Clinical Research

14_CH_8001_BA_INTERIEUR.qxd:DCNS#55 3/06/13 18:03 Page 147 Clinical research Milestones in the history of personality disorders Marc-Antoine Crocq, MD Introduction The objective of this article is to describe the history of the study of normal and abnormal personality. We will review the major concepts that have emerged up to the 20th century. The knowledge of historical antecedents helps us put into perspective the classifica- This paper analyzes the major historical milestones in the tion of personality disorders that has prevailed from study of normal and abnormal personality, from antiq- DSM-III through DSM-IV-TR. Also, we will pay special uity up until the 20th century. Special attention is paid attention to the interaction between dimensional and to the interaction between dimensional and typological typological classifications, since this was the focus of a approaches, which was a major issue during the prepa- heated debate during the preparation of DSM-5, the lat- ration of DSM-5. Theories of personality started with the est version of the Diagnostic and Statistical Manual of humoral theory of Greek medicine. Pinel, and later Mental Disorders of the American Psychiatric Esquirol and Prichard, are credited with the first descrip- Association. Indeed, the DSM-5 work group on person- tions of abnormal personalities in textbooks of psychia- ality and personality disorders debated several options: try. Between the late 19th and early 20th centuries, elab- (i) maintaining a typological classification of personality orate systems of normal and abnormal personality, disorders (as in DSM-IV-TR); (ii) switching to a dimen- associating to some degree types and dimensions, were sional system (adapted from the Five Factor model); or devised by a succession of European psychologists, such (iii) constructing a hybrid system associating both as Ribot, Heymans, and Lazursky. Emil Kraepelin and approaches. Both approaches have their own merits and Kurt Schneider proposed classifications of abnormal per- demerits. Dimensional systems are better at depicting sonality types. In parallel, psychoanalysts stressed the role the variegated nuances of normal personality; they of early life experiences. Towards the mid-20th century, emphasize the continuum between normal and abnor- statistical methods were applied to the scientific valida- mal personalities; and they usually define abnormal per- tion of personality dimensions with pioneers such as sonalities as the cases that exceed a threshold at the Cattell, anticipating the five-factor model. Keywords: personality; temperament; character; personality disorder; personality © 2013, AICH Dialogues Clin Neurosci. 2013;15:147-153. type; personality dimension; history of psychiatry; history of psychology; Théodule Ribot; Gerard Heymans; Aleksandr Lazursky; Emil Kraepelin; Kurt Schneider; DSM Author affiliations: Hospital specialist, Rouffach General Hospital, Rouffach, France Address for correspondence: Centre Hospitalier, 68250 Rouffach, France (e-mail: macrocq@aol.com) Copyright © 2013 AICH. All rights reserved 147 www.dialogues-cns.org 14_CH_8001_BA_INTERIEUR.qxd:DCNS#55 3/06/13 18:03 Page 148 Clinical research extreme(s) of a unipolar or bipolar dimension. On the activity and movement to the substances it penetrates, other hand, abnormal personality types have been according to traditional Chinese philosophy. described first with literary sketches, then clinical The first system of personality types in the Greco-Roman vignettes in psychiatric textbooks, and more recently lists world was expounded in a book called The Characters, by of criteria. Diagnostic categories agree with the diag- the Greek philosopher Theophrastus (c 371 to c 287 BC). nostic approach of traditional medicine, and they are Theophrastus joined Plato’s academy, before the latter’s more convenient to use than a dimensional system in death, and he was a close follower of Aristotle, his senior clinical settings. However, diagnostic categories cannot by 12 years. His book contains 30 descriptions that are all render the variety and complexity of personality, organized along the same structure; the character type is whether normal or abnormal. Often, patients with a per- first named, then briefly defined in one short sentence, sonality disorder are not adequately described by one and finally illustrated by a list of about ten examples distinct category, with the result that one of the most fre- showing how the person will typically react in different quent personality diagnoses in DSM-IV is “not other- life situations. This is in line with the notion, emphasized wise specified.” Also, personality types were created via since DSM-III, that personality is revealed by a fixed pat- the clinical intuition of gifted psychiatrists, and they are tern of reacting to various life circumstances. For instance, not based on scientific methods. Finally, another objec- the “Suspicious Man,” (Character 18, ἀπιστία) is analo- tive of this paper is to describe in more detail the con- gous to today’s paranoid personality3; he is defined by the tributions of a few key historical authors, who are often sentence “he believes that everybody is fraudulent,” and quoted but whose original papers are seldom read. An further described by typical patterns such as “The suspi- exhaustive report on all significant authors is beyond the cious man is the sort of person who sends a servant to scope of this paper; thus, a few important names have market and then sends another to watch him and find out been omitted. the price he pays.” The “Thankless Man” (Character 17, μεμψιμοιρία) always sees the negative aspects and is inca- Personality in ancient Chinese and pable of enjoying life; he is presenting traits that might be Greek philosophy qualified today as anhedonia, resentfulness, and nega- tivism. For instance, “when his sweetheart kisses him, he Both ancient Chinese and Greek medicine offer physi- says ‘I wonder if you really do love me so in your heart’.” ological and psychological explanations for the variety Theophrastus’ book exerted much influence in the 17th of personality types. The effect of the combination of and 18th century in Western Europe, where it prompted “blood and vital essence” (Chinese: 血氣; pinyin: xuè-qì) much literature on character description. There is a well- on temperament are mentioned in the Analects (XVI, known French translation by La Bruyère (Paris, 1688). 7), a collection of sayings attributed to Confucius (551– Because of Theophrastus, European languages have 479 BCE)1: adopted the term character. As suggested by the etymol- The gentleman guards against three things: when he is ogy of the Greek χαρακτήρ (instrument for marking or young, and his blood and vital essence (xuè-qì) are still graving, impress, stamp), character refers to a permanent unstable, he guards against the temptation of female or long-standing mode of functioning that is inscribed in beauty; when he reaches his prime, and his blood and vital the fabric of the person, like a coin that has been stamped. essence have become unyielding, he guards against being Long before DSM-III, the permanence of traits has been contentious; when he reaches old age, and his blood and part of the definition of a personality disorder, although vital essence have begun to decline, he guards against being certain personality disorders may be acquired to some acquisitive. degree, and are amenable to change as a result of treat- In this text, temperament is understood as variable, sub- ment. ject to variations induced by age. We might interpret Besides “character,” other terms such as “temperament” “blood and vital essence” as a physiological-psycholog- and “personality” were well also defined by the 18th cen- ical theory of human temperaments.2 The physiological tury. According to the Encyclopédie, the very influential element is the blood (xuè) and the substances that are French-language encyclopedia edited between 1751 and contained in it, whereas the psychological element is rep- 1772 by Denis Diderot and Jean d’Alembert,4 tempera- resented by “qì,” the immaterial energy that imparts ment (temperament) originates from the natural consti- 148 14_CH_8001_BA_INTERIEUR.qxd:DCNS#55 3/06/13 18:03 Page 149 History of personality disorders - Crocq Dialogues in Clinical Neuroscience - Vol 15 . No. 2 . 2013 tution of the individual. The definition goes on to men- sonality disorder in psychiatric nosology. In his Traité tion the four temperaments described by the Greco- médico-philosophique sur l’aliénation mentale ou la manie,8 Roman physician Galen, on the basis of the four humors Pinel introduced a category termed “manie sans délire” of the Hippocratic school: phlegmatic, sanguine, melan- (mania without delusion). At that time, “mania” referred cholic, and choleric. This illustrates how humoral theo- to states of agitation. Pinel described a few male patients ries of personalities remained influential well into the who appeared normal to the lay observer. Indeed, “with- 18th century. According to the Oxford English out delusion” meant, in Pinel’s depiction, that the patients Dictionary, the term “personality” has been used since did not present with abnormalities of understanding, per- the 18th century to designate the distinctive individual ception, judgment, imagination, memory, etc. However, qualities of a person. Personality traits are a continuum, they were prone to fits of impulsive violence, sometimes ranging from the normal to the pathological. However, homicidal, in response

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