest way.

The book is comprehensive, well ordered, and easy to read. Extended discussion of social components of axis II disorders are complemented by brief clinical vignettes and by chapters on relevant biological and social factors. Evidence for and against the clustering construct are presented, along with lucid discussions of treatment, clinical practice, and areas for future research. Social Factors in the Personality Disorders will be useful to both students and seasoned characterologists.

Dr. Brizer is director of adult inpatient psychiatry at Monmouth Medical Center in Long Branch, New Jersey.

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