Diagnostic and Statistical Manual history }
Before the 20th century Personality disorder is a term with a distinctly modern meaning, owing in part to its clinical usage and the institutional character of
modern psychiatry. The currently accepted meaning must be understood in the context of historical changing classification systems such as DSM-IV and its predecessors. Although highly anachronistic, and ignoring radical differences in the character of subjectivity and social relations, some have suggested similarities to other concepts going back to at least the
ancient Greeks. Physicians in the early nineteenth century started to diagnose forms of
insanity involving disturbed emotions and behaviors but seemingly without significant intellectual impairment or
delusions or
hallucinations.
Philippe Pinel referred to this as '
manie sans délire ' – mania without delusions – and described a number of cases mainly involving excessive or inexplicable anger or rage.
James Cowles Prichard advanced a similar concept he called
moral insanity, which would be used to diagnose patients for some decades. 'Moral' in this sense referred to
affect (emotion or mood) rather than simply the ethical dimension, but it was arguably a significant move for 'psychiatric' diagnostic practice to become so clearly engaged with judgments about individual's social behaviour. Prichard was influenced by his own religious, social and moral beliefs, as well as ideas in German psychiatry. These categories were much different and broader than later definitions of personality disorder, while also being developed by some into a more specific meaning of moral degeneracy akin to later ideas about 'psychopaths'. Separately,
Richard von Krafft-Ebing popularized the terms
sadism and masochism, as well as
homosexuality, as psychiatric issues. The German psychiatrist
Koch sought to make the moral insanity concept more scientific, and in 1891 suggested the phrase 'psychopathic inferiority', theorized to be a
congenital disorder. This referred to continual and rigid patterns of misconduct or dysfunction in the absence of apparent "
mental retardation" or illness, supposedly without a moral judgment. Described as deeply rooted in his Christian faith, his work established the concept of personality disorder as used today.
20th century In the early 20th century, another German psychiatrist,
Emil Kraepelin, included a chapter on psychopathic inferiority in his influential work on clinical psychiatry for students and physicians. He suggested six types – excitable, unstable, eccentric, liar, swindler and quarrelsome. The categories were essentially defined by the most disordered criminal offenders observed, distinguished between criminals by impulse, professional criminals, and morbid
vagabonds who wandered through life. Kraepelin also described three paranoid (meaning then delusional) disorders, resembling later concepts of schizophrenia, delusional disorder and paranoid personality disorder. A diagnostic term for the latter concept would be included in the DSM from 1952, and from 1980 the DSM would also include schizoid, schizotypal; interpretations of earlier (1921) theories of
Ernst Kretschmer led to a distinction between these and another type later included in the DSM, avoidant personality disorder. In 1933 Russian psychiatrist
Pyotr Borisovich Gannushkin published his book
Manifestations of Psychopathies: Statics, Dynamics, Systematic Aspects, which was one of the first attempts to develop a detailed
typology of psychopathies. Regarding maladaptation, ubiquity, and stability as the three main symptoms of behavioral pathology, he distinguished nine clusters of psychopaths: cycloids (including constitutionally depressive, constitutionally excitable, cyclothymics, and emotionally labile), (including psychasthenics), schizoids (including dreamers), paranoiacs (including fanatics), epileptoids, hysterical personalities (including pathological liars), unstable psychopaths, antisocial psychopaths, and constitutionally stupid. Some elements of Gannushkin's typology were later incorporated into the theory developed by a Russian adolescent psychiatrist,
Andrey Yevgenyevich Lichko, who was also interested in psychopathies along with their milder forms, the so-called
accentuations of character. In 1939, psychiatrist David Henderson published a theory of 'psychopathic states' that contributed to popularly linking the term to
anti-social behavior.
Hervey M. Cleckley's 1941 text,
The Mask of Sanity, based on his personal categorization of similarities he noted in some prisoners, marked the start of the modern clinical conception of psychopathy and its popularist usage. Towards the mid 20th century, psychoanalytic theories were coming to the fore based on work from the turn of the century being popularized by
Sigmund Freud and others. This included the concept of
character disorders, which were seen as enduring problems linked not to specific symptoms but to pervasive internal conflicts or derailments of normal childhood development. These were often understood as weaknesses of character or willful deviance, and were distinguished from
neurosis or
psychosis. The term 'borderline' stems from a belief some individuals were functioning on the edge of those two categories, and a number of the other personality disorder categories were also heavily influenced by this approach, including dependent, obsessive–compulsive and histrionic, the latter starting off as a conversion symptom of hysteria particularly associated with women, then a hysterical personality, then renamed histrionic personality disorder in later versions of the DSM. A passive aggressive style was defined clinically by Colonel
William Menninger during World War II in the context of men's reactions to military compliance, which would later be referenced as a personality disorder in the DSM.
Otto Kernberg was influential with regard to the concepts of borderline and narcissistic personalities later incorporated in 1980 as disorders into the DSM. Meanwhile, a more general
personality psychology had been developing in academia and to some extent clinically.
Gordon Allport published theories of
personality traits from the 1920s—and
Henry Murray advanced a theory called
personology, which influenced a later key advocate of personality disorders,
Theodore Millon. Tests were developing or being applied for personality evaluation, including
projective tests such as the
Rorschach test, as well as questionnaires such as the
Minnesota Multiphasic Personality Inventory. Around mid-century,
Hans Eysenck was analysing traits and
personality types, and psychiatrist
Kurt Schneider was popularising a clinical use in place of the previously more usual terms 'character', 'temperament' or 'constitution'. American psychiatrists officially recognized concepts of enduring personality disturbances in the first
Diagnostic and Statistical Manual of Mental Disorders in the 1950s, which relied heavily on psychoanalytic concepts. Somewhat more neutral language was employed in the
DSM-II in 1968, though the terms and descriptions had only a slight resemblance to current definitions. The
DSM-III published in 1980 made some major changes, notably putting all personality disorders onto a second separate 'axis' along with "mental retardation", intended to signify more enduring patterns, distinct from what were considered axis one mental disorders. 'Inadequate' and '
asthenic' personality disorder' categories were deleted, and others were expanded into more types, or changed from being personality disorders to regular disorders.
Sociopathic personality disorder, which had been the term for
psychopathy, was renamed Antisocial Personality Disorder. Most categories were given more specific 'operationalized' definitions, with standard criteria psychiatrists could agree on to conduct research and diagnose patients. In the DSM-III revision, self-defeating personality disorder and sadistic personality disorder were included as provisional diagnoses requiring further study. They were dropped in the DSM-IV, though a proposed 'depressive personality disorder' was added; in addition, the official diagnosis of passive–aggressive personality disorder was dropped, tentatively renamed 'negativistic personality disorder.' International differences have been noted in how attitudes have developed towards the diagnosis of personality disorder. Kurt Schneider argued they were '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, which has been attributed partly to resource pressures within the National Health Service, as well as to negative medical attitudes towards behaviors associated with personality disorders. In the US, the prevailing healthcare system and psychoanalytic tradition has been said to provide a rationale for private therapists to diagnose some personality disorders more broadly and provide ongoing treatment for them. == See also ==