The word “Personality” is derived from the Latin and Greek word “persona” or “prosopon”, meaning a mask worn by an actor to play certain roles or characters! The personality disorders conceptually from the ancient time until modern time, has meant deviation from the normal personality! But what has been considered a “normal personality” has been the big, not yet answered question throughout the time.

The ancient Greek philosophers such as Theophrastus described 29 ‘character’ or personality types, deviations from the norm, and Hippocrates 4 humours or character types. Physicians in the early 19th century expanded the concept to include some forms of insanity involving disturbed emotions and behaviors but seemingly without significant intellectual impairment, delusions or hallucinations, e.g. ‘manie sans délire’ or “insanity without delusion”, “moral insanity”, arguably based in part on religious, social and moral beliefs! Later on as we move into 20^th century, these moral judgments are expanded to many deviations from normal personality or behavior, mostly biased by cultural factors, e.g. the use of labels such as “psychopaths”, sadists and masochists!

In the 19th century, even prominent psychiatrists such as Emil Kraepelin, perhaps the father of modern psychiatry, used the derogatory terms, e.g. “psychopathic inferiority” in his influential work on clinical psychiatry for students and physicians. He suggested six types – excitable, unstable, eccentric, liar, swindler and quarrelsome. Kraepelin had referred to psychopathic conditions (or ‘states’) in his 1896 edition, including compulsive insanity, impulsive insanity, and even homosexuality. In fact from 1904 Kraepelin changed the section heading to ‘The born criminal’, moving it from under ‘Congenital feeblemindedness’ to a new chapter on ‘Psychopathic personalities’. Kraeplin distinguished born criminals (inborn delinquents) as pathological liars, querulous and driven by a basic compulsion. Kurt Schneider, another prominent psychiatrist at the time, criticized Kraepelin’s nosology for appearing to be a list of behaviors that he considered undesirable, rather than medical conditions, though Schneider’s alternative version has also been criticised on the same basis. Nevertheless, many essentials of these diagnostic systems were introduced into the diagnostic systems, and remarkable similarities remain in all the editions of DSM including DSM-IV, DSM 5 and ICD-10.

By the 20th century and the domination of psychoanalysis, particularly through the influence of Sigmund Freud, the concept of ‘character disorders’ or “personality disorders” were born as we know them today and were conceived as enduring problems linked not to specific symptoms but to pervasive internal conflicts or derailments of normal childhood development, different from neurosis and psychosis. Hereby the modern common terms, still existed in our current diagnostic system, such as “dependent”, “obsessive-compulsive”,“histrionic” or even “borderline” personality disorders came to common clinical use.

At the same time, psychologists were developing theories of personality, e.g. Gordon Allport with his “personality psychology” , from the 1920s, and Henry Murray with his theory of ‘personology’. Another German psychologist, Hans Eysenk classified personalities into main dimensions of Extraversion (E) and Neuroticism (N), in his 1947 book Dimensions of Personality. He somewhat based his personality dimensions, that he later on added the third dimension of “psychoticism” to Hippocrates’ four humours or personality dimensions! He formulated hippocrates’ four humours into his personality dimensions as high E and high N=Choleric type, high N and low E=Melancholic type, Low N and high E=Sanguine type and low N and low E=Phlegmatic type. Soon Eysenk with the help of his wife, expanded his theory of personality to psychological tests and measurements of such traits and beyond personality into the subject of intelligence. He believed like personality that is an inherent trait, so is the intelligence, hence some races are better than the others! Psychological tests for evaluation of personality soon became popular and in common use even to this day, e.g. the projective test of Rorshach, and the subjective questionnaire of MMPI (Minnesota Multiphasic Personality Inventory).

Theodore Millon (August 18, 1928 – January 29, 2014) , the American psychologist following the footstep of the “personality psychologists”, i.e. Gordon Allport and Henry Murray in early 20^th century, has been perhaps the modern psychologist influencing the current diagnostic classification of “personality disorders” in DSM and elsewhere. Millon’s classification of personality disorders are exacty the same as the current typology in DSM-IV and 5, except for “self-defeating (masochistic) personality” and “sadistic personality” that he labeled as “psychopathic” as well while labeling the current “antisocial personality” as “sociopathic”! Millon also had a few other extra personality disorders in his classification, i.e. “depressive” that used to be included in the older version of DSM,   “exuberant/hypomanic(turbulent)” and “decompensated” personality disorders that are not included in the current edition of DSM. Millon later on his life went as far as devising a “personalized psychotherapy” approach for personality disorders that he had a major role in inventing!

The most recently model of personality is the “Big Five Model” consisted of the following five personality traits: “Conscientiousness”, “Agreeableness”, “Neuroticism”, “Openness to experience”, and “Extraversion” with the acronym of “Canoe”! The proponents of this model, believe that the five traits underlie all personalities in normalcy and pathology, including all the current personality disorder categories in DSM 5! Despite all these and the common use of “personality disorders” diagnostic labels on patients in psychiatric wards and in the justice system, there are some debates and differences in opinions among experts in the field from early on until today! For example Kurt Schneider, the German psychiatrist in 19^th century and contemporary to Emil Kraeplin had argued that the personality disorders labels were simply ‘abnormal varieties of psychic life’ and therefore not necessarily the domain of psychiatry, a view said to still have influence in Germany today. British psychiatrists have also been reluctant to address such disorders or consider them on par with other mental disorders.

The “Big Five Model” like any predecessor ambitious theory of any kind tries to generalize and explain most of human’s personalities or characters. According to the following diagram, the model expands each factor “high” and “low” in a bipolar fashion to extrapolate all types of personality and characters.  But the “Big Five Model” is not the only model in history of figuring out human’s personality, though perhaps the most grandiose! Cloninger has proposed seven-dimensional model (four temperaments of harm avoidance, novelty seeking, reward dependence, and persistence, along with three character traits of self-directedness, cooperativeness, and self-transcendance) to explain our personalities. Livesley has a four-factor model consisting of emotional dysregulation, dissocial behavior, inhibitedness, and compulsivity. Clark and Watson believe the human’s personalities could simply be explained on their three-factor model, consisting of negative affectivity, positive affectivity, and constraint; so the interpersonal circumplex dimensions of agency and communion; and the three polarities (i.e., self-other, active-passive, and pleasure-pain) proposed by Millon.

But explaining the different traits of human’s personality or characters is one thing and making up disorders out of personalities as inherent traits that people are born with is another thing! In a survey of members of the International Society for the Study of Personality Disorders and the Association for Research on Personality Disorders, 80% of respondents indicated that “personality disorders are better understood as variants of normal personality than as categorical disease entities.” Despite the pressures by the proponents of dimensional theories of personality as described above, DSM still holds the old categorical model for personality disorders, believing people could be born into “paranoid, schizoid or schizotypal” personalities; or “antisocial, borderline, histrionic, or narcissistic” personalities, or “avoidant, dependent, or obsessive-compulsive” personalities!

In DSM, the difference between a “disease state” that is put under Axis I and “personality disorder” that is placed in Axis II in regard with “paranoid or delusional disorder” and “paranoid personality disorder”; “Schizophrenia” and “schizoid and schizotypal personality disorders”, “social anxiety disorder” or “social phobia” and “avoidant personality disorder”; “Obsessive Compulsive Disorder (OCD)” and “obsessive compulsive personality disorder” is all a matter of degrees and severity! So a person with paranoid personality could easily evolve to have a delusional or paranoid disorder, so a person with schizoid/schizotypal personality to schizophrenia; and n avoidant personality into social phobia or social anxiety disorder; and finally an obsessive compulsive personality into developing OCD!

 The argument against the personality disorders overlapped with disease states is that they could easily be milder forms of such disease states and not a different categorical personality disorders! Hence paranoid personality could be a mild form of paranoid or delusional disorder; schizoid and schizotypal personalities, milder forms of schizophrenia; avoidant personality disorder, a milder form of social phobia or social anxiety disorder; and obsessive compulsive personality disorder, a mild form of Obsessive Compulsive Disorder (OCD)! If that is true and these personality disorders are simply milder disease states, and not inherent personality traits, how the other personality disorders in DSM could be related to other disease states?!

Personality disorders by definition could not be diagnosed before the adulthood, so many of the above-mentioned disease states that are developed in adulthood. But some of the personality disorders, such as “antisocial” and “narcissistic” personalities could be evolution of some disease states in childhood, i.e. conduct and oppositional defiant disorders! “histrionic personality” could be linked to conversion or psychogenic disorders; “dependent personality” to any disease state that drives the person to dependency and needs onto others, e.g. depressive or anxiety disorders! The most complex and interesting of all the personality disorders, i.e. “Borderline Personality Disorder” is rarely seen without any disease states, e.g. mood disorders, particularly depression, substance use or eating disorders.

Historically in clinical practice, the diagnostic label of personality disorders have been used derogatorily and such patients have been approached like the waste baskets of psychiatry. The reason has perhaps been the field has not been able to treat these conditions as easy as the disease states, has not been certain about such diagnoses and due to not suffering sufficiently as disease states, the patients did not seek help either! In conclusion, perceiving the personality disorders as extensions of disease states would be the most compatible with clinical practice and experience, taking the derogatory labels off the patients and out of waste basket of psychiatry and into the disease state arena and candidates for treatment!

Dr.Mostafa Showraki, MD, FRCPC                                                               Lecturer, University of Toronto,School of Medicine,Author: “ADHD:Revisited” Book “adhdrevisited.com”/”medicinerevisited.com”

 References:

1. Suryanarayan, Geetha (2002). The history of the concept of personality disorder and its classification. The Medicine Publishing Company LTD.
2. Gutmann, P (2008). “Julius Ludwig August Koch (1841–1908): Christian, philosopher and psychiatrist”. History of Psychiatry 19 (74 Pt 2): 202–14.
3. Richard F. Wetzell (2000) Inventing the criminal: a history of German criminology,1880-1945.
4. Henning Sass & Alan Felthous (2008) Chapter 1: History and Conceptual Development of Psychopathic Disorders in International Handbook of Psychopathic Disorders and the Law. Edited by Alan Felthous, Henning Sass.
5. Eysenk Hans. Dimensions of Personality (1947).Transaction Publishers.
6. Eysenck Hans(1973). Race, Education and Intelligence. Maurice Temple Smith.
7. Millon, Theodore (1969) Modern Psychopathology: A Biosocial Approach to Maladaptive Learning and Functioning. Philadelphia: J.B. Saunders Company.
8. Millon, Theodore, Davis Roger (1996) Disorders of Personality: DSM IV and Beyond 2nd ed. New York.John Wiley and Sons.
9. Millon, Theodore, Grossman, Seth.(2007) Moderating Severe Personality Disorders: A Personalized Psychotherapy Approach. Hoboken: John Wiley and Sons.
10. McCrae RR, Costa PT Jr. Updating Norman’s “Adequate Taxonomy”: intelligence and personality dimensions in natural language and in questionnaires. J Pers Soc Psychol. 1985 Sep;49(3):710-21.
11. Widiger TA, Costa PT., Jr. Five-Factor model personality disorder research. In: Costa Paul T, Jr, Widiger Thomas A., editors. Personality disorders and the five-factor model of personality. 2nd. Washington, DC, US: American Psychological Association; 2002. pp. 59–87. 2002.
12. Widiger, Thomas A., Costa, Paul T. (2012). Personality Disorders and the Five-Factor Model of Personality, Third Edition.
13. Saulsman LM, Page AC. The five-factor model and personality disorder empirical literature: A meta-analytic review. – Clinical Psychology Review, 2004 – Elsevier Science.
14. Trull TJ, Widiger TA. Dimensional models of personality: the five-factor model and the DSM-5. Dialogues Clin Neurosci. 2013 Jun;15(2):135-46.
15. Bernstein DP., Iscan C., Maser J. Opinions of personality disorder experts regarding the DSM-IV personality disorders classification system . J Personal Disord. 2007;21:536–551.
16. Cloninger CR. A practical way to diagnose personality disorder: a proposal. J Personal Disord. 2000;14:98–108.
17. Livesley WJ. A framework for integrating dimensional and categorical classification of personality disorder. J. Personal Disord. 2007;21:199–224.
18. Clark LA. Watson D. Temperament: an organizing paradigm for trait psychology. In: OP John, RW Robins, LA Pervin, eds. Handbook of Personality. Theory and Research. 3rd Ed. New York, NY: Guilford. 2008:265–286.
19. Tellegen A., Waller NG. Exploring personality through test construction: development of the Multidimensional Personality Questionnaire. In: Boyle GJ, Matthews G, Saklofske DH, eds. The Sage Handbook of Personality Theory and Assessment. Los Angeles, CA: Sage. 2008:261–291.
20. Pincus AL. The interpersonal nexus of personality disorders. In: Strack S, ed. Handbook of Personology and Psychopathology.New York, NY: Wiley. 2005:120–139.
21. Millon T. Disorders of Personality. Introducing a DSMIICD Spectrum from Normal to Abnormal 3rd Ed. New York, NY: John Wiley & Sons. 2011.