Personality Disorders

   Even though upsetting behavior is as old as the human condition, systematic attention to disorders of the personality appears relatively late in the development of psychiatry. On the whole, the asylum generation of psychiatrists had little to say about character disorders, unless they occurred in conjunction with psychoses, because patients with such traits did not end up in the asylum. The oldest of the personality disorders by far is "hysteria," understood classically as a convulsive disorder combined with such somatic symptoms as a lump in the throat ("globus hystericus") or blinding headache ("clavus hystericus"). In the nineteenth century, it became interpreted also as a personality type.

   The beginning of the inclusion of personality disorders in psychiatric nosology:

   Pinel’s "emotional insanity" (1801). In his textbook, Philippe Pinel differentiated madness with psychosis (manie avec délire) from madness without psychosis (manie sans délire), or emotional insanity, a form of insanity that did not involve loss of reasoning (l’entendement) but rather was characterized "by a sort of instinctual fury, as though only the affective faculties had been impaired." (See the discussion of Pinel’s "emotional insanity" at Psychosis: Emergence: Pinel [1801].) He then gave several examples of patients quite unable to bridle unruly tempers or violent impulses, including one gentleman farmer who had thrown a woman down a well (pp. 155–157 of second edition, 1809).

   Hysteria as a character type (1845). Hysteria becomes understood in part as a personality type, found principally in the female sex. References to a hysterical type of character peculiar to women go well back into the history of psychiatry. But a landmark is Viennese psychiatry professor Ernst von Feuchtersleben’s (1806–1849) Textbook of Medical Psychology (Lehrbuch der ärztlichen Seelenkunde), published in 1845: "[The causes of hysteria] include everything that increases sensitivity, weakens spontaneity, gives predominance to the sexual sphere, and validates the feelings and drives associated with sexuality" (p. 245).

   Koch introduces the first classification of "psychopathic inferiorities" (1888). Inspired by French accounts of degeneration, Julius Ludwig August Koch (1841–1908), director of the state asylum at Zwiefalten in Württemberg, compiled in his Brief Guide to Psychiatry (Kurzgefasster Leitfaden der Psychiatrie, 1888) a list of what he called "psychopathic inferiorities" (psychopathische Minderwertigkeiten). Some of the patients were born psychopathically laden, others acquired their psychopathic inferiority (for Koch, a further subpopulation of both of these groups counted as "degenerate"). Those whose inferiority was constitutional in nature would have certain personality characteristics, such as obsessiveness; those with degenerate weakness were worse off, suffering from a lack of forcefulness or a "pathological lack of reproductive drive" (p. 45). None of the entities represented actual mental illnesses, he said, although the degenerate group could easily tip over into mental illness. Koch’s own observations extended back over his experiences in private nervous clinics, one in Swabia owned by his family, another in Göppingen where he had worked before joining the civil service.

   Janet profiles "hysterical" personality (1893). Even though Pierre Janet considered hysteria a constitutional disease, hysterical personality was something one acquired, he said, a response to developing hysterical physical symptoms such as cutaneous anesthesia. As he wrote in his 1893 book on the psychology of hysteria, "The mental state of the hysteric patient, overwhelmed and much reduced by the illness, becomes definitively reorganized along certain lines." "[Such symptoms] represent a mental illness, a psychological illness; [the anesthesia] does not exist in the limbs, nor the spinal cord, nor in the nuclei of the brain, but in the mind." For Janet, the essence of the hysterical personality was dissociation: "[Hysteria] is based on a very special kind of mental operation: on the personal perception that permits someone at any moment of one’s life to assimilate the ensemble of new sensations to one’s personality. Hysteria is due to a weakness of this synthesis of psychological elements that I have called elsewhere psychological disaggregation. Hysterical anesthesia is an illness of the personality" (L’état mental des hystériques, 1893, pp. 48–50).

   Kraepelin classifies the "psychopathic personalities" (1904). In the seventh edition of his book Psychiatry, Emil Kraepelin said that "among those forms of mental illness that arise from a pathological constitution, there is a broad borderland between those frankly pathological conditions and those personal eccentricities that we find in healthy people as well" (Psychiatrie, 7th ed., II, p. 815). Among the "pathological personal deviations" in this borderland were (1) "the born criminal" (here he cited Cesare Lombroso, as well as Eugen Bleuler’s 1896 book on the born criminal) (see Conduct Disorder; Criminality and Psychiatry); (2) the "irresolute," suffering from lack of will power (die Haltlosen, with Willenschwäche, or weak will); (3) "the pathological liars and swindlers"; (4) the "pseudo-querulants" (the real querulants had a delusional illness classified elsewhere in his book Psychiatry). By "pseudo-" is meant people who become excitable about petty matters without actually becoming psychotic.

   By the eighth edition of his Psychiatry, published in 1915, the list had expanded to seven types of "psychopathic personalities": (1) the excitable (die Erregbaren); (2) the irresolute; (3) those suffering from "driven" behavior (die Triebmenschen), including wastrels, drifters, periodic drinkers, and pleasure-lovers; (4) the eccentric (die Verschrobenen); (5) the liars and swindlers; (6) "the enemies of society (the antisocial)"; (7) the quarrelsome (die Streitsüchtigen), a label that had now replaced the "pseudoquerulants." Inevitably, a list of this nature represents as much the compiler’s pet-peeves as it does scientifically validated disorders. Kraepelin himself led a highly ascetic lifestyle and was completely teetotal; it is unsurprising that he would pathologize social drinking and "pleasure-seeking."

   Freud and the "anal character" (1908). Freud, generally speaking, was not terribly interested in the issue of differing personality types. Yet, his main contribution to the subject was his essay on "Character and Anal Eroticism" ("Charakter und Analerotik") in the Psychiatric-Neurological Weekly (Psychiatrisch-Neurologische Wochenschrift). He wrote, "Among the people whom one attempts to help through psychoanalytic treatments, there is quite frequently a certain type characterized by the coincidence of certain character qualities. . . . I can no longer recall on which specific occasions I started to get the impression that there was a relationship between that kind of character and behavior surrounding a certain body organ." The patients who caught his attention were distinguished by three character qualities: they were orderly, in the sense of being clean, but also tidy and meticulous about the conduct of business; they were parsimonious, sometimes to the point of miserliness; and they could be stubborn. As Freud quizzed them about their childhood, their memories of toilet training caught his attention. "There was a very clear emphasis on the anal region in the sexual constitutions that they subsequently developed." Freud speculated that this triad of character qualities had arisen as these patients attempted later in life to shuck off their anal fixations (Gesammelte Werke, VII, pp. 203–204). Jaspers distinguishes between "abnormal" and "pathological" types of personalities (1913). In his General Psychopathology, Jaspers distinguished between abnormal character variations that represented just extreme versions of normal personalities—such as neurasthenic and hysteric personalities—and pathological changes in personality arising from a "process," such as schizophrenia, in which the dissolution of the personality in disease bears little in common with the premorbid personality. He did not attempt a systematic classification of personality types. (See also Jaspers, Karl; Psychopathology: Jaspers [1913]; Paranoia: "pathological jealousy" [1910]; Psychosis: Emergence.)

   Kretschmer’s constitutionally based character types (1921). (See Kretschmer, Ernst; see also Psychosis: Emergence: Kretschmer’s constitutional psychoses [1921].) In his book Body Structure and Character (Körperbau und Charakter, 1921), Kretschmer classified the temperaments on the basis of the body types producing them (and according to the psychiatric illnesses for which the temperaments furnished a substrate). Thus he differentiated between:

   • The "cycloid" temperament (fluctuating in and out of circular psychosis) as being "almost childishly good-hearted, trusting and tractable" (p. 116).

   • The "schizoid" temperament that lapses into schizophrenia in episodes (rather than in "waves" as the cycloid); Kretschmer denoted them as individuals whom one could never really know, having the quality Bleuler had called "autism": "That of living inside themselves. You can never know what they feel; sometimes they don’t know it themselves, or only uncertainly. . . . What they feel, whether it is a banality, a whim [eine Schrulle], a commonplace or a magical notion, nobody else will know—they keep it for themselves" (p. 131) (quotes from seventh ed., 1929).

   Jung’s "extraverted" vs. "introverted" personalities (1921). See Jung, Carl Gustav.

   A comprehensive schema of psychopathic personalities: Schneider (1923).

   Kurt Schneider set out to construct a comprehensive scheme of all character traits and their opposites as an exercise in the study of character, not psychiatric pathology. His character chart was based on psychologist Ludwig Klages’s (1872–1956) book Principles of Characterology (Prinzipien der Charakterologie, 1910). Schneider denied that any of these traits represented illness: Just as previous observers such as Paul Julius Möbius (1853–1907) had claimed that, "The degenerate individual is not mentally ill in the sense of the law, and he must bear the consequences of his actions as any other person," so Schneider did not see psychopathic personalities as "ill individuals" but rather as "characterological varieties." In his 1923 book, Psychopathic Personalities (Die psychopathischen Persönlichkeiten), Schneider said, "Psychopathic personalities are those abnormal personalities who suffer from their abnormality or from whose abnormality others suffer" (p. 16). Although he saw character as constitutional in nature—one has the personality one is born with—he rejected previous notions of "degeneracy" in understanding character abnormality.

   Schneider devised the following types, supporting each with an extensive review of the literature: (1) hyperthymic psychopaths, psychopathic only when they—people with basically happy dispositions—spill over into hypomania; (2) depressive psychopaths, individuals who are continually gloomy; (3) insecure psychopaths, of whom he distinguished the subtypes: highly sensitive individuals and those prone to obsessive thoughts (anancastic); (4) fanatical psychopaths, people who struggle on behalf of overvalued ideas; (5) psychopaths with labile moods, highly reactive one day, tolerant and easy-going the next; (6) recognition-seeking psychopaths (Geltungsbedürftige) (Schneider said that Karl Jaspers seized the core of this: "To appear to be more than one is"); (7) emotionally-blunted psychopaths (Gemütlose): Schneider would have accepted antisocial as a synonym, he said, were the latter term not a sociological rather than a characterological construct; (8) weak-willed psychopaths, shallow people with little resolve; (9) asthenic psychopaths, meaning people who are "nervous" and "neurasthenic" (Schneider said of the decades-long speculation about the purported neurophysiology of neurasthenia, "That is all mythology"); (10) explosive psychopaths, people who "blow a fuse" at the slightest occasion (Schneider said "affective epilepsy" was a close neurological neighbor). The list was revised somewhat in subsequent editions.

   Abraham links child-development phases to character types (1924). Berlin psychiatrist Karl Abraham (1877–1925), one of Freud’s closest lieutenants, said in 1924 that a separate character type was associated with disruptions in each of the three phases of psychosexual development that Freud believed children passed through. An arrest at the oral stage could produce a dependent type of character; at the anal stage, obsessive-compulsive character; at the phallic stage, hysterical character. Abraham’s essay "A Short History of the Development of the Libido" ("Versuch einer Entwicklungsgeschichte der Libido auf Grund der Psychoanalyse seelischer Störungen") appeared in the volume New Studies in Medical Psychoanalysis (Neue Arbeiten in der ärztlichen Psychoanalyse, 1924). This codified many of Freud’s previous thoughts about the development of the libido. (See Id; Narcissism; Paranoia.)

   Wittels’ "hysterical character" (1930). Siegfried ("Fritz") Wittels (1880–1950) acquired most of his psychiatric experience in the private sector, as consulting internist and psychiatrist to Vienna’s "Cottage Sanatorium," an exclusive clinic for often female nervous patients. Yet in the late 1920s, Wittels was in the United States a good deal, de-finitively settling in New York in 1932. In 1951 his last book, Sex Habits of American Women, appeared posthumously, and it was doubtless out of the crossruff between Vienna and New York that his influential but misogynistic sketch of the "hysterical character"—later called the "hysterical" or "histrionic personality"—appeared in the Medical Review of Reviews. "As an actress," he said, "the hysteric is capable of achievements that cannot be surpassed. But she is unreliable, and at times will prove to be unsupportably bad in the same or some other role. . . . As a loving woman she represents a veritable martyrdom for the serious, compulsive male who, enwrapped in love and enjoyment in an hour of happiness, sees himself betrayed the following day." The cause of hysterical character, according to Wittels, was the fixation of character development at the "infantile level." "Hence [the character] cannot attain its actuality as a grown-up human being; it plays the part of a child, and also of the woman" (p. 187).

   Partridge introduces "sociopathic personality" (1930). Differentiating "sociopaths" from the general pool of "psychopathic personality" in an article in the American Journal of Psychiatry, psychologist George Everett Partridge (1870–1953) at the Sheppard and Enoch Pratt Hospital in Baltimore identified sociopathy as an almost constitutional trait that "produces persistent anti-social or socially futile behavior." Characteristic of the sociopathic personality were "emotional excesses and instability, [they are] generally unstable, have difficulty in acquiring permanent moods or sentiments in their social relations, are egocentric and show . . . decided lack of good sense and judgment, have the child’s impractical attitude towards values . . . and have the child’s irresponsibility and attitudes toward authority" (p. 97).

   Reich’s analysis of "character armor" (1933). Among early psychoanalysts, it was Vienna’s Wilhelm Reich (1897–1957) who developed most fully the concept of character disorders. Reich saw "the character of the ego . . . as an armor protecting the id against the stimuli of the outer world" as well as against repressed inner drives. Various kinds of character types, all flying against "the original contrary tendencies," performed this function: (1) The "hysterical character," which Reich called "the simplest, most transparent type of character armor," was the result of a genital fixation in childhood. To deal with anxiety surrounding this fixation, the bearers of this particular set of armor, in this case usually but not necessarily women, developed an "importunate sexual attitude, yet backed away or became frigid when it was time to close the deal. (2) The "compulsive character," hallmarked by a "pedantic sense of order," parsimony, and a mix of hostility and aggression, served as a reaction against the fixation of ego development at the anal-sadistic stage. (3) The "phallic-narcissistic character," which Reich himself had first described in 1926, bore armor that was "predominantly inhibited, reserved, depressive." Filled with aggression, people of this type displayed their narcissism by going on the offensive. Just at the cusp of mature sexual development, their psychosexual growth had been arrested at the "proud, self-confident concentration on one’s own penis," a way of defending oneself against backsliding to earlier stages. (4) The "masochistic character," a concept Reich had developed in 1932 as a way of breaking with Freud’s theory of the death instinct (which implied that we suffer because of a biological will to do so, or "death instinct"). (See Masochism: Reich [1932].) Reich said that masochists have "a chronic, subjective feeling of suffering which is manifested objectively . . . as a tendency to complain. Additional traits of the masochistic character are chronic tendencies to inflict pain upon and debase oneself . . . and an intense passion for tormenting others" (pp. 237–238). The character armor function here was a "fantasized or actual non-fulfillment of a quantitatively inordinate demand for love." This demand creates anxiety. The psyche tries to bind the anxiety by "courting love through provocation and defiance" (quotes from the English translation, 3rd ed., p. 246).

   Beginning of "borderline personality disorder" (1938). See Borderline Personality Disorder.

   Eysenck’s dimensions of personality (1948). In his book Dimensions of Personality,

   Hans Jürgen Eysenck, then director of the psychological department of the Maudsley Hospital, began to elaborate his lifelong interest in pathological personality types. He distinguished between neuroticism and introversion–extraversion. In 1952 in The Scientific Study of Personality, he added psychoticism, arguing that these qualities were entrenched deep in the nervous system and body type: "The introverted neurotic shows symptoms of anxiety, depression, and irritability; he has overly high levels of aspiration . . . and tends to be of the leptomorph [asthenic] body build." "The extraverted neurotic is characterized by hysterical conversion symptoms; he has unduly low levels of aspiration . . . and tends to be of the eurymorph [short, heavy] type of body build" (Scientific Study of Personality, p. 122). In general, Eysenck (and others) argued for a dimensional approach to personality disorders, seeing them as maladaptive variants of normal personality.

   See Schizoid Personality Disorder (1952).

   "Personality disorders" in DSM "One" (1952). Personality disorders in the first edition of the DSM series were understood as "developmental defects" in indivudals who had little anxiety or distress. They were subdivided into (A) Personality pattern disturbances that were almost constitutional in nature and inaccessible to basic change through psychotherapy; these included: "inadequate personality," "schizoid personality," "cyclothymic personality," and "paranoid personality"; (B) Personality trait disturbances that were potentially less serious than the above, and included: "emotionally unstable personality" (formerly psychopathic personality), "passive-aggressive personality," and "compulsive personality"; (C) Sociopathic personality disturbances whose bearers were defined largely as rule-breakers, including: "antisocial reaction," "dyssocial reaction," and "sexual deviation" (homosexuality, fetishism, and the like).

   Sociopathic personality: the diagnosis validated (1966). On the basis of a follow-up study of 500 children brought to child guidance clinics in St. Louis and then tracked down 30 years later, Lee Nelken Robins (1922–) in the department of sociology of Washington University in St. Louis found that conduct-disordered children often became sociopathic adults. Her book Deviant Children Grown Up: A Sociological and Psychiatric Study of Sociopathic Personality (1966) again focused light on a disorder to which Emil Kraepelin (see above) had called attention in 1915 as "the antisocial" personality and that became in DSM-II in 1968 (see below) "antisocial personality disorder."

   "Personality disorders" in DSM-II (1968). This part of DSM-II deviated from DSMI in two ways: first, it abolished the subdivisions of the personality disorders (PDs) and simply gave a straight list; second, now under psychoanalytic guidance, it was insisted in the Manual that the personality "disorder" be differentiated from the "neurosis" of the same name, distinguishing in other words between brain-malfunction-style "maladaptive behavior" (as in a PD) and "neurotic symptoms" explicable in psychodynamic terms. The disorders included "paranoid personality," "cyclothymic personality," "schizoid personality," "explosive personality (epileptoid personality disorder)," "obsessive compulsive personality (anankastic personality)," "hysterical personality (histrionic personality disorder)," "asthenic personality" (which had to be differentiated from "neurasthenic neurosis"), "antisocial personality," "passiveaggressive personality," and "inadequate personality." "Sexual deviations" went into another category.

   Chodoff attacks the "hysterical personality" disorder as pejorative (1974). Recognizing as pejorative many descriptions of the supposedly "hysterical" female— accounts that made her labile, egocentric, seductive, frigid, and childish—Washington, D.C., psychoanalyst Paul Chodoff (1914–) proposed in the American Journal of Psychiatry that classic "hysterical" PD be scrapped. "I have had the impression," he wrote, "that susceptible male residents may classify as a hysterical personality any reasonably attractive woman with whom they come into therapeutic contact" (p. 1076). Chodoff proposed that the concept of "histrionic" PD, already foreshadowed in DSM-II, be adopted instead. These recommendations were partly acted on in DSM-III (1980; see below), and more fully in DSM-III-R (1987), when Chodoff was on the subcommittee for personality disorders.

   "Personality disorders" in DSM-III (1980). The third edition of the DSM series broke from the second edition in assigning all of the personality disorders (along with the developmental disorders) to a separate axis, called "axis II." (All other psychiatric illnesses went on "axis I.") It defined PDs as "personality traits" that cause dysfunction and distress. The PDs were grouped into "clusters." One cluster included paranoid, schizoid, and schizotypal PDs, the latter being new. (See Schizoid Personality.) This cluster embraced individuals who "often appear ‘odd’ or eccentric."

   The second cluster included histrionic, antisocial, narcissistic, and borderline personality disorders (BPD). (See Borderline Personality Disorder.) The latter two were new in the DSM series: psychoanalytic categories now operationalized by developing observable criteria; by the end of the twentieth century, "BPD" would be by far the most commonly diagnosed PD.* A portion of what had formerly been considered borderline personality disorder became classified in this edition as schizotypal PD. As for narcissism, Reich in 1933 (see above) had developed the concept of narcissistic personality disorder, and New York psychoanalyst, Heinz Kohut (1913–1981), in his book The Analysis of the Self (1971), had seen to it that it retained a high place in psychoanalysis even after Reich was excommunicated from the temple. Typically, individuals in this second cluster "often appear dramatic, emotional, or erratic." In the third cluster were avoidant, dependent, compulsive (in later editions "obsessive-compulsive"), and passive-aggressive PDs, whereby avoidant and dependent were new. Common to this cluster were individuals who "appear anxious or fearful." In this edition, the distinction between PD and neurosis, so central to the second edition, was abolished. This classification was arrived at after extensively querrying practitioners in the field and represented a consensus, rather than being derived from any particular theoretical system.

   DSM-III-R (1987) made no changes in the basic structure of the PD section of DSM-III.

   DSM-IV (1994) removed "passive-aggressive" PD from the main list and, under the alternative title "negativistic personality disorder," made it a candidate for "further study" in the nonofficial diagnoses at the end of the book (along with "depressive personality disorder").

   ICD-10 Classification of personality disorders (1992). The tenth edition of the World Health Organization’s nosology did not diverge sharply from the personality disorder classification of the DSM, except for making the PDs just an additional group * The deliberations of the advisory committee on personality disorders of the task force were evidently influenced by the work of Harvard psychoanalyst John Gunderson. (See Borderline Personality Disorder: Gunderson defines [1978].) of disorders rather than a separate axis. Among the PDs listed in The ICD-10 Classifi-cation of Mental and Behavioural Disorders (1992) were paranoid, schizoid (schizotypal disorder was classed elsewhere), dissocial, emotionally unstable (subdivided into impulsive type and borderline type), histrionic, anankastic, anxious (avoidant), dependent, and a grab-bag category that mentioned the following as acceptable PD diagnoses without specifying their characteristics: eccentric, "haltlose" type, immature, narcissistic, passive-aggressive, and psychoneurotic.