With history as an aid to understanding the present

In Personality Disorders, Alan Horowitz describes the history of personality disorders*. It also becomes a history of the concept of the character as such, since the central question is What A personality disorder is a disorder. The reader is accompanied by a number of questions: Are personality disorders medical diseases or problems in life? Are they distinct entities or extreme variants of normal personality traits? Can it be separated from the social, cultural and historical contexts?

Similar questions were already asked in ancient Greece. Theophrastus (c. 320 BC) described about thirty “characters” (which was the prevailing concept until “personality” prevailed at the end of the nineteenth century). Descriptions of the type are similar to early diagnostic models still in existence today. The fundamental difference was that certain personality traits were desirable and something that could be achieved, in complete contrast to later conceptions of personality as something fixed and innate.

When societies were built around groups, there was not much natural space for an individual’s personality. A more systematic exploration of personality emerged in response to revolutionary social changes at the end of the nineteenth century. However, personality disorders have ended up in no-go territory. Psychiatrists met completely different groups of patients in mental hospitals. Psychoanalysis mainly dealt with various neurological symptoms that differed from the basic personality of the patient. And so the field was opened to burgeoning new fields of science—psychology, sociology, and anthropology.

For psychology it has become important to create a niche between psychiatry and philosophy but at the same time operate as strictly as the natural sciences. With intelligence tests as a model, various personality tests began to develop. The basic thesis, which still holds today, was that personality can be broken down into different traits that are measured along a continuum based on measures of self-evaluation. Disorder was defined on the basis of statistical deviations.

From the 1930s through the 1980s, the social and cultural aspects of personality were given more space. However, no region has exclusive rights to a character. Therefore, no consensus was developed either, which resonates to this day. Sociologists showed how social conditions affected personality, anthropologists how widely different cultures valued traits that were considered disordered in others, and neo-Freudians studied personality based on comprehensive models. As psychiatry and psychoanalysis became more and more intertwined, the personality instead ended up at the center of the development of psychiatry.

The paradigm shift when the DSM-III was launched was described by Horowitz in another book. For personality disorders, this has led to a growing mechanistic understanding in terms of genes and molecules. The studies separated personal from individual experiences. Another contradiction has increasingly emerged: that between researchers, who strive for universal laws and patterns, and physicians, who want to understand and help individual patients. It became even more clear when the DSM-5 was developed. Personality disorders that were so absent in psychiatry at the turn of the last century, a hundred years later, served as a model for other psychiatric conditions as well. But the dimensional system presented by the researchers was voted on by the doctors. Horowitz describes the unsustainability of a situation in which clinicians lean toward a misplaced diagnostic guideline while researchers propagate a dimensional system that clinicians don’t want.

Horowitz concludes that most schools of the past 150 years have attempted to squeeze personality disorders under the natural sciences portion of Kant’s model of scientific theory. The difficulties in this work were that personality inevitably includes an understanding of social and cultural aspects. One cannot, so to speak, ignore the personal side of the personality. The book ends with an optimistic look at integrative approaches, such as the biopsychosocial model and successful treatment methods for personality disorders. Personality Disorders is exactly the kind of book that makes it easier to understand the present with the help of history.

*The National Council for Health and Care uses “personality disorder” in ICD-10. The English term in the ICD-11 and DSM-5 is “personality disorder.” In the Swedish translation of the DSM-5, “personality syndrome” is used in order to move away from the stigmatizing concept of a “disorder”. This text uses “personality disorder” because the word “disorder” was specifically discussed in detail by Horowitz.

Lakartidningen.se 2023-07-19