INPC YOUNG PSYCHIATRISTS PROGRAMME History of personality disorders Gerd Huber & Gisela Gross Bonn, Germany Personality disorders (PD) were explained as states of volitional failure or loss of coherence between cognitive-emotional and conative functions or of automatism, i.e. the manifestation of lower (primitive) forms of behaviour, escaping the control of higher (human) ones. By DSM-III-R PD are defined ’’as clusters of personality traits that are inflexible and maladaptive and cause either significant functional impairment or subjective distress’’. ’’Personality traits’’ thus remain the conceptual unit of analysis, and are defined as ’’enduring patterns of perceiving, relating and thinking about the environment and oneself exhibited in a wide range of important social and personal contexts’’ (1]. In the history PD were first considered as forms of attenuated insanity (’’Geisteskrankheit’’). ICD-10 in turn suggests ’’conditions and patterns of behaviour that emerge early in the course of individual development, as a resultant of both constitutional factors and social experience, while others are acquired later in life’’. DSM-III-R and ICD-10 accounts of PD can be described as palimpsests, whose earlier text has been hidden by recent layers of ’’empirical’’ varnish. The clinician must be mindful of the rich German and French conceptual tradition of thinking on personality and PD from which recent scripts have emerged. It must be considered that during the last 150 years terms as personality, PD, character, temperament, constitution, self, type, trait or psychopathic inferiority have changed and exchanged meanings. We notice that by conflating the history of PD as a term, as a behavioural form and as a concept, confusion has been caused. Words are the concern of historical semantics. Patterns of behaviour, similar to those currently named PD (or personality types), albeit called differently, have been known for millennia. Concepts, models and theories have been created to explain such behaviour patterns. The historian must locate the moment in which name, behaviour and concept converged; in the case of PD these seem to have taken place in the beginning of the 20th century. Numerous questions have to be answered e.g. regarding the relationship between psychoses and PD or are the terms currently favoured really better than older ones, e.g. psychopathy or ’’moral insanity’’? In the 19th century there were two predominant psychological theories: Faculty psychology conceived the mind as a set of cognitive (intellectual), emotional and volitional (conative) functions; the second theory, associationism, starting with LOCKE, conceived the mind as an empty slate, i.e. knowledge originated from ideas, obtained from the external world or from their combination by means of rules of association. Thomas REID and KANT had expressed a preference for faculty psychology; their main argument was that experience alone could not explain all knowledge, i.e. innate structures were necessary. Faculty psychology inspired phrenology, a theory, leading to new ideas on personality profiling and brain localisation; associatonism, in turn, was instrumental in the development of psychophysics and quantification in psychology. Both contributed to the creation of the new descriptive psychopathology, of psychiatric taxonomy and of the concepts of trait, type and character.


The view that human character was innate was challenged by the view that behaviour was also shaped by environmental factors. The notion of habitude (habit) became popular and in the 2nd half of the 19th century the term (ÔhabitudeÕ) was incorporated into medical parlance. Terms derived from the same Latin stem, were later used by KRETSCHMER (21) and SHELDON, who referred to specific types of human physique. Mind and behaviour were divided into recognizable traits (parts); first monolithic descriptions of human character were broken up into their ingredients, thereby transforming ÔmolarÕ descriptions into molecular ones. Traits became the unit of analysis for human behaviour, measurement scales developed and as cerebral localization theories gained acceptance, correlations between traits and brain sites were sought. By the beginning of the 19th century psychological typologies were well known and constituted the theoretical framework within which the new concept of character (personality) has to be analyzed. As the measurement of psychological data had reached a high level, it has been also tried to measure personality traits. This was helped by the work of GALTON and the expansion of statistics and probability theory. The notion of correlation, discovered by GALTON (3), provided a new form of evidence for the view that some personality traits went together. GALTON believed that intellectual differences had a hereditary origin. Relevant terms, imported into the 19th century, as self, temperament, constitution, character and personality, had to be refurbished with new meanings. The notion constitution, equivalent to diathesis or habit (e.g. pyknic habit) was until the 20th century used in a bodycentered view, unlike to Hippocratic usage, emphasizing environmental variables. The analysis of personality, consciousness and introspection, revolving around the concept of ’’self’’, achieved clarity in the work of DESCARTES, and later in the systems of LOCKE, LEIBNIZ and KANT. JANET (16) pleaded that personality should become a topic for experimental psychology and suggested that a scientific period was about to begin in which personality would be defined in objective terms and on the basis of material obtained from new sources such as the study of the mentally ill. During the late 19th century aggressive acts, committed by the insane were characterized as ’’involuntary’’, dealt with under the notion of impulsion and explained as unmotivated motor explosions or as disorders of the will, i.e. as irresistible feelings, difficult to control. Impulsion and impulsive insanity provided one of the kernels around which the notion of psychopathic personality was to be organized. The volitional explanation had then disappeared, as the psychological aspects of the concept of ’’will’’ (20) came under scrutiny. During the 1920s the observation of the major behavioural sequelae of Encephalitis Economo spoke in favour of an organic explanation. Encephalitis in childhood gave rise to severely antisocial behaviour. Degeneration theory and personality disorder Degeneration theory was developed by MOREL (23) according to which noxious behaviour (alcoholism, masturbation) caused alterations in the human seed, which in later generations expressed themselves as mental illnesses (melancholia, mania or dementia) and physical stigmata. MAGNAN emphasized its neurobiological aspects. Without the framework of degeneration theory the concept of

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psychopathic inferiority would have made little sense. Degeneration theory was relevant to the development of later typologies, such as those of KRETSCHMER, SCHNEIDER, KAHN and HENDERSON (7,18,21,8,6). Psychopathic Disorders The terms Ôpsychopathic personalityÕ (and psychopathic disorder) have disappeared from current classifications. In ICD-10 they have been incorporated into dissocial PD (F60.2), in DSM-III-R into cluster B (antisocial personality disorder, 301.70). However, the behaviours to which these terms referred, remain diagnostically relevant (24). E.g., KOCH (19) grouped under ’’psychopathic inferiority’’ abnormal behavioural states that were not to be considered as diseases. Severe such inferiorities, seen as the result of degeneration, included antisocial behaviours. According to SCHNEIDER KOCH’s main classificatory criterion had been moral rather than scientific (30). Here we must, also in order to understand SCHNEIDER’s view, realize, how ideas and concepts about PD have developed since the beginning of the 19th century. In this connection belong the descriptions of ’’Manie sans de´lire’’ by PINEL, of the ’’moral insanity’’ by PRICHARD (25) and of Henry MAUDSLEY (22), who continued the concept of moral insanity and the introduction of the term ’’psychopathic inferiority’’ (1891) with marked abnormalities of behaviour in the absence of mental illness or intellectual impairment. Later the word inferiority was replaced by (psychopathic) personality, to avoid judgemental overtones. KRAEPELIN, sharing the general doubt about the best way to classify such people, only in the 8th edition of his textbook finally adopted the term ’’psychopathic personality’’, devoted a long chapter to it and described seven separate types: Excitable, unstable, eccentric, liars, swindlers, antisocial and quarrelsome. A further and, at that time, thoroughly new step was taken by Kurt SCHNEIDER. Whereas KRAEPELIN’s seven types of psychopathic personality included only those causing inconvenience, annoyance or suffering to other people, SCHNEIDER extended the concept by including those causing suffering to themselves and not necessarily to others. Thus, he included people with markedly depressive, sensitive and insecure personality. For SCHNEIDER psychopathic personality covered the whole range of abnormal and not just antisocial personalities. In this way the term came to have two meanings: The wider meaning of abnormal personality of all kinds and the narrower meaning of antisocial personality (26, 30). Further variations in the meaning of the term ÔpsychopathicÕ were introduced by HENDERSON (7) and by the Mental Health Act for England and Wales, for which psychopathic disorder was defined as ’’persistent disorder or disability of mind, which results in abnormally aggressive or seriously irresponsible conduct’’, a definition, returning to the idea of aggressive or irresponsible acts, causing suffering to other people. HENDERSON has extended his definition by referring also to a group of passive and inadequate personalities including also those prone to suicide, drug addiction and alcohol abuse. Classifications of abnormal personalities as given in ICD-10 and DSM may also seem necessary for the purpose of collecting statistics. In everyday clinical work it may be sometimes better, to give a brief description of the main features of the personality than the names of the ICD-10- or the DSM-IV-classification. This was also the view of the authors of the 2nd edition of the Oxford Textbook of Psychiatry (4). Above all we should avoid the error which JASPERS (17) called ’’pseudo-insight through terminology’’ and classify types of personality disorders according to the medical model of diseases. One merit of SCHNEIDER’s understanding lies in the clear conceptual demarcation of the types of personality disorders from the psychotic illnesses, i.e. the organic psychosyndromes and the affective and schizophrenic psychoses. Another advantage is in our view, to avoid as far as possible value judgements. SCHNEIDER set out to replace KRAEPELIN’s socially valuating descriptions of such patients with an unsys-

tematic typology which was non-evaluating, psychological and clinically relevant (s.32,33). For each type SCHNEIDER provided a description and a background review, including genetic studies and social impact. There is a high degree of internal consistency in his accounts (33). ’’The psychopath simply is such a person’’, he said: We should not speak of a ’’disorder’’, unless we see in suffering, sensitivity or depressivity on .principle a disorder and not the expression of the ’’condition humana’’. SCHNEIDER published the 1st edition of the ’’Psychopathic personalities’’ in 1923. The 9th edition (English translation 1958) includes a preface and reply to critics, finding its strength in the simplicity of its criteria and the empirical approach. SCHNEIDER defined abnormal personality as a state of divergence from the average. Psychopathic personalities are a subclass of the abnormal personality and referred to those, who suffer under themselves or make society suffer on account of their abnormality. Abnormal personalities are not pathological in a medical sense and fall outside the disease model. SCHNEIDER described ten psychopathic types, i.e. hyperthymic, depressive, insecure-self-distrusting psychopaths with the subtypes sensitives and anancastics; then fanatic, attentionseeking, labile, explosive, affectionless, weakwilled and asthenic psychopathic personalities. He conceived these types not as diagnostic entities; they are not always permanent, they could, as e.g. also KAHN suggested, be ’’reactive’’ and ’’episodic’’. SCHNEIDER did not see any relationship between his types and the psychoses, but, that personality whether normal or abnormal, might modulate the appearance, the themes (the ’’Sosein’’) of the psychosis. SCHNEIDER’s book was often subject to criticism. Authors as HUMBERT (1947) denied the existence of a separate clinical category for psychopathic disorders, believing that they either were attenuated forms of psychotic illness, i.e. in the sense of KRETSCHMER schizothymic and schizoid or cyclothymic and cycloid personalities, or acquired states, e.g. childhood neurosis of character, susceptible to psychodynamic treatment. According to Schneider it is a selfdeception to believe that abnormal personalities are but developmental syndromes. Eugen KAHN, publishing his ’’Psychopathic personalities’’ in 1928 and PETRILOWITSCH in his book ’’Abnormal personalities’’ (3rd edition 1966), supported SCHNEIDERs definition of psychopathic personalities as states that make their bearer and/ or the society suffer. The predominant explanatory hypothesis of PD is neurobiological (2). Nevertheless, it is not unnecessary to explore the impact of psychodynamic models. Pierre JANET (16) used the model of ’’psychological automatism’’, based on the hierarchical levels of Hughlings JACKSON, to explain both mental symptoms and the ’’alterations of personality’’. He spoke of psychological automatism, when a part or all of the mental apparatus escaped the control of the will or of consciousness and continued functioning in an independent manner. He used the model of psychological automatism, to explain hysterical and dissociative states with their disconnection between the conscious and unconscious aspects of the personality. The mechanism of psychological automatism has remained popular in psychiatry, e.g. in the work of CLERAMBAULT. KRETSCHMER, following KRAEPELIN’s division of the psychoses, published his book ’’Physique and character’’ first in 1921, suggesting cycloid and schizoid temperaments. According to KRETSCHMER there are four types of physique, i.e. asthenic or leptosomatic, athletic, pyknic and dysplastic and there exist correlations between manic-depressive illness and the pyknic type and between schizophrenia and the leptosomatic-asthenic and dysplastic type. KRETSCHMER suggested not only a relationship between personality and body build, but also an association between personality and schizophrenic and manic-depressive psychoses. Schizoid and cycloid personalities are conceived as part way to schizophrenic and manic-depressive psychoses respectively. Although this theory remained without convincing support, it lingers on in the names cycloid and schizoid. According to GELDER

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and co-workers could be some less specific genetic connection between mental disorder and personality disorder, as suggested by reports of an increased frequency of various kinds of personality abnormality among relatives of schizophrenic patients and of patients with manic-depressive disorder (4). To this question and to the controversial discussion on the psychopathic personality and the possibility of its psychotherapy (27,29,31) we refer to our comment in the 15th edition of SCHNEIDER’s ’’Clinical Psychopathology’’ (31, pp 89–94), and, regarding the fascinating debate on the questions of ’’free will’’, ’’free will and brain’’ (20) and ’’Neurobiology of Psychotherapy’’, we refer to the comprehensive new literature and here also on the academic lecture of KORNHUBER at this congress. References: 1. Berrios GE. European views on personality disorders: A conceptual history. Compr Psychiatry 1993;34:14–30. 2. Cloninger CR. A systematic method for clinical description and classification of personality variants. Arch Gen Psychiatry 1987;44:573–588. 3. Galton F. Personality. Nature 1894;62:517–518. 4. Gelder M, Gath D, Mayou R. Oxford Textbook of Psychiatry. 2nd edn. Oxford Univ Press, Oxford New York Melbourne, 1989. 5. Gross G, Huber G, Morgner J (eds.) Perso¨nlichkeit – Perso¨nlichkeitssto¨rung – Psychose. Schattauer, Stuttgart New York, 1996. 6. Gross G, Huber G. Somatically based psychoses and the problem of symptomatic schizophrenia. Neurol Psychiatry Brain Res 2007;14:131–142. 7. Henderson DK. Psychopathic states. Norton, New York, 1939. 8. Hoenig J. Kurt Schneider and anglophone psychiatry. Compr Psychiatry 1982;23:391–400. 9. Huber G. Personality and schizophrenia. In: Sarteschi P. Maggini C (eds.) Personalita` e Psicopatologia. Vol I. ETS Editrice, Pisa, 1990:pp 365–379. 10. Huber G. Psychopathologie – eine versiegende Quelle? Fortschr Neurol Psychiat 2002;70:393–402. 11. Huber G (2002) The psychopathology of K. Jaspers and K. Schneider as a fundamental method for psychiatry. World J Biol Psychiatry 2002;3:50–57. 12. Huber G. Psychiatrie. Lehrbuch fu¨r Studium und Weiterbildung. 7th edition. Schattauer, Stuttgart New York, 2005. 13. Huber G 50 years of schizophrenia research in a personal view. Neurol Psychiatry Brain Res 2006;13:41–54. 14. Huber G, Gross G. Bridges between Neurology and Psychiatry. Neurol Croat 2003;52(S2):65–77. 15. Huber G, Gross G. History of exogenous reaction types. Neurol Croat 2007;56(S2):34–45. 16. Janet P. LÕautomatisme psychologique. Alcan, Paris, 1889. 17. Jaspers K. Allgemeine Psychopathologie. 4th edn. Springer, Berlin, 1946. 18. Kahn E. Psychopathic personalities. CT Yale Univ Press, New Haven, 1931. 19. Koch JA. Die psychopathischen Minderwertigkeiten. Maier, Ravensburg, 1891. 20. Kornhuber HH, Deecke L. Wille und Gehirn. Edn Sirius, Bielefeld Locarno, 2007. 21. Kretschmer E. Physique and character. Transl. by Sprott WJ. Kegal Paul Trench Trubner & Co, London UK, 1936. 22. Maudsley H. Responsibility in mental disease. Kegan Paul & Trench, London, 1885. 23. Morel BA. Traite´ des de´ge´ne´rescences physiques, intellectuelles et morales de lÕespe`ce humaine. Baillie`re, Paris, 1957. 24. Pichot P. Psychopathic behaviour. A historical overview. In: Hare RD, Schalling D (eds.) Psychopathic behaviour: Approaches to research. Wiley, New York, 1978:pp 55–70. 25. Prichard JC Treatise of insanity. Sherwood Gilbert & Piper, London, 1835.


26. Schneider K. Die psychopathischen Perso¨nlichkeiten. Deuticke, Wien (9th edn. 1950), 1923. 27. Schneider K. Zur Frage der Psychotherapie endogener Psychosen. Dtsch Med Woschr 1954;79:873–875. 28. Schneider K. Kraepelin und die gegenwa¨rtige Psychiatrie. Fortschr Neurol Psychiat 1956;24:1–7. 29. Schneider K. ’’Der Psychopath’’ in heutiger Sicht. Fortschr Neurol Psychiat 1958;26:1–6. 30. Schneider K. Psychopathic Personalities. Cassell, London, 1958. 31. Schneider K. Klinische Psychopathologie. 15th edn. With a commentary by Huber G and Gross G. Thieme, Stuttgart New York, 2007. 32. Standage K. A clinical and psychometric investigation comparing Schneider’s and the DSM-III typologies of personality disorders. Compr Psychiatry 1986;27:35–46. 33. Standage K 1989. Psychopathic personalities: Kurt Schneider. Books reconsidered. Br J Psychiatry 1986;155:271–273.

Treatment choice in psychiatry? Would trainees choose similar treatments to those prescribed, and what influences decision-making? A survey of the European Federation of TraineesÕ (EFPT) Research Group Sameer Jauhar, on behalf of the EFPT Research Group* General Adult Psychiatry, Gartnavel Royal Hospital, Glasgow.*The Members of EFPT are S. Gerber, O. Andlauer, J. G. Marques, L. Mendonca, I. Dumitrescu, C. Roventa, G. Lydall, S. Guloksuz, E. Dobrzynska, N. De Vriendt, A. Mufic, J. Van Zanten F Riese, G. Favre, A. Nazaralieva, M. Bendix, I. Nwachukwu, S. Soriano & A. Nawka. Keywords: Survey, rainees, decision-making, efficacy, antipsychotics, antidepressants, mood stabilisers Introduction: Recent evidence has questioned modern psychiatric clinical practice, specifically the prescribing of ’’atypical’’ antipsychotics (1–4). Our Pan-European Research Group asked Psychiatry trainees for their own treatment preferences and factors influencing decision-making. We questioned if traineesÕ own choices differed to those for patients, what their actual choices were, and what factors influenced decision-making. Material and methods: A semi-structured survey was constructed from prior literature (5–7), piloted, and a homogenous sample size of 50 was agreed upon from each country, with 50% minimum response rate. It was distributed in English, via web-link, with questions on guidelines, preference of antipsychotic/mood stabiliser/ antidepressant for patients in given scenarios, and factors influencing choice. Physicians were asked for their own preference. Results: As the survey is ongoing, data are preliminary, that pertaining to antipsychotics presented below. i) Treatment choice of antipsychotic 95% (n = 208) chose to receive ’’atypical’’ antipsychotics (excluding Clozapine), 5% (n = 10) choosing ’’typical’’ antipsychotics, one choosing Clozapine as first-line therapy. ii) Factors influencing choice These mapped onto three domains: efficacy, side-effect profile and cost (less than 5% other reasons). Strikingly, for antipsychotics, 81% (n = 177) felt efficacy most important, 48% (n = 105) felt side-effect profile most important and 3% (n = 7) considered cost of paramount importance. Discussion: Though data are preliminary, it appears Psychiatry trainees would choose to receive some treatments based on perceived benefits, as opposed to evidence base and recent literature. It will be interesting to analyse factors influencing decision-making in clinical practice. Word count 240 words Acknowledgements: We would like to thank all those who contributed to the survey and Drs Malik and Rojnic (EFPT President and President-Elect) for their continued support and guidance.

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History of personality disorders.

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