My name is Sam Vaknin. I am the author of Malignant Self-Love, Narcissism Revisited.
Today we will discuss the history of personality disorders.
Where did this concept come from?
Are personality disorders the same as character disorders, psychosis, other forms of mental illness?
Well, it all started less than a hundred years ago.
Well into the 18th century, more than 200 years ago, the only types of mental illness, then collectively known as delirium or mania, were depression or melancholy, psychosis and delusions.
A hundred years later, at the beginning of the 19th century, the French psychiatrist Pinel coined the phrase, mal de son, insanity without delusions.
He described patients who lacked impulse control, often raged when they were frustrated and were prone to outbursts of violence. He noted that such patients were not subject to delusions.
They were not delusional. Pinel, without knowing it, was referring of course to psychopaths, patients with antisocial personality disorder.
Across the ocean, just about the same time in the United States, Benjamin Rush made similar observations.
And so in 1835, the Britishphysician John Snow, working as senior physician at Bristol in February hospital, published a seminal work titled Treatise on Insanity and Other Disorders of the Mind.
Snow in turn suggested the neologism, moral insanity.
To quote Snow, moral insanity consisted of a morbid perversion of the natural feelings, affections, inclinations, temper, habits, moral dispositions and natural impulses, without any remarkable disorder or defect of the intellect or knowing or reasoning faculties, and in particular, without any insane delusion or hallucination.
Not bad for a 19th century description.
Pritchard then proceeded to elucidate a psychopathic antisocial personality in great detail.
He said, he wrote, it is a propensity to theft. This is sometimes a feature of moral insanity, but sometimes it is its leading if not sole characteristic.
Eccentricity of conduct, singular and observed habits, the propensity to perform the common actions of life in a different way from that usually practiced is a feature of many cases of moral insanity, but can hardly be said to contribute sufficient evidence of its existence.
He admitted.
However, such phenomena are observed in connection with a wayward and intractable temper, with a decade of social affections, an aversion to the nearest relatives and friends formerly beloved, in short, with a change in the moral character of the individual.
Pritchard says the case becomes tolerably well marked.
But the distinctions between personality, affective and mood disorders were still way in the future.
In the 19th century, these boundaries were murky, not marked.
Pritchard muddied the distinctions further by writing, a considerable proportion among the most striking instances of moral insanity are those in which a tendency to gloom or sorrow is a predominant feature.
State of gloom or melancholy depression occasionally gives way to the opposite condition of preternatural excitement, and of course he's referring to bipolar disorder.
Another half century went to pass before a system of classification emerged that offered differential diagnosis of mixed states without delusions.
These disorders later came to be known as personality disorders, and they were for the first time at the end of the 19th century, clearly distinguished from affective disorders, schizophrenia and depressive illnesses.
Still, the term moral insanity was being widely used for almost a century.
Henry Maudsley applied moral insanity in 1885 to a patient.
He described this patient as having no capacity for true moral feeling. All his impulses and desires to which he yields without check are egotistic.
His conduct appears to be governed by immoral motives which are cherished and obeyed without any evident desire to resist them.
This is in his book Responsibility in Mental Illness.
But Maudsley already belonged to a generation of physicians who felt increasingly uncomfortable with a vague and judgmental coinage moral insanity.
They sought to replace it with something a bit more objective, a bit more neutral and scientific.
And so Maudsley bit a decrease as the ambiguous term moral insanity in his book.
He wrote, it is a form of mental alienation which has so much the look of vice or crime that many people regard it as an unfounded medical invention.
And to this very day many people consider psychopathy or antisocial personality disorder to be a culture-bound syndrome, a value judgment, not a mental illness or disorder.
In his book The Psychopartition, Niederlehre Verteidigung published in 1891, the German doctor J.N.A. Koch tried to improve the situation by suggesting the phrase psychopathic inferiority.
He limited his diagnosis to people who are not retarded or mentally ill, but still display a rigid pattern of misconduct and dysfunction throughout their increasingly disordered lives.
In later editions Koch replaced the word inferiority with personality to avoid sounding judgmental and hence was born the psychopathic personality.
Twenty years of controversy later the diagnosis found its way to the eighth edition of E.K. Ripley's seminal Lebouch depsechiatie, Clinical Psychiatry, a textbook for students and physicians.
By that time it merited a whole lengthy chapter in which Ripley suggested six additional types of disturbed personalities.
He said that they were psychopathic and then excitable, unstable, eccentric, liar, swindler and quarrelsome, all these personality types.
But still the focus was on antisocial behavior. If one's conduct caused inconvenience or suffering or even merely annoyed someone or flaunted the norms of society, one was liable to be diagnosed as psychopathic.
In his influential books, The Psychopathic Personality, the ninth edition of which was published in 1950, and Clinical Psychopathology, 1959, another German psychiatrist, K. Schneider, sought to expand the diagnosis of psychopathy to people who harm and inconvenience themselves, as well as others.
Patients who are depressed, socially anxious, excessively shy and insecure, were all deemed by him to be psychopaths.
But in his terminology, psychopath meant abnormal.
He lumped everything and everyone together, which was not really very helpful.
This broadening of the definition of psychopathy directly challenged the earlier work of Scottish psychiatrist Sir David Henderson.
In 1939, Henderson published a book called Psychopathic States, which was to become an instant classic. In it, he postulated that though not mentally sub-normal, psychopaths are people who, I quote, throughout their lives or from a comparatively early age, have exhibited disorders of conduct of an antisocial or asocial nature, usually of a recurrent episodic type, which in many instances have proved difficult to influence by methods of social, funeral and medical care, or for whom we have no adequate provision of preventative or curative nature.
As you see, they loved long sentences back then.
But Henderson went a lot further with that, and he transcended the narrow view of psychopathy, the German school, then prevailing throughout Europe.
In his work, again in 1939, Henderson described three types of psychopaths.
Aggressive psychopaths were violent, suicidal, and prone to substance abuse.
Passive and inadequate psychopaths were possessive, unstable, and hypochondriacal. They were also introverts, schizoids, and pathological liars.
Creative psychopaths were all dysfunctional people who managed to become famous or infamous somehow, and despite their disorder.
Twenty years later, in the 1959 Mental Health Act for England and Wales, psychopathic disorder was defined in section four, subsection four.
A persistent disorder of disability of mind, whether or not including sub-normality of intelligence, which results in abnormally aggressive or seriously irresponsible conduct on the part of the patient and requires or is susceptible to medical treatment.
This definition reverted to the minimalist, cyclical, tautological approach.
Normal behavior is that which causes harm, suffering, or discomfort to others. Such behavior is ipso facto, aggressive, and or irresponsible.
Additionally, this definition failed to tackle and even excluded manifestly abnormal behavior that does not require or is not susceptible to medical treatment.
Today, for instance, we believe that both narcissistic personality disorder and antisocial personality disorder are not amenable to treatment. Yet, they are definitely, or at least narcissism is, a mental disorder.
Thus, psychopathic personality came to mean both abnormal and antisocial, which is a source of confusion to this very day.
This confusion persists. Scholarly debate still rages between those such as the Canadian Robert Heyer, who distinguished the psychopath from the patient with mere antisocial personality disorder, and those, here for the sake of the diagnostic and statistical manual, who wish to avoid ambiguity by using only the term antisocial personality disorder.
So Heyer makes a distinction between psychopaths and antisocial, and the Diagnostic and Statistical Manual Committee does not make this distinction, and regards Heyer as a mayor.
Moreover, these nebulous constructs resulted in comorbidity, the diagnosis of several mental health disorders or personality disorders in the same patient.
Patients were frequently diagnosed with multiple, largely overlapping personality disorders, traits, and styles.
As early as 1950, the aforementioned German Schneider wrote, any clinician would be greatly embarrassed if asked to classify into appropriate types the psychopaths, that is, abnormal personalities encountered in any one year in his practice.
So what situation today?
Most practitioners rely on either the Diagnostic and Statistical Manual, now in its fifth edition, or on the International Classification of Diseases, ICT, now in its tenth edition.
The two tones disagree on some issues, but by and large conform to each other. And they both include reference narcissism into psychopathy.
The field is young. These disorders have been included in the DSM only 40 years ago, less than 40 years ago.
And so there is still a lot of room for differentiation, more subtle distinctions, the better understanding of what makes narcissists and psychopaths tick.
And how can society fend them off and defend itself against them?.