Mind, Brain, and Personality Disorders
Glen O. Gabbard, M.D.
Objective: The use of the terms “mind” and “brain” in psychiatry is often associated with a set of polarities. Concepts such as environment, psychosocial, and psychotherapy are linked with “mind,” while genes, biology, and medication are often associated with “brain.” The author examines these dichotomies asthey apply to personality disorders. Method: Research on antisocial and borderline personality disorders that is relevant to these dichotomies is evaluated. The implications of the findings for the understanding of pathogenesis and treatment are reconsidered. Results: In the clinical setting, it is problematic to lump together terms such as “genes,” “brain,” and “biological” as though they areseparate and distinct from terms s uch as “en vironm ent,” “mind,” and “psychosocial.” These dichotomies are problematic, because genes and environment are inextricably intertwined in the pathogenesis of personality disorders, psychosocial experiences may result in permanent changes in the brain, and psychotherapy may have its effect by altering brain structure and function. The “theory of mind” is auseful construct for bridging “mind” and “brain” in the treatment of personality disorders. Conclusions: Severe personality disorders are best understood and treated without “either-or” dichotomies of brain and mind. Each domain has a different language, however, and the language of the mind is necessary to help the patient develop a theory of mind. (Am J Psychiatry 2005; 162:648–655)
hemind-brain relationship has vexed philosophers for centuries and continues to be the subject of controversy. In psychiatric discourse, we often refer to “mind” and “brain” as though they are separate entities, even though most psychiatrists in the post-Cartesian era regard the mind as the activity of the brain (1). The persistence of these terms in contemporary psychiatric discussions reflects thefact that references to “mind” and “brain” have become a form of code for different ways to think about patients and their treatment. As Cloninger (2) noted, “biomedical” and “psychosocial” define two discrete paradigms, and the division into these separate models has had a stagnating effect on the science of mental health. Polarities such as genes versus environment, medication versuspsychotherapy, and biological versus psychosocial are often glibly subsumed under categories of “brain” and “mind” (Figure 1). Using what we know about personality disorders, we can begin to deconstruct some of these problematic dichotomies while still preserving the broadly biopsychosocial framework of diagnosis and treatment that is essential to the provision of comprehensive and effective intervention forpatients with these disorders. Virtually all major psychiatric disorders are complex amalgams of genetic diatheses and environmental influences. Genes and environment are inextricably connected in shaping human behavior. Experience shuts down the transcriptional function of some genes, while turning on that of others (3). As
Michael Rutter has emphasized, “Genetic influences, as they apply toindividual differences in the liability to show particular behaviors, are strong and pervasive but rarely determinative” (4, p. 996). Similarly, psychosocial stressors, such as interpersonal trauma, have profound effects of a biological nature by changing the functioning of the brain. Teasing apart biological and psychosocial phenomena may be a formidable challenge when treating a patient.Finally, to think of psychotherapy as a treatment for “psychologically based disorders” and medications as a treatment for “biological or brain-based disorders” is to make a specious distinction. The effect of psychotherapy on the brain is well established (5). A review of recent research on personality disorders suggests that these constructs can be dichotomized only in the abstract. In clinical work...