Journal of Personality Disorders, 28(1), 172-179, 2014 © 2014 The Guilford Press CICCHETTI COMMENTARY ON THE SPECIAL ISSUE

Illustrative Developmental Psychopathology Perspectives on Precursors and Pathways to Personality Disorder: Commentary on the Special Issue Dante Cicchetti, PhD Within the psychiatric literature, personality disorders are conceptualized as relatively enduring character-based patterns of psychopathology that emerge in adolescence or adulthood. In this Special Issue of the Journal of Personality Disorders, devoted to a developmental psychopathology perspective, contributors have focused predominately on one of the major tenets of the field of developmental psychopathology—namely, the mutual interplay between normal and abnormal development across the lifespan. A major goal of this Special Issue is to increase understanding of the genesis and epigenesis of personality disorders throughout the life course. In this commentary, I propose that adherence to a fuller array of developmental psychopathology principles can provide a conceptual framework for investigating personality disorders. Historically, it was believed that personality disorders should not be diagnosed in children because their personalities are not fully integrated. An additional concern with diagnosing personality disorders in children relates to the possibility that stigmatization could result (Cicchetti & Crick, 2009a, 2009b; Hinshaw & Cicchetti, 2000). Specifically, because personality pathology has often been viewed as being unmodifiable and recalcitrant to intervention, it was thought that diagnosing a child with a personality disorder could lead to a lifelong categorization of dysfunction. However, longitudinal investigations of normal personality development, as well as of personality pathology, reveal that personality processes are more dynamic than previously believed (Caspi & Shiner, 2006; Rutter, Kim-Cohen, & Maughan, 2006). Consequently, it should not be assumed that the future functioning outcomes of individuals with personality disorder will necessarily be pathological. In the past decade, there has been a growing consensus that there is a great need to incorporate a developmental perspective into the conceptualization of personality disorders across the lifespan (Tackett, Balsis, Oltmanns, & Krueger, 2009; Widiger, De Clercq, & De Fruyt, 2009). Adherence to such an approach would entail conducting prospective longitudinal From the Institute of Child Development, University of Minnesota, and Mt. Hope Family Center, Rochester, New York. Work on this commentary was supported by grants from the Jacobs Foundation and the Spunk Fund, Inc. Address correspondence to Dante Cicchetti, PhD, Institute of Child Development, University of Minnesota, 51 E. River Rd., Minneapolis, MN 55455; E-mail: [email protected]

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studies in order to gain knowledge of the diverse childhood antecedents of personality disorders. To date, there is still a paucity of research on the early precursors and pathways to personality disorders. Because personality disorders do not appear de novo in late adolescence, the investigation of the precursors and pathways to personality disorders during childhood and adolescence is critical to the formulation of lifespan developmental models of personality pathology. Even prior to the emergence of a personality disorder, certain pathways signify adaptational failures in normal development that probabilistically foretell subsequent pathology. Although the term developmental psychopathology frequently has been equated with the study of mental disorders among children and youths, this perspective encompasses a much broader approach to studying development, normal and abnormal, across the lifespan (Cicchetti, 1984, 1993; Cicchetti & Cohen, 1995). The incorporation of developmental psychopathology principles into the conceptualization and investigation of personality pathology would contribute greatly to elucidating the antecedents and sequelae of personality disorder across the life course. A developmental psychopathology perspective espouses the viewpoint that in order to comprehend personality disorders in their full complexity it is necessary to possess an understanding of the organization and integration of diverse biological, psychological, and social systems at multiple levels of analysis within individuals across different contexts and varying developmental periods (Cicchetti, 2006). The undergirding developmental orientation impels researchers to pose new questions about the phenomena they study. For example, with regard to personality disorders, it becomes necessary to move beyond identifying features that differentiate children, adolescents, and adults who do and do not have personality pathology to articulating how such differences have evolved developmentally within a multilevel and dynamic social ecology. Likewise, rather than being concerned with merely describing the symptoms of personality disorder in children, adolescents, and adults, the emphasis shifts to ascertaining how similar and different biological and psychological organizations contribute to the expression of various pathological or nonpathological outcomes at each specific developmental level. Because personality pathology unfolds over time in a dynamically developing organism, the adoption of a developmental perspective is critical in order to comprehend the processes underlying pathways to adaptive and maladaptive outcomes in individuals with personality disorders. Although abnormalities in the broad domains of genetics, neurobiology, cognition, social cognition, emotion, and interpersonal relations are present to varying degrees among individuals with personality disorders, these diverse areas do not exist in isolation. Rather, they are complexly interrelated and mutually interdependent. Consequently, it is essential for researchers to strive to comprehend the interrelations among the biological, psychological, and social systems in order to delineate the nature of personality disorder, including the discovery of ways in which the organization and integration

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of these systems may promote nonpathological functioning. Furthermore, as there are numerous risk factors associated with personality disorders, researchers must acquire a firm grasp of the multilevel biological and psychological processes and mechanisms that contribute to the emergence, maintenance, and recurrence of personality disorders and their sequelae. DEVELOPMENTAL ANALYSIS

A developmental analysis is essential for tracing the roots, etiology, and nature of maladaptation so that interventions may be timed and guided as well as developmentally appropriate (Toth & Cicchetti, 1999; Toth, GravenerDavis, Guild, & Cicchetti, in press). Moreover, a developmental analysis will prove useful for uncovering the compensatory mechanisms, biological, psychological, and social-contextual, that may be used to function resiliently despite the experience of significant adversity (Cicchetti, 2013; Curtis & Cicchetti, 2003). A developmental analysis presupposes change and novelty, highlights the critical role of timing in the organization of behavior, underscores multiple determinants, and cautions against expecting invariant relations between cause and outcome. A developmental analysis is as applicable to the study of the gene or cell as it is to the investigation of the individual, family, or society (Cicchetti & Pogge-Hesse, 1982; Werner & Kaplan, 1963). A developmental analysis strives to examine the prior sequences of adaptation or maladaptation in development that have contributed to an outcome in a particular developmental period. Thus, for example, it is essential that the current status of the functioning of an adolescent or adult with personality disorder be examined in the context of how that status was attained across the course of development. Given the multiplicity of biological and psychological processes affected by personality disorders, directing research attention to examining early developmental functioning that may be theoretically related to later appearing personality disorder organization may prove to be very fruitful. Researchers could begin by investigating the early development of the core features of specific personality disorders, the developmental course of these features, and their interrelations with other psychological and biological systems of individuals with personality disorders (Cicchetti & Sroufe, 2000). Given the importance of a lifespan view of developmental processes and an interest in delineating how prior development influences later development, a major issue in developmental psychopathology involves how to determine continuity in the quality of adaptation across developmental time. The same behaviors in different developmental periods may represent quite different levels of adaptation. For example, behaviors indicating competence within a developmental period may indicate incompetence when evidenced within subsequent developmental periods. Normative behaviors early in development may indicate maladaptation when exhibited later in development. The manifestation of competence in different developmental periods is rarely indicated by isomorphism in behavior presentation.

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SOME ILLUSTRATIVE PRINCIPLES OF DEVELOPMENTAL PSYCHOPATHOLOGY MUTUAL INTERPLAY BETWEEN NORMAL AND ABNORMAL DEVELOPMENT

A focus on the boundary between normal and abnormal development is central to a developmental psychopathology analysis (see Cicchetti & Toth, 2009 for a more complete delineation of developmental psychopathology principles). Such a perspective emphasizes not only how knowledge from the study of normal development can inform the study of high-risk conditions and psychopathology, but also how the investigation of risk and pathology can enhance our comprehension of normal development. Before one is capable of identifying deviances that exist in a system, one must possess an accurate description of the system itself. Only when we understand the total ongoing development of normal systems can we fully comprehend developmental deviations as adaptational regularities of those systems (von Bertalanffy, 1968). Conversely, the examination of aberrations in the biological, cognitive, social cognitive, emotional, and interpersonal domains in individuals with personality disorders contributes to a more complete comprehension of how these systems function in normal development. THE IMPORTANCE OF A LIFESPAN PERSPECTIVE

With respect to psychopathology, all periods of life are consequential in that the developmental process may undergo a pernicious turn toward mental disorder at any phase. Many mental disorders have several distinct phases. The factors that are associated with the onset of a disorder may be very different from those that are associated with the cessation of a disorder or with its recurrence. Within the field of developmental psychopathology, “adaptive” and “maladaptive” may assume differing definitions depending on whether one’s time referent is immediate circumstances or long-term development, and processes within the individual can be characterized as having shades or degrees of psychopathology. With respect to personality disorders, such a lifespan perspective suggests that, even with chronic recurrences, future remission and more adaptive functioning are possible. DEVELOPMENTAL PATHWAYS: DIVERSITY IN PROCESS AND OUTCOME

Since the emergence of developmental psychopathology as an interdisciplinary science, diversity in process and outcome has been among the hallmarks of its perspective. For example, it would be expected that there are multiple contributors to personality disorder outcomes, that the contributors vary between individuals with personality disorder, that there is heterogeneity among persons with personality disorder in the features of their biological and psychological disturbances and underlying dysfunctions, and that there

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are numerous pathways to personality disorder. Furthermore, it would be expected that there is heterogeneity among individuals who possess many of the risk factors for personality disorder, but who do not develop the disorder. In this regard, the principles of equifinality and multifinality, derived from general systems theory, are germane (Cicchetti & Rogosch, 1996; von Bertalanffy, 1968). Equifinality refers to the observation that a diversity of paths may lead to the same outcome. This alerts us to the possibility that a variety of developmental progressions may eventuate in personality disorder rather than positing a singular primary pathway to disorder. In contrast, multifinality suggests that the effect of any one component may function differently depending on the organization of the system in which it operates (Cicchetti & Rogosch, 1996). Multifinality states that the effect on functioning of any one component’s value may vary in a different system; thus, the same risk factor or starting point may eventuate in a wide dispersion of outcomes. The growing knowledge that subgroups of individuals manifesting similar problems arrived at them from different beginnings and that the same risk factors may be associated with different outcomes has proven to be critical not only because it has the potential to bring about important refinements in the diagnostic classification of mental disorders, but also because it calls attention to the importance of conducting process-oriented studies. The examination of patterns of commonality within relatively homogeneous subgroups of individuals with personality disorder and concomitant similarity in profiles of contributory processes becomes an important data analytic strategy. Moreover, the need to examine the totality of attributes, psychopathological conditions, and risk and protective processes in the context of each other rather than in isolation is seen as crucial for undertaking the course of development taken by individuals. For example, the presence of personality disorder in a child, adolescent, or adult would have different developmental implications depending on whether it occurs alone or in conjunction with other types of psychopathology. The meaning of any one attribute, process, or psychopathological condition needs to be considered in light of the complex matrix of individual biological and psychological characteristics, experiences, and social-contextual influences involved, the timing of events and experience, and the developmental history of the individual. MULTIPLE LEVELS OF ANALYSIS

In order to comprehend personality disorders in their full complexity, all levels of analysis must be examined and integrated. Along these lines, the investigation of multiple aspects of the developmental process concurrently can shed light on the nature of the interrelations among various biological and psychological domains. For example, how do cognitive, affective, social, and neurobiological growth relate with one another at various points during ontogeny? One of the major goals of developmental psychopathology is to comprehend individual patterns of adaptation and to understand the whole organism (Sroufe & Rutter, 1984; Zigler & Glick, 1986). Accordingly, calls

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for interdisciplinary research and a multiple-levels-of-analysis approach are gaining momentum across the country (Cicchetti & Dawson, 2002; Cicchetti & Posner, 2005; Masten, 2007). Rather than adhering to a single domain or unitary disciplinary focus, striving for a multilevel synthesis may lead to the formulation of integrative developmental theories that can elucidate precursors and pathways to normal personality and personality disorders across developing biological, psychological, and social systems. RESILIENCE

Resilience has been operationalized as the individual’s capacity for adapting successfully and functioning competently despite experiencing chronic adversity or after exposure to prolonged or severe trauma (Luthar, Cicchetti, & Becker, 2000). Resilience is a dynamic developmental process; it is multidimensional in nature, exemplified by findings that individuals who are at high risk for or who have a mental disorder may manifest competence in some domains and contexts, whereas they may exhibit problems in others. Research on the determinants of resilience also highlights the need to examine functioning across multiple domains of development (Curtis & Cicchetti, 2003). The ability to function in a resilient fashion in the presence of biological, psychological, and sociocultural disadvantage may be achieved through the use of developmental pathways that are less typical than those negotiated in usual circumstances. Thus, an important question for researchers studying the development of personality disorders to address is whether the employment of alternative pathways to attaining competence renders individuals more vulnerable to manifesting delays or deviations in development. A multilevel approach to resilience also affords an additional avenue for examining the biological and psychosocial constraints that may operate on aspects of the developmental process throughout the life course. Moreover, through investigating the multiple biological and psychosocial determinants of resilient adaptation, researchers are in a position to discover the range of variability in individuals’ attempts to respond adaptively to challenge and ill fortune. Finally, investigations aimed at discovering the processes leading to resilient outcomes and the processes underlying recovery of positive function offer great promise as an avenue for facilitating the development of prevention and intervention studies (Cicchetti & Blender, 2006; Luthar et al., 2000). Through the examination of the proximal and distal processes and mechanisms that contribute to positive adaptation in situations that more typically eventuate in maladaptation, prevention and intervention scientists will be better prepared to devise ways of promoting competent outcomes in individuals at high risk for developing personality disorder. TRANSLATIONAL RESEARCH/PREVENTION AND INTERVENTION

The conduct of randomized prevention and intervention trials should incorporate both behavioral and biological measures into their design and evalu-

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ation (Cicchetti & Gunnar, 2008). Such multiple-levels-of-analysis intervention evaluations would enable researchers to assess theoretically informed behavior changes in individuals with personality disorders. Moreover, they also would provide the opportunity to ascertain whether abnormal biological structures, functions, and organizations are modifiable or are refractory to intervention. Successful preventive interventions may alter behavior and physiology through producing alterations in DNA methylation and gene expression that create a new structural organization in the brain. Furthermore, the incorporation of a multilevel framework into interventions seeking to improve maladaptation, promote resilient functioning, or repair positive adaptations gone awry in individuals with personality disorders may contribute to the ability to design individualized interventions that are based on knowledge gleaned from multiple biological and psychological levels of analysis. In conclusion, as the field of developmental psychopathology ushers in its next era of scientific and clinical challenges, the collaborative agenda set forth by the editors of this Special Issue has the potential to foster significant advances in the understanding of normal personality and personality disorders. The continuation of the dialogue and interchange between researchers studying normal and pathological personality will not only enhance the science of developmental psychopathology and personality disorders, but will also provide benefits to be derived for society as a whole. A major key to further progress in this interdisciplinary collaboration will be an enhanced and continued emphasis on the concept of development. References Caspi, A., & Shiner, R. L. (2006). Personality development. In W. Damon & R. Lerner (Series Eds.) & N. Eisenberg (Vol. Ed.), Handbook of child psychology, Vol. 3, Social, emotional, and personality development (6th ed., pp. 300–365). New York: Wiley. Cicchetti, D. (1984). The emergence of developmental psychopathology. Child Development, 55(1), 1–7. Cicchetti, D. (1993). Developmental psychopathology: Reactions, reflections, projections. Developmental Review, 13, 471–502. Cicchetti, D. (2006). Development and psychopathology. In D. Cicchetti & D. J. Cohen (Eds.), Developmental psychopathology (Vol. 1, 2nd ed., pp. 1–23). New York: Wiley. Cicchetti, D. (2013). Resilient functioning in maltreated children: Past, present, and future perspectives. Journal of Child Psychology and Psychiatry, 54, 402–422. Cicchetti, D., & Blender, J. A. (2006). A multiplelevels-of-analysis perspective on resilience: Implications for the developing brain, neural plasticity, and preventive interventions.

Annals of the New York Academy of Sciences, 1094, 249–258. Cicchetti, D., & Cohen, D. J. (1995). Perspectives on developmental psychopathology. In D. Cicchetti & D. J. Cohen (Eds.), Developmental psychopathology: Theory method (Vol. 1, pp. 3–20). New York: Wiley. Cicchetti, D., & Crick, N. R. (Eds.). (2009a). Precursors of and diverse pathways to personality disorder in children and adolescents, Part 1. [Special issue]. Development and Psychopathology, 21(3). Cicchetti, D. & Crick, N. R. (Eds.). (2009b). Precursors of and diverse pathways to personality disorder in children and adolescents, Part 2. [Special issue]. Development and Psychopathology, 21(4). Cicchetti, D., & Dawson, G. (Eds.). (2002). Multiple levels of analysis [Special issue]. Development and Psychopathology, 14(3). Cicchetti, D., & Gunnar, M. R. (2008). Integrating biological processes into the design and evaluation of preventive interventions. Development and Psychopathology, 20(3), 737–743.

COMMENTARY ON THE SPECIAL ISSUE 179 Cicchetti, D., & Pogge-Hesse, P. (1982). Possible contributions of the study of organically retarded persons to developmental theory. In E. Zigler & D. Balla (Eds.), Mental retardation: The developmental-difference controversy (pp. 277–318). Hillsdale, NJ: Lawrence Erlbaum Associates. Cicchetti, D., & Posner, M. I. (Eds.). (2005). Integrating cognitive and affective neuroscience and developmental psychopathology [Special issue]. Development and Psychopathology, 17(3), 569–891 Cicchetti, D., & Rogosch, F. A. (1996). Equifinality and multifinality in developmental psychopathology. Development and Psychopathology, 8, 597–600. Cicchetti, D., & Sroufe, L. A. (2000). The past as prologue to the future: The times, they’ve been a changin’. Development and Psychopathology, 12, 255–264. Cicchetti, D., & Toth, S. L. (2009). The past achievements and future promises of developmental psychopathology: The coming of age of a discipline. Journal of Child Psychology and Psychiatry, 50, 16–25. Curtis, W. J., & Cicchetti, D. (2003). Moving research on resilience into the 21st century: Theoretical and methodological considerations in examining the biological contributors to resilience. Development and Psychopathology, 15, 773–810. Hinshaw, S. P., & Cicchetti, D. (2000). Stigma and mental disorder: Conceptions of illness, public attitudes, personal disclosure, and social policy. Development and Psychopathology, 12, 555–598. Luthar, S. S., Cicchetti, D., & Becker, B. (2000). The construct of resilience: A critical evaluation and guidelines for future work. Child Development, 71, 543–562. Masten, A. S. (Ed.). (2007). Multilevel dynamics in developmental psychopathology: Pathways to the future. Mahwah, NJ: Erlbaum.

Rutter, M., Kim-Cohen, J., & Maughan, B. (2006). Continuities and discontinuities in psychopathology between childhood and adult life. Journal of Child Psychology and Psychiatry, 163, 1009–1018. Sroufe, L. A., & Rutter, M. (1984). The domain of developmental psychopathology. Child Development, 55, 17–29. Tackett, J. L., Balsis, S., Oltmanns, T. F., & Krueger, R. F. (2009). A unifying perspective on personality pathology across the life span: Developmental considerations for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. Development and Psychopathology, 21(3), 687–713. Toth, S. L., & Cicchetti, D. (1999). Developmental psychopathology and child psychotherapy. In S. Russ & T. Ollendick (Eds.), Handbook of psychotherapies with children and families (pp. 15–44). New York: Plenum Press. Toth, S. L., Gravener-Davis, J. A., Guild, D. J., & Cicchetti, D. (in press). Relational interventions for child maltreatment: Past, present, & future perspectives. Development and Psychopathology, 25(5). von Bertalanffy, L. (1968). Organismic psychology and systems theory. Worcester, MA: Clark University Press. Werner, H., & Kaplan, B. (1963). Symbol formation: An organismic developmental approach to language and the expression of thought. New York: John Wiley. Widiger, T. A., De Clercq, B., & De Fruyt, F. (2009). Childhood antecedents of personality disorder: An alternative perspective. Development and Psychopathology, 21(3), 771–791. Zigler, E., & Glick, M. (1986). A developmental approach to adult psychopathology. New York: John Wiley & Sons.

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