Module I: History and epidemiology of personality disorders

Overview and concept of personality disorders

Historical evolution of clusters of personality disorders

Systems of Classification: DSM 5, ICD-10, similarities and differences in personality

disorders

Epidemiology of different types personality disorders

Questionsx

1. What is PD? The concepts of PD

2. Cluster of personality. 1 or 2 lines on them. Understanding on 3 types

3. Classification of dsm 5

4. Similarities and differences of icd-10 and dsm-5 personality disorders

5. Similarities and differences in personality disorders

6. Models of personality

- cognitive model

- Psychoanalytic

1. What is PD? The concepts of PD

Definitions

● “People with a personality disorder have unusual ways of thinking about themselves and

others (cognitive features), experiencing expressing emotions (affective features),

interacting with others (interpersonal features) and controlling impulses (impulse

control)” Kearney & Trull 2017

 ● “Ingrained patterns of relating to other people, situations and events with a rigid and

maladaptive pattern of inner experience and behaviour dating back to adolescence or

early adulthood.” Whitbourne & Krauss (2017)

Concept

● Some people show extreme levels of personality traits that cause problems. E.g.,

people who have trouble controlling their emotions, who always fight with family

members, or who are impulsive or suspicious of others

● However, many people with intense personality traits still function fairly well because

others tolerate their idiosyncrasies or because their behavior does not significantly

interfere with their job or family life

● Intense personality traits can even be adaptive, as when someone who is overly pushy

does well in a sales career

● People with extreme levels of personality traits that cause great impairment in

functioning, especially social and occupational functioning, have a personality disorder

Extreme PT - significant distress - PD

Intense PT - no distress- function properly

● Personality disorders lie at the end of a dimensional spectrum

● E.g., someone who is overly suspicious→Suspiciousness is a personality trait with

cognitive (“Other people want to hurt me”), affective (angry or hostile outbursts),

and interpersonal (keeping others at “arm’s length”) features

● Personality disorders involve stable, long-standing, and inflexible traits – are a key

aspect of personality disorder

● E.g., someone’s impulsive behaviour at a party – being spontaneous & taking some risks

might seem normal in this situation. Being impulsive and goofing around at a job site or

during a funeral, however, would be maladaptive & inappropriate

● People with a personality disorder have great difficulty changing their behavior from

one situation to another and from one interpersonal context to another

● Such inflexibility causes significant distress or impairment in social , occupational, or

other areas of functioning

● Personality disorders involve traits that deviate significantly from the expectations of a

culture. This is important to remember because what may appear to be strange or deviant

from the perspective of one culture may be quite normal and adaptive in another (Skodol,

2012; Wakeeld, 2012)

● For a personality disorder to be diagnosed, the person’s enduring pattern of behavior

must be pervasive & inflexible, as well as stable & of long duration

● It must also cause either clinically significant distress or impairment in functioning and

be manifested in at least two of the following areas: cognition, affectivity,

interpersonal functioning, or impulse control

● From a clinical standpoint, people with personality disorders often cause at least as

much difficulty in the lives of others as they do in their own lives

● Other people tend to find the behaviour of individuals with personality disorders

confusing, exasperating, unpredictable, &, to varying degrees, unacceptable

2. Cluster of personality
 Cluster A - Odd & Eccentric:

● These disorders are generally marked by difficult social interaction and thoughts that

don’t conform to reality.

● Individuals find it difficult to relate to other people.

● They are viewed as odd and eccentric by other people.

● Eccentric behavioral symptoms - that is, behaviour that may be strange, erratic,

awkward, and isolating.

● Individuals with Cluster A PD have limited emotional expression

1. Paranoid

● Paranoid personality disorder is characterized by a pervasive distrust of others,

including even friends, family, and partners.

● As a result, this person is guarded, suspicious, and constantly on the lookout for clues

or suggestions to validate his fears.

● He also has a strong sense of personal rights: He is overly sensitive to setbacks and

rebuffs, easily feels shame and humiliation, and persistently bears grudges.

● Unsurprisingly, he tends to withdraw from others and to struggle with building close

relationships.

● The principal ego defense in paranoid PD is projection, which involves attributing

one’s unacceptable thoughts and feelings to other people.

● A large, long-term twin study found that paranoid PD is modestly heritable, and that it

shares a portion of its genetic and environmental risk factors with schizoid PD and

schizotypal PD.

● Individuals with PPD tend to be excessively suspicious and distrustful of others, often

without sufficient basis.

● They may interpret benign remarks or actions as malevolent and hold persistent

grudges.

● People with PPD are hypervigilant to perceived threats and may be reluctant to confide

in others due to fear of betrayal. Their suspiciousness can strain relationships and lead to

social isolation.

2. Schizoid
● The term "schizoid" designates a natural tendency to direct attention toward one’s

inner life and away from the external world.

● A person with schizoid PD is detached and aloof and prone to introspection and

fantasy.

● He has no desire for social or sexual relationships, is indifferent to others and to social

norms and conventions, and lacks emotional response.

● A competing theory about people with schizoid PD is that they are in fact highly

sensitive with a rich inner life: They experience a deep longing for intimacy, but find

initiating and maintaining close relationships too difficult or distressing, and so

retreat into their inner world.

● People with schizoid PD rarely present to medical attention, because despite their

reluctance to form close relationships, they are generally well functioning and quite

untroubled by their apparent oddness.

3. Schizotypal

● Schizotypal PD is characterized by oddities of appearance, behavior, and speech,

unusual perceptual experiences, and anomalies of thinking similar to those seen in

schizophrenia.

● These latter can include odd beliefs, magical thinking (for instance, thinking that

speaking of the devil can make him appear), suspiciousness, and obsessive

ruminations.

● People with schizotypal PD often fear social interaction and think of others as

harmful.
● This may lead them to develop so-called ideas of reference — that is, beliefs or

intuitions that events and happenings are somehow related to them.

● So whereas people with schizotypal PD and people with schizoid PD both avoid social

interaction, with the former (schizotypal) it is because they fear others, whereas with

the latter (schizoid) it is because they have no desire to interact with others or find

interacting with others too difficult.

● People with schizotypal PD have a higher than average probability of developing

schizophrenia, and the condition used to be called "latent schizophrenia."

Cluster B - Dramatic, Erratic, Emotional, Impulsive

● Cluster B personality disorders are on the other end of the spectrum from Cluster A’s

limited emotional expression.

● Personality disorders are considered highly emotional and dramatic, while at the same

time being extremely unpredictable.

● They tend to be impulsive and erratic.

1. Antisocial

● Antisocial PD is much more common in men than in women and is characterized by a

callous unconcern for the feelings of others.

● The person disregards social rules and obligations, is irritable and aggressive, acts

impulsively, lacks guilt, and fails to learn from experience.

● In many cases, he has no difficulty finding relationships — and can even appear

superficially charming (the so-called "charming psychopath") — but these

relationships are usually fiery, turbulent, and short-lived.

● As antisocial PD is the mental disorder most closely correlated with crime, he is likely

to have a criminal record or a history of being in and out of prison.

2. Borderline

● In borderline PD (or emotionally unstable PD), the person essentially lacks a sense of

self and, as a result, experiences feelings of emptiness and fears of abandonment.

● There is a pattern of intense but unstable relationships, emotional instability,

outbursts of anger and violence (especially in response to criticism), and impulsive

behavior.

● Suicidal threats and acts of self-harm are common, for which reason many people with

borderline PD frequently come to medical attention.

● Borderline PD was so called, because it was thought to lie on the "borderline" between

neurotic (anxiety) disorders and psychotic disorders, such as schizophrenia and

bipolar disorder.

● It has been suggested that borderline personality disorder often results from childhood

sexual abuse, and that it is more common in women, in part because women are more

likely to suffer sexual abuse.

● However, feminists have argued that borderline PD is more common in women, because

women presenting with angry and promiscuous behavior tend to be labeled with it,

whereas men presenting with similar behaviour tend instead to be labeled with antisocial

PD.

3. Narcissistic

● In narcissistic PD, the person has an extreme feeling of self-importance, a sense of

entitlement, and a need to be admired.

● He is envious of others and expects them to be the same as him.

● He lacks empathy and readily lies and exploits others to achieve his aims.

● To others, he may seem self-absorbed, controlling, intolerant, selfish, or insensitive.

● If he feels obstructed or ridiculed , he can fly into a fit of destructive anger and revenge.

Such a reaction is sometimes called "narcissistic rage" and can have disastrous

consequences for all those involved.

4. Histrionic

● People with histrionic PD lack a sense of self-worth and depend on attracting the

attention and approval of others for their wellbeing.

● They often seem to be dramatizing or "playing a part" in a bid to be heard and seen.

● Indeed, "histrionic" derives from the Latin histrionicus, "pertaining to the actor."

● People with histrionic PD may take great care of their appearance and behave in a

manner that is overly charming or inappropriately seductive.

● As they crave excitement and act on impulse or suggestion, they can place themselves at

risk of accident or exploitation.

● Their dealings with others often seem insincere or superficial, which in the longer term

can adversely impact their social and romantic relationships.

● This is especially distressing to them, as they are sensitive to criticism and rejection

and react badly to loss or failure.

● A vicious circle may take hold in which the more rejected they feel, the more histrionic

they become — and the more histrionic they become, the more rejected they feel. It

can be argued that a vicious circle of some kind is at the heart of every personality

disorder and, indeed, every mental disorder.

 Cluster C - Anxious, fearful

● Personality disorders are focused on anxiety and fearful thoughts and behaviors.

● Personality disorders are afraid of specific things and avoid confronting those fears.

● This behavior leads to trouble in interpersonal relationships.

1. Avoidant

● People with avoidant PD believe that they are socially inept, unappealing, or inferior,

and constantly fear being embarrassed, criticized, or rejected.

● They avoid meeting others unless they are certain of being liked and are restrained even

in their intimate relationships.

● Avoidant PD is strongly associated with anxiety disorders, and may also be associated

with actual or felt rejection by parents or peers in childhood.

● Research suggests that people with avoidant PD excessively monitor internal reactions,

both their own and those of others, which prevents them from engaging naturally or

fluently in social situations.

● A vicious circle takes hold in which the more they monitor their internal reactions,

the more inept they feel; and the more inept they feel, the more they monitor their

internal reactions.

2. Dependent

● Dependent PD is characterized by a lack of self-confidence and an excessive need to be

looked after.

● This person needs a lot of help in making everyday decisions and surrenders important

life decisions to the care of others.

● He greatly fears abandonment and may go through considerable lengths to secure and

maintain relationships.

● A person with dependent PD sees himself as inadequate and helpless, and so surrenders

his personal responsibility and submits himself to one or more protective others.

● He imagines that he is at one with these protective other(s), whom he idealizes as

competent and powerful, and towards whom he behaves in a manner that is ingratiating

and self-effacing.

● People with dependent PD often end up with people with a cluster B personality disorder,

who feed on the unconditional high regard in which they are held.

● Overall, people with dependent PD maintain a naïve and child-like perspective and

have limited insight into themselves and others.

● This entrenches their dependency, leaving them vulnerable to abuse and exploitation.

3. Obsessive Compulsive PD

● characterised by an excessive preoccupation with details, rules, lists, order,

organization, or schedules.

● Perfectionism is so extreme that it prevents a task from being completed; and devotion

to work and productivity at the expense of leisure and relationships.

● A person with anankastic PD is typically doubting and cautious, rigid and controlling,

humorless, and miserly.

● His underlying anxiety arises from a perceived lack of control over a world that

eludes his understanding, and the more he tries to exert control, the more out of

control he feels.
 ● As a consequence, he has little tolerance for complexity or nuance, and tends to

simplify the world by seeing things as either all good or all bad.

● His relationships with colleagues, friends, and family are often strained by the

unreasonable and inflexible demands that he makes upon them.

3. Similarities And Differences Of Icd-10 And Dsm-5 Personality Disorders

Similarities are within the cluster. Differences are within the clusters and between the disorders

ICD-10: 8 PD

- Paranoid personality disorder

- Schizoid PD

- Dissocial PD (DSM antisocial)

- Emotionally unstable personality disorder

- Impulsive type

- Borderline type

- Histrionic PD

- Anankastic PD (dsm 5 ocpd)

- Anxious PD (dsm avoidant)

- Dependent PD

No schizotypal and Narcisstic in ICD

DSM V

Cluster A

- Paranoid

- Schizoid
 - Schizotypal Personality Disorders.

Cluster B

- Borderline personality disorder

- Histrionic personality disorder

- Narcissistic personality disorder

- Antisocial personality disorder

Cluster C

- Avoidant PD

- Dependent PD

- Obsessive Compulsive PD

Classification of DSM 5

- General diagnostic criteria of PD

- Specific Cluster - explain the differences and similarities and Diagnostic criteria

ICD-10 (International Classification of Diseases, 10th Revision) and DSM-5 (Diagnostic and

Statistical Manual of Mental Disorders, 5th Edition) are two widely used classification systems

for diagnosing mental disorders, including personality disorders. Here are the similarities and

differences between ICD-10 and DSM-5 regarding personality disorders:

Similarities:

1. Classification of Personality Disorders:

● Both ICD-10 and DSM-5 provide classifications for various personality disorders.

They recognize similar types of personality disorders, such as borderline personality

disorder, narcissistic personality disorder, and antisocial personality disorder.

2. Diagnostic Criteria:

● Both systems outline specific diagnostic criteria for each personality disorder,

including patterns of behavior, thoughts, and feelings that are characteristic of each

disorder.

3. Focus on Dysfunction:

● Both systems emphasize the presence of dysfunctional patterns of behavior, cognition,

and inner experience that deviate significantly from cultural norms and cause

impairment in social, occupational, or other important areas of functioning.

Differences:

● Schizotypal disorder is classified in the section on schizophrenia in ICD-10

● Narcissistic personality disorder is not included in ICD-10

● In DSM borderline is a single category while it is a subtype of emotionally unstable

personality disorder (EUPD) in ICD-10

● Impulsive personality disorder is in ICD-10 as a subtype of EUPD while in DSM-5 it is

included in the group Disruptive Impulse-Control and Conduct Disorders, separate

from personality disorder

1. Number of Disorders:

● ICD-10 recognizes fewer specific personality disorders compared to DSM-5, 8

Personality Disorder.

● For example, ICD-10 includes dissocial personality disorder (equivalent to antisocial

personality disorder in DSM-5) and anankastic personality disorder (equivalent to

 obsessive-compulsive personality disorder in DSM-5), but it does not include specific

disorders like avoidant personality disorder or narcissistic personality disorder.

2. Categorical vs. Dimensional Approach:

● DSM-5 takes a dimensional approach to personality disorders, which means it

emphasizes the severity and range of symptoms across a continuum rather than rigid

categories.

● In contrast, ICD-10 uses a more categorical approach, where personality disorders are

defined by specific sets of criteria, without as much consideration for varying levels of

severity.

3. Cultural Considerations:

● ICD-10 tends to place more emphasis on cultural factors in the diagnosis of

personality disorders compared to DSM-5. This reflects the World Health Organization's

broader international perspective, which takes into account cultural variations in the

expression of mental disorders.

4. Terminology and Criteria:

● While both systems generally describe similar patterns of behavior for each personality

disorder, there are differences in the specific terminology and diagnostic criteria used.

● For example, the diagnostic criteria for borderline personality disorder in ICD-10 may

differ slightly from those in DSM-5, even though they describe the same underlying

condition.

5. Axis

● ICD-10 Classification of Mental and Behavioural Disorders does not distinguish them

either and classifies them on a single axis

 ● Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric

Association, 1994) classified personality disorder on a separate axis from mental state

disorders.

Historical evolution of clusters of personality disorders

Confucius - Blood and Vital Essence

● The effect of the combination of “blood and vital essence” on temperament are

mentioned in the Analects (XVI, 7), a collection of sayings

● Blood and vital essence” can be interpreted as a physiological- psychological theory

of human temperaments

● The physiological element is the blood and the substances that are contained in it,

whereas the psychological element is the immaterial energy that imparts activity and

movement to the substances it penetrates, according to traditional Chinese philosophy

Theophrastus

● The first system of personality types in the Greco-Roman world was expounded in a

book called The Characters, by the Greek philosopher Theophrastus

● His book contains 30 descriptions that are all organized along the same structure; the

character type is first named, then briefly defined in one short sentence, and finally

illustrated by a list of about ten examples showing how the person will typically react

in different life situations

1. Character - definition

Examples:
 ● This is in line with the notion, emphasized since DSM-III, that personality is revealed by

a fixed pattern of reacting to various life circumstances

● For instance, the “Suspicious Man,” is analogous to today’s paranoid personality; he is

defined by the sentence “he believes that everybody is fraudulent,” and further described

by typical patterns such as “The suspicious man is the sort of person who sends a servant

to market and then sends another to watch him and find out the price he pays.”

● The “ Thankless Man” always sees the negative aspects and is incapable of enjoying

life; he is presenting traits that might be qualified today as anhedonia, resentfulness, and

negativism

For instance, “when his sweetheart kisses him, he says ‘I wonder if you really do love me

so in your heart.’ ”

● Theophrastus’ book exerted much influence in the 17th and 18th century in Western

Europe, where it prompted much literature on character description

● There is a well known French translation by La Bruyère (Paris, 1688). Because of

Theophrastus, European languages have adopted the term character

● Long before DSM-III, the permanence of traits has been part of the definition of a

personality disorder, although certain personality disorders may be acquired to some

degree, and are amenable to change as a result of treatment

● Besides “character,” other terms such as “temperament” and “personality” were well also

defined by the 18th century

Denis Diderot and Jean d’Alembert

 ● According to the Encyclopédie, the very influential French-language encyclopedia

edited between 1751 and 1772 by Denis Diderot and Jean d’Alembert, temperament

originates from the natural constitution of the individual

● The definition goes on to mention the four temperaments described by the Greco-

Roman physician Galen, on the basis of the four humors of the Hippocratic school:

phlegmatic, sanguine, melancholic, and choleric

● This illustrates how humoral theories of personalities remained influential well into

the 18th century

● According to the Oxford English Dictionary, the term “personality” has been used

since the 18th century to designate the distinctive individual qualities of a person

● Personality traits are a continuum, ranging from the normal to the pathological . However,

in current usage, personality tends to refer to the traits or qualities that are strongly

developed or strikingly displayed, rather than to usual features

● This raises the issue of defining abnormality, a task complicated by the fact that the same

terms are often used to designate both normal personality traits and psychiatric diagnoses

Galen

● The definition goes on to mention the four temperaments described by the Greco-

Roman physician Galen, on the basis of the four humours of the Hippocratic school:

phlegmatic, sanguine, melancholic, and choleric

● This illustrates how humoral theories of personalities remained influential well into the

18th century

● According to the Oxford English Dictionary, the term “personality” has been used since

the 18th century to designate the distinctive individual qualities of a person.

 Humor Temperament Characteristics

Blood Sanguine (excess blood) Courageous, Hopeful, Amorous,

Yellow Bile choleric Short tempered, ambitious,

Black Bile Melancholic Introspective, Sentimental

Phlegm Phlegmatic Calm, unemotional

Personality & the Birth of Psychiatry

Phrenology

● Psychiatry, as a medical science, began to take shape toward the end of the 18th

century. One very popular way of describing personality characteristics at that time was

phrenology

● Although this science is now discredited, it was a sincere attempt to describe personality

on a neuroanatomical basis

● Phrenology is associated with Franz Joseph Gall (1758–1828) a German physician

who was active in Vienna and ultimately settled in Paris

● However, it was Johann Gaspar Spurzheim, an associate of Gall, who coined the

term phrenology

● Progress in neuroanatomy led to the hypothesis that personality traits have their basis

in the cerebral cortex where they could be localised with precision.

● Phrenology models indicated the location of many personality facets of cranial

● Phrenology remains an important milestone.

 ● For instance, combativeness, or courage and the tendency to fight, were located behind

the ear and above the mastoid process; self- esteem, “was placed at the top, or crown

of the head, precisely at the spot from which the priests of the Roman Catholic Church

are obliged to shave the hair”; cautiousness was situated nearly in the middle of the

parietal bones; and conscientiousness was located next to cautiousness

● The concept of phrenology started losing its appeal in the middle of the 19th century.

However, it remains an important milestone in the development of psychiatry, since it

highlighted the role of the cerebral cortex

Philippe Pinel

● According to most historians of psychiatry, Philippe Pinel (1745- 1826) was the first

author to include a personality disorder in psychiatric nosology

● Nosology : the branch of medical science dealing with the classification of diseases.

● In his Traité médico-philosophique sur l’aliénation mentale ou la manie, Pinel introduced

a category termed “manie sans délire” (mania without delusion). At that time, “mania”

referred to states of agitation

● Pinel described a few male patients who appeared normal to the lay observer. Indeed,

“without delusion” meant, in Pinel’s depiction, that the patients did not present with

abnormalities of understanding, perception, judgment, imagination, memory, etc

● However, they were prone to fits of impulsive violence, sometimes homicidal, in

response to minor frustration. One such patient grappled a woman who had insulted him,

and threw her into a well

 ● Pinel considered that a possible etiology of such cases was “a deficient and ill directed

upbringing of the child, or an undisciplined or perverse nature ... [for instance in] an only

son, raised by a weak and permissive mother”

● Subsequent French alienists and psychologists retained an interest in the conditions that

were characterized by peculiarities in the expression of emotions and behaviors, in the

absence of delusions, hallucinations, and without disorders of the intellect

Jean-Étienne Dominique Esquirol

● Jean-Étienne Dominique Esquirol (1772–1840) introduced the concept monomanie

raisonnante, which he illustrated with a motley collection of clinical cases; a few of

those cases would still be considered personality disorders today

● Esquirol also acknowledged Prichard, noting that monomanie raisonnante was similar

to the moral insanity described by James Cowles Prichard (1786-1848)

● Moral insanity refers to a type of mental disorder consisting of abnormal emotions and

behaviours in the absence of delusions, hallucinations or intellectual impairment.

● Prichard was born into a Quaker family and knew many foreign languages, including

French, which may explain his interest for French psychiatry and allowed him to

reappraise Pinel’s work

● Neither Esquirol’s monomania raisonnante, nor Prichard’s moral insanity, were well

delimited; they included a heterogeneous collection of cases that would fall under a

variety of modern diagnostic categories today

● As would be the case for Kraepelin later, many cases that captured the interest of both

Esquirol and Prichard had forensic consequences

 ● This shows that the practical question was whether psychiatry could explain patterns of

abnormal behavior, in subjects with a normal intellect and no acute psychiatric symptoms

who had come into contact with the law

● The period between the late 19th century and early 20th century was marked by the

emergence of several elaborate systems of normal and abnormal personality, associating

to some degree types and dimensions

Théodule Ribot

● Théodule Ribot (1839-1916), a French psychologist known for coining the term

“Anhedonia,” wrote on normal and abnormal characters

● Ribot’s treatise was translated into English within a year (the Psychology of Emotions,

1897), and English-speaking contemporaries were familiar with his ideas

● Like his predecessors, Ribot stressed that character is stable, appearing in childhood and

lasting all life

● Ribot’s classification had “subtypes,” defined by the association of several “primary

types.” Ribot’s terminology is antiquated, but his system becomes more limpid when one

realizes that he is, in fact, describing dimensions

Normal personality was characterized by the three following primary types:

1. The sensitive or emotional, whose nervous system was easily impressed by pleasant or

unpleasant emotions, and whose feelings were introverted

2. The active, who were extraverted, spontaneous, and courageous

3. The apathetic, corresponding to the lymphatic of the humoral classification, who

displayed little propensity to excitation and reaction

These three primary categories were further subdivided into various “subtypes,” according to

the association of several dimensions

For instance, the sensitive were subdivided into:

1. The humble, with limited intelligence and energy

2. The contemplative, who showed sensitivity, a keen intellect, and little activity (Hamlet,

indecisive, was given as an example)

3. The emotional, stricto sensu

● Among the active, the association of high activity, high intelligence, and little sensitivity

could produce historical figures such as empire builders (Ribot mentioned Hernan Cortez

and Pizarro)

● Subjects associating apathy with intelligence were good at strategy and unemotional

reasoning (e.g., Benjamin Franklin, or Philip II of Spain)

● It is noteworthy that intelligence was an important modifier of personality according to

Ribot; later authors would also stress this

Gerard Heymans

● Gerard Heymans (1857–1930) was a professor of philosophy and psychology at the

University of Groningen (in the Netherlands). He co authored articles with Enno Dirk

Wiersma (1858–1940), a professor of psychiatry at the same university

● Heymans was one the first to apply empirical methods to the study of personality.

● He wrote his habilitation in Freiburg im Breisgau (Germany), and introduced Wilhelm

Wundt’s methods of experimental psychology into the Netherlands

● The “Cube of Heymans” that constructs personality types on the basis of dimensions

represents his description of personalities

 ● Heymans defined three bipolar dimensions: activity level, emotionality, and primary

vs secondary functioning (i.e., functioning immediately vs according to plans)

● These three dimensions are represented on the x-, y- and z-axes of the Heymans cube

● All possible combinations of the three dimensions defined eight personality types,

represented at the eight extremities of the cube

● The eight types are: amorphous, sanguine, nervous, choleric, apathetic, phlegmatic,

sentimental, and passionate

● Heymans’ terminology, obviously inspired by Greek medicine, constitutes a link between

ancient schools and modern experimental psychology

Aleksandr Fyodorovich Lazursky

● Aleksandr Fyodorovich Lazursky (1874-1917) was a psychologist in Saint Petersburg

(Russia), where he studied under Bekhterev

● He developed one of the first comprehensive theories of personality and had very creative

intuitions

● His work did not enjoy international recognition, probably because of the author’s early

death, the fact that he published in Russian, and because historical upheavals isolated his

country from international scientific contacts after his death

● Like others, he described personality as a stable and long-lasting ensemble. Lazursky’s

first original contribution was his distinction between “endopsychic” and

“exopsychic” aspects of personality

● Endopsychic features comprise the traditional psychological functions (e.g., memory,

representations, attention) that are largely innate or inherited “Temperament” (associated

with physiological processes) and “character” (linked to the exercise of will and reason)

belong to the “endopsychic” core of personality

● Exopsychic becomes Endopsychic at some point

● In contrast, exopsychic characteristics result from the favourable or unfavourable

reciprocal interactions between the personality and the outside world; they are

influenced by the person’s interests and are capable of evolving

● The endopsychic sphere has to do with the psychological and neurological constitution.

In contrast, the exopsychic interface encompasses psychosocial elements, the

consequences of upbringing and education, and the individual’s adaptive capacity

● The individual acquires a few exopsychic traits – such as the attitude toward work and

property, and the vision of the world – but they become as durable as the endopsychic

personality traits
 ● The interaction between the endo- and exopsychic spheres determines three levels of

functioning (inferior, intermediate, superior)

● Individuals functioning at an inferior level are personalities that are weak, ungifted,

poorly organized; they have difficulties adjusting to the environment; their life is guided

by exterior factors and not by their endopsychic capacities (exopsychic)

● Individuals functioning at an intermediate level are more able to use the environment for

their purposes; they can find an occupation that corresponds to their inclination; they

achieve higher levels of comfort and more freedom of initiative; in the end, they are more

useful to society (both)

● Highly gifted, talented people functioning at a superior level can develop their creativity

even in unfavourable circumstances; they not only adjust to the environment, but

they even actively adapt the environment to their needs (endopsychic)

Personality Dimensions & Personality Types in Contemporary Psychiatry

Emil Kraepelin

● Emil Kraepelin (1856–1926) introduced personality types into modern psychiatric

classification, under the term “psychopathic personalities”

● At the beginning of the 20th century, in German-speaking psychiatry, the meaning of the

term “psychopathy” was limited from the broad notion of mentally ill to the more

restricted abnormal personality

● Kraepelin stressed the existence of a broad overlap between overt pathological

conditions and personal features that are encountered in normal people. He noted

that the limit between pathological and normal is gradual and arbitrary
● In entering the field of personality, psychiatry was taking an interest in conditions that

were not previously considered to be liable to psychiatric interpretation

● In the 7th edition of his textbook, Kraepelin assumed that psychopathic personalities

were the consequence of a faulty constitution, which had previously been approached

under the ill- defined concept of degeneracy

● Encouraged categorical model - DSM

● Psychopathic personalities result from a psychological inborn “defect,” which

explains why the symptoms of psychopathic personalities have always been present in

the individual and persist with little modification during his or her whole life

● Their pathological nature is not deduced from the fact the symptoms appear in the patient

after a period of normal functioning, but rather from the fact that symptoms deviate from

the range of normalcy

● Patients with psychopathic personalities often have good cognitive capabilities, but

their affects and emotions are problematic

● In the 7th edition of Kreapelin’s textbook, the list of pathological personalities comprised

only four types:

1. The born criminal (der Geborene Verbrecher), modeled on earlier description by Cesare

Lombroso (l’uomo delinquente) and James C. Prichard (moral insanity)

2. The irresolute or weak-willed (die Haltlosen), who are unable of applying themselves to

sustained and long-term work

3. The pathological liars and swindlers (die krankhaften Lügner und Schwindler) whose

disorder is due to hyperreactive imagination, unfaithful memory, an unstability of

emotions and willpower

 4. The pseudoquerulants (die Pseudoquerulanten) who correspond to today’s paranoid

personality

● The prefix “Pseudo” was meant to differentiate this personality from the delusional

disorder of the same name. In the 8th edition (1915), the list was expanded to seven

types:

1. The excitable (die Erregbaren), possibly sharing some characteristics with today’s

borderline personality disorder

2. The irresolute

3. Persons following their instincts (Triebmenschen) such as periodic drinkers and pleasure

lovers

4. Eccentrics (Verschrobene)

5. Pathological liars and swindlers

6. Enemies of society (Gesellschaftsfeinde)

7. The quarrelsome (die Streitsüchtige)

● Kraepelin studied patients whose symptoms had consequences on social adaptation, and

for whom a psychiatric opinion might be sought after some problem with the law

● Most of Kraepelin’s personality types do not correspond to DSM-IV- TR categories

Kurt Schneider

● Kurt Schneider (1887–1967) described several “psychopathic” (i.e. abnormal)

personalities in the successive editions of his textbook

● Schneider’s various types of psychopaths are as follows:

1. The hyperthymic (Hyperthymische)

2. The depressive
3. The insecure (Selbstunsichere)

4. The fanatical (Fanatische)

5. The recognition-seeking (Geltungsbedürftige)

6. With labile mood (Stimmungslabile)

7. Explosive (Explosible)

8. Emotionally-blunted (Gemütlose) 9. The weak-willed (Willenlose) [Link] asthenics

(Asthenische)

● Kurt Schneider stated several key concepts that are still valid. He defined

“psychopathic” personalities as those individuals who suffer, or cause society to

suffer, because of their personality traits

● Abnormal personalities are largely inborn constitutions, but they can evolve as a

result of personal development or outside influences

● Kurt Schneider made an observation that is extremely relevant to the debate surrounding

the preparation of DSM-5

● He noted that a hybrid system of personality, associating dimensions of normal

personality and pathological types, was an artificial construction

● One could build a “characterological system” describing normal human personality

dimensions, but it would be meaningless to derive clinically relevant abnormal types

from the exaggerations of these normal personality dimensions

● He remarked that characterological systems would produce mostly bipolar dimensions,

such as “explosive-unexcitable” or “weak-willed- strong-willed.

● However, the clinically relevant abnormal personality types could not be accommodated

at the extremities of these axes

 ● He was against the dimension of categorical model. From dsm 3, they used his idea

Sigmund Freud

● Sigmund Freud (1856–1939) was born in the same year as Kraepelin, which is their only

shared characteristic

● Psychoanalysts reshaped contemporary thinking by centering their attention on the

impact of early life events

● In addition, they assumed that these early events remained out of awareness, kept

unconscious, owing to their potentially troublesome character

● It was Sigmund Freud, Karl Abraham, and Wilhelm Reich who laid the foundation of

the psychoanalytic character typology

● The first model of a psychoanalytic approach to a faulty personality is Freud’s paper

on “Character and anal erotism,” published in 1909

● Before this, Freud had already associated money and miserliness with excrements in a

letter to Fliess in 1897

● Freud established a connection between character traits and childhood experiences

● He described patients who are especially “orderly, parsimonious and obstinate.” These

three character traits were interrelated

● When exploring the early childhood of these patients, Freud had the impression that they

had belonged to the “class who refuse to empty their bowels when they are put on the pot

because they derive a subsidiary pleasure from defecating”

● He postulated that such people were born with a sexual constitution in which the

erotogenicity of the anal zone was exceptionally strong

 ● This description of the compulsive personality by Freud opened the way for the

subsequent psychoanalytic definitions of other personality types

● The classification of personality disorders in DSM-II was influenced by

psychoanalysis, at least as regards terminology

Raymond Cattel

● Modern dimensional systems of personality are based on the statistical analysis of the

many thousands of adjectives that are used to describe personality in all languages

● The pioneer of this approach, Raymond Bernard Cattell (1905-1998), was a British-born

psychologist who moved to the USA

● Believing that psychology should be based on measures, he pioneered the use of statistics

to discover personality dimensions

● With the help of correlation and factor analyses, made possible by the first computers, he

grouped the multitude of terms usually used to describe personality into a smaller number

of traits

● Cattell discovered a variable number of “source traits” arranged along bipolar

dimensions

● The number of these source traits varied as Cattell’s work evolved; they amounted to

sixteen in the final versions of his system

● Initially, Cattell chose to name these dimensions with letters, in alphabetical order,

starting with A for the factor accounting for the most variance, B for the next one, etc

● He reasoned that it was more prudent to use letters to name these dimensions, in the same

way as biologists had used letters to name vitamins, since giving names would entail a

risk of erroneously interpreting dimensions whose true nature was unknown

 ● Cattell’s factor B (bright, abstract thinking versus dull, concrete thinking) is supposed to

be similar to Charles Spearman’s g factor, measuring general intelligence

● Cattell coined a few words to name his source traits. For instance, he adopted “surgent”

to designate a distinct type characterized by resourcefulness, responsiveness, joyfulness,

and sociability

● The word “surgent,” from the Latin surgo, conveys the idea of “leaping” or “rising up”

with facility. Systems of personality have been described with a varying number of

dimensions, often with three or five dimensions

DSM

● The long history of personality theories The most successful dimensional model is the

five-factor model, which was adapted for the dimensional description of personality

in DSM-5

● helps put DSM classifications of personality disorders into perspective

● DSM-II (1968) was influenced by psychoanalysis; in DSM-II, some personality

disorders had to be differentiated from the neuroses of the same name (eg, hysterical,

obsessive-compulsive, and [neur]asthenic personalities and neuroses)

● In DSM-III (1980), and the subsequent DSM-III-R (1987) and DSM-IV (1994),

personality disorders were described as discrete types, grouped into three clusters, placed

on a separate axis (axis II)

● This categorical approach was in line with the medical model advanced by Emil

Kraepelin

● Borderline and narcissistic personality disorders, which entered DSM- III, were adapted

from psychoanalytic concepts

● The preparation of DSM-5 questioned the merits of combining typological and

dimensional models of personality, reopening a century-old debate

Personality Disorders: Epidemiology

● Epidemiological studies suggest that somewhere between 10 and 12 percent of people

meet criteria for at least one personality disorder when the time period being asked

about is the person’s behavior over the last 2 to 5 years (Lenzenweger, 2008;

Torgersen, 2012)

● When we consider the DSM clusters, we find that (Togersen, 2012):

○ Cluster C disorders are most common, with a prevalence of around 7%

○ Cluster A disorders are next, with a prevalence of approximately 4%

 ○ Finally, the prevalence of Cluster B disorders is slightly lower, in the range of

3.5 to 4%

Cluster C > Cluster A > Cluster B

● Due to the high comorbidity between clusters, some individuals meet criteria for

personality disorders in more than one cluster, so the percentage of people in each

cluster adds up to more than 10 to 12%

● Personality disorders are often associated with (or comorbid with) anxiety disorders,

mood disorders, substance use problems, and sexual difficulties & disorders (Hooley,

Butcher, Nock, & Mineka, 2017)

● One summary of evidence estimated that about three-quarters of people diagnosed with

a personality disorder also have another disorder as well (Dolan-Sewell et al., 2001)

● Among people with antisocial personality disorder, the lifetime prevalence rate of

alcohol dependence is 27 % and 59 % for nicotine dependence (Trull, Jahng, Tomko,

Wood, & Sher, 2010)

Countries And Culture

● A lower prevalence of PDs is reported in community samples in Asian countries in

comparison to the West; in the Republic of China, at least 4.10% of the population has

one personality disorder, while in Lebanon it is 6.20% (Huang et al., 2006)

● Not only is the PD prevalence in China lower than in Western countries but also some

PDs, such as avoidant, dependent, and borderline, are not specified in the Chinese

Classification of Mental Disorders (Tang & Huang, 1995)

● Interestingly, although the worldwide prevalence of borderline PD is the highest, it is not

specified in the Chinese Classification. Borderline PD is more prevalent in the American

than Spanish or Asian populations (Grant et al., 2008)

● Comparably, avoidant PD has not been reported in India (Loranger et al., 1997)

● Another difference is that antisocial PD is identified in all cultures at a similar rate while

in Taiwan its prevalence is exceptionally low, at 0.20%, while in the USA and other

countries it is about 3.00% (Calliess et al., 2008)

● The findings in Taiwan were interpreted as reflecting cultural aspects associated with a

common tendency to negate antisocial behavior and social rules of expression towards

antisocial behaviour
 ● Asians and Filipinos express shame more frequently than Europeans and North

Americans and have a different manner of expressing fear and passiveness

● This might be attributed to some PD traits (Calliess et al., 2008). Some social attitudes

may be related to philosophical aspects; Chinese interpersonal relationships are

influenced by Confucian principles such as forgiveness, righteousness, and propriety

(Kline, Horton, & Zhang, 2008)

● On the other hand, modern societies, such as Japan, demand a high measure of

responsibility and perfectionism from an individual, which may contribute to creating a

background for PD behavior

● Cultural components of Japanese society are perfectionism, carefulness, and orderliness

(Chang, 1965). This, in turn, may be related to the high prevalence of obsessive-

compulsive PD reported in Japan, the USA, and Europe (Calliess et al., 2008)

Gupta & Mattoo (2010)

● Personality disorders had a prevalence of 1.07%, with a preponderance of those

○ aged 21–40 years (69.4%),

○ men (64.9%),

○ employed and students (37.3% and 32.8% respectively),

○ unmarried (56%),

○ graduates and undergraduates (27.6% each), and

○ referred by the family (68.7%)

● The most common personality disorders were anxious-avoidant and borderline

● Compared with the anxious-avoidant group, the borderline group was younger (mean age

24.44 vs 29.66 years) and had a preponderance of females (60% vs 27.1%)