Olmstead v. L.C., 527 U.S. 581 (1999), is a United States Supreme Court case regarding discrimination against people with mental disabilities.
The Supreme Court held that under the Americans with Disabilities Act, individuals with mental disabilities have the right to live in the community rather than in institutions if, in the words of the opinion of the Court, “the State’s treatment professionals have determined that community placement is appropriate, the transfer from institutional care to a less restrictive setting is not opposed by the affected individual, and the placement can be reasonably accommodated, taking into account the resources available to the State and the needs of others with mental disabilities.”
The case was brought by the Atlanta Legal Aid Society, Inc.
Tommy Olmstead, Commissioner, Georgia Department of Human Resources, et al. v. L. C., by Zimring, guardian ad litem and next friend, et al. (Olmstead v. L.C.) was a case filed in 1995 and decided in 1999 before the United States Supreme Court. The plaintiffs, L.C. (Lois Curtis) and E.W. (Elaine Wilson, deceased 04 December 2005), two women were diagnosed with schizophrenia, intellectual disability and personality disorder. They had both been treated in institutional settings and in community based treatments in the state of Georgia.
Guardian ad litem: A legal guardian is a person who has been appointed by a court or otherwise has the legal authority to care for the personal and property interests of another person, called a ward.
Next Friend: In common law, a next friend is a person who represents another person who is underage, or, because of disability or otherwise, is unable to maintain a suit on his or her own behalf and who does not have a legal guardian. Also known as litigation friends.
Following clinical assessments by state employees, both plaintiffs were determined to be better suited for treatment in a community-based setting rather than in the institution. The plaintiffs remained confined in the institution, each for several years after the initial treatment was concluded. Both sued the state of Georgia to prevent them from being inappropriately treated and housed in the institutional setting.
Opinion of the Court
The case rose to the level of the United States Supreme Court, which decided the case in 1999, and plays a major role in determining that mental illness is a form of disability and therefore covered under the Americans with Disabilities Act (ADA). Title II of the ADA applies to ‘public entities’ and include ‘state and local governments’ and ‘any department, agency or special purpose district’ and protects any ‘qualified person with a disability’ from exclusion from participation in or denied the benefits of services, programs, or activities of a public entity.
The Supreme Court decided mental illness is a form of disability and that “unjustified isolation” of a person with a disability is a form of discrimination under Title II of the ADA. The Supreme Court held that community placement is only required and appropriate (i.e. institutionalisation is unjustified), when:
The State’s treatment professionals have determined that community placement is appropriate;
The transfer from institutional care to a less restrictive setting is not opposed by the affected individual; and
The placement can be reasonably accommodated, taking into account the resources available to the State and the needs of others with mental disabilities.
Unjustified isolation is discrimination based on disability. Olmstead v. L.C., 527 U.S. 581, 587 (1999).
The Supreme Court explained that this holding “reflects two evident judgments.”
First, “institutional placement of persons who can handle and benefit from community settings perpetuates unwarranted assumptions that persons so isolated are incapable or unworthy of participating in community life.”
Second, historically “confinement in an institution severely diminishes the everyday life activities of individuals, including family relations, social contacts, work options, economic independence, educational advancement, and cultural enrichment.” Id. at 600-601.
However, a majority of Justices in Olmstead also recognized an ongoing role for publicly and privately operated institutions:
“We emphasize that nothing in the ADA or its implementing regulations condones termination of institutional settings for persons unable to handle or benefit from community settings…Nor is there any federal requirement that community-based treatment be imposed on patients who do not desire it.” Id. at 601-602.
A plurality of Justices noted: “[N]o placement outside the institution may ever be appropriate . . . ‘Some individuals, whether mentally retarded or mentally ill, are not prepared at particular times – perhaps in the short run, perhaps in the long run – for the risks and exposure of the less protective environment of community settings ’ for these persons, ‘institutional settings are needed and must remain available’” (quoting Amicus Curiae Brief for the American Psychiatric Association, et al). “As already observed [by the majority], the ADA is not reasonably read to impel States to phase out institutions, placing patients in need of close care at risk… ‘Each disabled person is entitled to treatment in the most integrated setting possible for that person—recognizing on a case-by-case basis, that setting may be an institution’[quoting VOR’s Amici Curiae brief].” Id. at 605.
Justice Kennedy noted in his concurring opinion, “It would be unreasonable, it would be a tragic event, then, were the Americans with Disabilities Act of 1990 (ADA) to be interpreted so that states had some incentive, for fear of litigation to drive those in need of medical care and treatment out of appropriate care and into settings with too little assistance and supervision.” Id. at 610.
The Supreme Court did not reach the question of whether there is a constitutional right to community services in the most integrated setting.
About ten years after the Olmstead decision, the State of Georgia and the United States Department of Justice entered a settlement agreement to cease all admissions of individuals with developmental disabilities to state-operated, federally licensed institutions (“State Hospitals”) and, by 01 July 2015, “transition all individuals with developmental disabilities in the State Hospitals from the Hospitals to community settings,” according to a Department of Justice Fact Sheet about the settlement. The settlement also calls for serving 9,000 individuals with mental illness in community settings. Recently, the federal court’s Independent Reviewer for the settlement found significant health and safety risks, including many deaths, plaguing former State Hospital residents due to their transition from a licensed facility home to community-settings per the settlement. The Court has approved a moratorium on such transfers until the safety of those impacted can be assured.
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Organic personality disorder (OPD), irrespective of the apparent nomenclature, is not included in the group of personality disorders.
For this reason, the symptoms and diagnostic criteria of the organic personality disorder are different from those of the other mental health disorders included in this various group. According to the Tenth Revision of the International Classification of Diseases (ICD-10) organic personality disorder is associated with a “significant alteration of the habitual patterns of premorbid behaviour”. There are crucial influences on emotions, impulses and personal needs because of this disorder.
Thus, all these definitions about the organic personality disorder support that this type of disorder is associated with changes in personality and behaviour.
Organic personality disorder is associated with “personality change due to general medical condition”. The organic personality disorder is included in a wide group of personality and behavioural disorders. This mental health disorder can be caused by disease, brain damages or dysfunctions in specific brain areas in frontal lobe. The most common reason for this profound change in personality is the traumatic brain injury (TBI). Children, whose brain areas have been injured or damaged, may present attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and organic personality disorder. Moreover, this disorder is characterised as “frontal lobe syndrome”. This characteristic name shows that the organic personality disorder can usually be caused by lesions in three brain areas of frontal lobe. Specifically, the symptoms of organic personality disorder can also be caused by traumatic brain injuries in orbitofrontal cortex, anterior cingulate cortex and dorsolateral prefrontal cortex. It is worth mention that organic personality disorder may also be caused by lesions in other circumscribed brain areas.
Diagnosis and Symptoms
The ICD-10 includes a diagnostic guideline for the wide group of personality and behavioural disorders. However, every disorder has its own diagnostic criteria. In case of the organic personality disorder, patient has to show at least three of the following diagnostic criteria over a six or more months period. Organic personality disorder is associated with a large variety of symptoms, such as deficits in cognitive function, dysfunctional behaviours, psychosis, neurosis, emotional changes, alterations in expression function and irritability. Patients with organic personality disorder can present emotional lability that means their emotional expressions are unstable and fluctuating. In addition, patients show reduction in ability of perseverance with their goals and they express disinhibited behaviours, which are characterised by inappropriate sexual and antisocial actions. For instance, patients can show dissocial behaviours, like stealing. Moreover, according to diagnostic guideline of ICD-10, patients can suffer from cognitive disturbances and they present signs of suspiciousness and paranoid ideas. Additionally, patients may present alteration in process of language production that means there are changes in language rate and flow. Furthermore, patients may show changes in their sexual preference and hyposexuality symptoms.
Another common feature of personality of patients with organic personality disorder is their dysfunctional and maladaptive behaviour that causes serious problems in these patients, because they face problems with pursuit and achievement of their goals. It is worth to be mentioned that patients with organic personality disorder express a feeling of unreasonable satisfaction and euphoria. Also, the patients show aggressive behaviours sometimes and these serious dysfunctions in their behaviour can have effects on their life and their relationships with other people. Specifically patients show intense signs of anger and aggression because of their inability to handle their impulses. The type of this aggression is called “impulsive aggression”. Furthermore, it is worth to be mentioned that the pattern of organic personality disorder presents some similarities with pattern of temporal lobe epilepsy (TLE). Specifically patients who suffer from this chronic disorder type of epilepsy, express aggressive behaviours, likewise it happens to patients with organic personality disorder. Another similar symptom between Temporal lobe epilepsy and organic personality disorder is the epileptic seizure. The symptom of epileptic seizure has influence on patients’ personality that means it causes behavioural alterations”. The Temporal lobe epilepsy (TLE) is associated with the hyperexcitability of the medial temporal lobe (MTL) of patients. Finally, patients with organic personality disorder may present similar symptoms with patients, who suffer from the Huntington’s disease as well. The symptoms of apathy and irritability are common between these two groups of patients.
As it has already been mentioned, patients with organic personality disorder show a wide variety of sudden behavioural changes and dysfunctions. There are not a lot of information about the treatment of this mental health disorder. The pharmacological approach is the most common therapy among patients with organic personality disorder. However, the choice of drug therapy relies on the seriousness of patient’s situation and what symptoms are shown. The choice and administration of specific drugs contribute to the reduction of symptoms of organic personality disorder. For this reason, it is crucial for patients’ treatment to be assessed by clinical psychologists and psychiatrists before the administration of drugs.
Additionally, the dysfunctions in expression of behaviour of patients with organic personality disorder and the development of symptom of irritability, which are caused by aggressive and self-injurious behaviours, can be dealt with the administration of carbamazepine. Moreover, the symptoms of this disorder can be decreased by the administration of valproic acid. Also, emotional irritability and signs of depression can be dealt with the use of nortriptyline and low-dose thioridazine. Except from the symptom of irritability, patients express aggressive behaviours. At the onset of drug therapy for effective treatment of anger and aggression, the drug of carbamazepine, phenobarbital, benztropine (or benzatropine) and haloperidol can be administrated in order to reduce the symptoms of patients with organic personality disorder. In addition, the use of propranolol may decrease the frequent behaviours of rage attacks.
Finally, it is important for patients to take part in psychotherapy during drug therapy. In this way, many of the adverse effects of the medications, both physiological and behavioural, can be lessened or avoided entirely. Furthermore, the clinicians can provide useful and helpful support to patients during these psychotherapy sessions. Thus, the combination of drug therapy with psychotherapy can lead to the reduction of symptoms of this disorder and the improvement of patients’ situation.
Self-defeating personality disorder (also known as masochistic personality disorder) was a proposed personality disorder.
It was discussed in an appendix of the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) in 1987, but was never formally admitted into the manual. As an alternative, the diagnosis personality disorder not otherwise specified remains in use in the DSM-5. A classification proposed for future versions is the personality disorder-trait specified (PD-TS). Some researchers and theorists continue to use the DSM-III-R criteria. The official diagnostic code number was 301.90 (personality disorder NOS).
Definition Proposed in DSM III-R for Further Review
Self-defeating personality disorder is:
A) A pervasive pattern of self-defeating behaviour, beginning by early adulthood and present in a variety of contexts. The person may often avoid or undermine pleasurable experiences, be drawn to situations or relationships in which they will suffer, and prevent others from helping them, as indicated by at least five of the following:
Chooses people and situations that lead to disappointment, failure, or mistreatment even when better options are clearly available.
Rejects or makes ineffective the attempts of others to help them.
Following positive personal events (e.g. new achievement), responds with depression, guilt, or a behaviour that produces pain (e.g. an accident).
Incites angry or rejecting responses from others and then feels hurt, defeated, or humiliated (e.g. makes fun of spouse in public, provoking an angry retort, then feels devastated).
Rejects opportunities for pleasure, or is reluctant to acknowledge enjoying themselves (despite having adequate social skills and the capacity for pleasure).
Fails to accomplish tasks crucial to their personal objectives despite having demonstrated ability to do so (e.g., helps fellow students write papers, but is unable to write their own).
Is uninterested in or rejects people who consistently treat them well.
Engages in excessive self-sacrifice that is unsolicited by the intended recipients of the sacrifice.
The person may often avoid or undermine pleasurable experiences […]
B) The behaviors in A do not occur exclusively in response to, or in anticipation of, being physically, sexually, or psychologically abused.
C) The behaviors in A do not occur only when the person is depressed.
Exclusion from DSM-IV
Historically, masochism has been associated with feminine submissiveness. This disorder became politically controversial when associated with domestic violence which was considered to be mostly caused by males. However a number of studies suggest that the disorder is common. In spite of its exclusion from DSM-IV in 1994, it continues to enjoy widespread currency amongst clinicians as a construct that explains a great many facets of human behaviour.
Sexual masochism that “causes clinically significant distress or impairment in social, occupational, or other important areas of functioning” is still in DSM-IV.
True self (also known as real self, authentic self, original self and vulnerable self) and false self (also known as fake self, idealised self, superficial self and pseudo self) are psychological concepts, originally introduced into psychoanalysis in 1960 by Donald Winnicott.
Winnicott used true self to describe a sense of self based on spontaneous authentic experience and a feeling of being alive, having a real self. The false self, by contrast, Winnicott saw as a defensive façade, which in extreme cases could leave its holders lacking spontaneity and feeling dead and empty, behind a mere appearance of being real.
The concepts are often used in connection with narcissism.
Winnicott saw the true self as rooted from early infancy in the experience of being alive, including blood pumping and lungs breathing – what Winnicott called simply being. Out of this, the baby creates the experience of a sense of reality, a sense that life is worth living. The baby’s spontaneous, nonverbal gestures derive from that instinctual sense, and if responded to by the parents, become the basis for the continuing development of the true self.
However, when what Winnicott was careful to describe as good enough parenting – i.e., not necessarily perfect – was not in place, the infant’s spontaneity was in danger of being encroached on by the need for compliance with the parents’ wishes/expectations. The result for Winnicott could be the creation of what he called the false self, where “Other people’s expectations can become of overriding importance, overlaying or contradicting the original sense of self, the one connected to the very roots of one’s being”. The danger he saw was that “through this false self, the infant builds up a false set of relationships, and by means of introjections even attains a show of being real”, while, in fact, merely concealing a barren emptiness behind an independent-seeming façade.
The danger was particularly acute where the baby had to provide attunement for the mother/parents, rather than vice versa, building up a sort of dissociated recognition of the object on an impersonal, not personal and spontaneous basis. But while such a pathological false self stifled the spontaneous gestures of the true self in favour of a lifeless imitation, Winnicott nevertheless considered it of vital importance in preventing something worse: the annihilating experience of the exploitation of the hidden true self itself.
There was much in psychoanalytic theory on which Winnicott could draw for his concept of the false self. Helene Deutsch had described the “as if” personalities, with their pseudo relationships substituting for real ones. Winnicott’s analyst, Joan Riviere, had explored the concept of the narcissist’s masquerade – superficial assent concealing a subtle hidden struggle for control. Freud’s own late theory of the ego as the product of identifications came close to viewing it only as a false self; while Winnicott’s true/false distinction has also been compared to Michael Balint’s “basic fault” and to Ronald Fairbairn’s notion of the “compromised ego”.
Erich Fromm, in his book The Fear of Freedom distinguished between original self and pseudo self – the inauthenticality of the latter being a way to escape the loneliness of freedom; while much earlier the existentialist like Kierkegaard had claimed that “to will to be that self which one truly is, is indeed the opposite of despair” – the despair of choosing “to be another than himself”.
Karen Horney, in her 1950 book, Neurosis and Human Growth, based her idea of “true self” and “false self” through the view of self-improvement, interpreting it as real self and ideal self, with the real self being what one currently is and the ideal self being what one could become.
The second half of the twentieth century has seen Winnicott’s ideas extended and applied in a variety of contexts, both in psychoanalysis and beyond.
Heinz Kohut extended Winnicott’s work in his investigation of narcissism, seeing narcissists as evolving a defensive armour around their damaged inner selves. He considered it less pathological to identify with the damaged remnants of the self, than to achieve coherence through identification with an external personality at the cost of one’s own autonomous creativity.
Alexander Lowen identified narcissists as having a true and a false, or superficial, self. The false self rests on the surface, as the self presented to the world. It stands in contrast to the true self, which resides behind the façade or image. This true self is the feeling self, but for the narcissist the feeling self must be hidden and denied. Since the superficial self represents submission and conformity, the inner or true self is rebellious and angry. This underlying rebellion and anger can never be fully suppressed since it is an expression of the life force in that person. But because of the denial, it cannot be expressed directly. Instead it shows up in the narcissist’s acting out. And it can become a perverse force.
James F. Masterson argued that all the personality disorders crucially involve the conflict between a person’s two selves: the false self, which the very young child constructs to please the mother, and the true self. The psychotherapy of personality disorders is an attempt to put people back in touch with their real selves.
Neville Symington developed Winnicott’s contrast between true and false self to cover the sources of personal action, contrasting an autonomous and a discordant source of action – the latter drawn from the internalisation of external influences and pressures. Thus for example parental dreams of self-glorification by way of their child’s achievements can be internalised as an alien discordant source of action. Symington stressed however the intentional element in the individual’s abandoning the autonomous self in favour of a false self or narcissistic mask – something he considered Winnicott to have overlooked.
As part of what has been described as a personal mission to raise the profile of the condition, psychology professor (and self-confessed narcissist) Sam Vaknin has highlighted the role of the false self in narcissism. The false self replaces the narcissist’s true self and is intended to shield him from hurt and narcissistic injury by self-imputing omnipotence. The narcissist pretends that his false self is real and demands that others affirm this confabulation, meanwhile keeping his real imperfect true self under wraps.
For Vaknin, the false self is by far more important to the narcissist than his dilapidated, dysfunctional true self; and he does not subscribe to the view that the true self can be resuscitated through therapy.
Alice Miller cautiously warns that a child/patient may not have any formed true self, waiting behind the false self façade; and that as a result freeing the true self is not as simple as the Winnicottian image of the butterfly emerging from its cocoon. If a true self can be developed, however, she considered that the empty grandiosity of the false self could give way to a new sense of autonomous vitality.
Orbach (False Bodies)
Susie Orbach saw the false self as an overdevelopment (under parental pressure) of certain aspects of the self at the expense of other aspects – of the full potential of the self – producing thereby an abiding distrust of what emerges spontaneously from the individual himself or herself. Orbach went on to extend Winnicott’s account of how environmental failure can lead to an inner splitting of mind and body, so as to cover the idea of the false body – falsified sense of one’s own body. Orbach saw the female false body in particular as built upon identifications with others, at the cost of an inner sense of authenticity and reliability. Breaking up a monolithic but false body-sense in the process of therapy could allow for the emergence of a range of authentic (even if often painful) body feelings in the patient.
Jungians have explored the overlap between Carl Jung’s concept of the persona and Winnicott’s false self; but, while noting similarities, consider that only the most rigidly defensive persona approximates to the pathological status of the false self.
Stern’s Tripartite Self
Daniel Stern considered Winnicott’s sense of “going on being” as constitutive of the core, pre-verbal self. He also explored how language could be used to reinforce a false sense of self, leaving the true self linguistically opaque and disavowed. He ended, however, by proposing a three-fold division of social, private, and of disavowed self.
Neville Symington criticised Winnicott for failing to integrate his false self insight with the theory of ego and id. Similarly, continental analysts like Jean-Bertrand Pontalis have made use of true/false self as a clinical distinction, while having reservations about its theoretical status.
The philosopher Michel Foucault took issue more broadly with the concept of a true self on the anti-essentialist grounds that the self was a construct – something one had to evolve through a process of subjectification, an aesthetics of self-formation, not something simply waiting to be uncovered: “we have to create ourselves as a work of art”.
Wuthering Heights has been interpreted in terms of the true self’s struggle to break through the conventional overlay.
In the novel, I Never Promised You a Rose Garden, the heroine saw her outward personality as a mere ghost of a Semblance, behind which her true self hid ever more completely.
Sylvia Plath’s poetry has been interpreted in terms of the conflict of the true and false selves.
The words sadism and sadist are derived from Marquis de Sade.
Sadism involves deriving pleasure through others undergoing discomfort or pain. The opponent-process theory is one way to help explain how an individual may come to not only display, but also enjoy committing sadistic acts. Individuals possessing sadistic personalities tend to display recurrent aggression and cruel behaviour. Sadism can also include the use of emotional cruelty, purposefully manipulating others through the use of fear, and a preoccupation with violence.
Theodore Millon claimed there were four subtypes of sadism, which he termed enforcing sadism, explosive sadism, spineless sadism, and tyrannical sadism.
Including avoidant features
Insecure, bogus, and cowardly; venomous dominance and cruelty is counterphobic; weakness counteracted by group support; public swaggering; selects powerless scapegoats.
Including negativistic features
Relishes menacing and brutalising others, forcing them to cower and submit; verbally cutting and scathing, accusatory and destructive; intentionally surly, abusive, inhumane, unmerciful.
Including compulsive features
Hostility sublimated in the “public interest,” cops, “bossy” supervisors, deans, judges; possesses the “right” to be pitiless, merciless, coarse, and barbarous; task is to control and punish, to search out rule breakers.
Including borderline features
Unpredictably precipitous outbursts and fury; uncontrollable rage and fearsome attacks; feelings of humiliation are pent-up and discharged; subsequently contrite.
Comorbidity with other Personality Disorders
Sadistic personality disorder has been found to occur frequently in unison with other personality disorders. Studies have also found that sadistic personality disorder is the personality disorder with the highest level of comorbidity to other types of psychopathological disorders. In contrast, sadism has also been found in patients who do not display any or other forms of psychopathic disorders. One personality disorder that is often found to occur alongside sadistic personality disorder is conduct disorder, not an adult disorder but one of childhood and adolescence. Studies have found other types of illnesses, such as alcoholism, to have a high rate of comorbidity with sadistic personality disorder.
Researchers have had some level of difficulty distinguishing sadistic personality disorder from other forms of personality disorders due to its high level of comorbidity with other disorders.
Removal from the DSM
Numerous theorists and clinicians introduced sadistic personality disorder to the DSM in 1987 and it was placed in the DSM-III-R as a way to facilitate further systematic clinical study and research. It was proposed to be included because of adults who possessed sadistic personality traits but were not being labelled, even though their victims were being labelled with a self-defeating personality disorder. Theorists like Theodore Millon wanted to generate further study on SPD, and so proposed it to the DSM-IV Personality Disorder Work Group, who rejected it. Millon writes that “Physically abusive, sadistic personalities are most often male, and it was felt that any such diagnosis might have the paradoxical effect of legally excusing cruel behavior.”
Sub-Clinical Sadism in Personality Psychology
There is renewed interest in studying sadism as a personality trait. Sadism joins with subclinical psychopathy, narcissism, and Machiavellianism to form the so-called “dark tetrad” of personality.
A personality development disorder is an inflexible and pervasive pattern of inner experience and behavior in children and adolescents, that markedly deviates from the expectations of the individual’s culture.
Personality development disorder is not recognised as a mental disorder in any of the medical manuals, such as the ICD-10 or the DSM-IV, nor the more recent DSM-5. DSM-IV allows the diagnosis of personality disorders in children and adolescents only as an exception. This diagnosis is currently proposed by a few authors in Germany. The term personality development disorder is used to emphasize the changes in personality development which might still take place and the open outcome during development. Personality development disorder is considered to be a childhood risk factor or early stage of a later personality disorder in adulthood.
Adults usually show personality patterns over a long duration of time. Children and adolescents however still show marked changes in personality development. Some of these children and adolescents have a hard time developing their personalities in an ordinary way. DSM-IV states, for example, that children and adolescents are at higher risk to develop an antisocial personality disorder if they showed signs of conduct disorder and attention deficit disorder before the age of 10. This led Adam & Breithaupt-Peters (2010) to the idea that these children and adolescents need to be looked at more carefully. The therapy which these children and adolescents need might be more intense and maybe even different from looking at the disorders traditionally. The concept of personality development disorders also focuses on the severity of the disorder and the poor prognosis. An early diagnosis might help to get the right treatment at an early stage and thus might help to prevent a personality disorder outcome in adulthood.
Similar to the adult diagnosis personality disorder these children display enduring patterns of inner experience and behaviour deviating markedly from the expectations of the individual’s culture. These patterns are inflexible and pervasive across a broad range of personal and social situations, lead to clinically significant distress or impairment in social, occupational or other important areas of functioning and they are stable and of long duration (more than a year).
The term personality development disorder (Persönlichkeitsentwicklungsstörung) was first used in German by Spiel & Spiel (1987). Adam & Breithaupt-Peters (2010) adapted the term to a more modern concept and suggested the below definition.
Similar to adult personality disorders there are multiple causes and causal interactions for personality development disorders. In clinical practice it is important to view the disorder from multiple perspectives and from an individual perspective. Biological and neurological causes need to be observed just as much as psychosocial factors. Looking at the disorder from only one perspective (e.g. (s)he had a bad childhood) often results in ignorance of important other factors or causal interactions. This might be one of the main reasons why traditional treatment methods often fail with these disorders. Only a multi-perspective view can provide for a multi-dimensional treatment approach which seems to be the key for these disorders.
The diagnosis personality development disorder should only be given carefully and after a longer period of evaluation. Also a thorough diagnostic evaluation is necessary. Parents should be questioned separately and together with the child or adolescent to evaluate the severity and duration of the problems. In addition standardised personality tests might be helpful. It is also useful to ask the family what treatment approaches they have already tried so far without success.
According to Adam und Breithaupt-Peters personality development disorders are defined as complex disorders:
Which show similarity to a certain type of personality disorder in adulthood.
Which persist over a long period of time (more than a year) and show a tendency towards being chronic.
Which have a severe negative impact on more than one important area of functioning or social life.
Which show resistance to traditional educational and therapeutic treatment methods.
Which result in a reduced insight into or ignorance of the own problem behaviour. The family usually suffers more than the child or adolescent and has a hard time dealing with the diminished introspection.
Which make positive interactions between the children/adolescents and other people merely impossible. Instead social collisions are part of everyday life.
Which threaten the social integration of the young person into a social life and might result in an emotional disability.
Personality development disorders usually need a complex and multi-dimensional treatment approach (Adam & Breithaupt-Peters, 2010). Since the problems are complex, treatment needs to affect the conditions in all impaired functional and social areas. Both educational and therapeutic methods are helpful and problem and strength based approaches work hand in hand. Parents need to be included as well as the school environment. Treatment methods need to be flexible and adjustable to the individual situation. Even elements of social work can be helpful when supporting the families and in some cases medication might be necessary. When suicidal behaviours or self-injuries are prominent treatment might best be done in a hospital.
In the study of psychology, neuroticism has been considered a fundamental personality trait.
For example, in the Big Five approach to personality trait theory, individuals with high scores for neuroticism are more likely than average to be moody and to experience such feelings as anxiety, worry, fear, anger, frustration, envy, jealousy, guilt, depressed mood, and loneliness. Such people are thought to respond worse to stressors and are more likely to interpret ordinary situations, such as minor frustrations, as appearing hopelessly difficult. They are described as often being self-conscious and shy, and tending to have trouble controlling urges and delaying gratification.
People with high scores on the neuroticism index are thought to be at risk of developing common mental disorders (mood disorders, anxiety disorders, and substance use disorders have been studied), and the sorts of symptoms traditionally referred to as “neuroses”.
Neuroticism is a trait in many models within personality theory, but there is significant disagreement on its definition. It is sometimes defined as a tendency for quick arousal when stimulated and slow relaxation from arousal, especially with regard to negative emotional arousal. Another definition focuses on emotional instability and negativity or maladjustment, in contrast to emotional stability and positivity, or good adjustment. It has also been defined in terms of lack of self-control, poor ability to manage psychological stress, and a tendency to complain.
Various personality tests produce numerical scores, and these scores are mapped onto the concept of “neuroticism” in various ways, which has created some confusion in the scientific literature, especially with regard to sub-traits or “facets”.
Individuals who score low in neuroticism tend to be more emotionally stable and less reactive to stress. They tend to be calm, even-tempered, and less likely to feel tense or rattled. Although they are low in negative emotion, they are not necessarily high in positive emotion. Being high in scores of positive emotion is generally an element of the independent trait of extraversion. Neurotic extraverts, for example, would experience high levels of both positive and negative emotional states, a kind of “emotional roller coaster”.
Like other personality traits, neuroticism is typically viewed as a continuous dimension rather than a discrete state.
The extent of neuroticism is generally assessed using self-report measures, although peer-reports and third-party observation can also be used. Self-report measures are either lexical or based on statements. Deciding which measure of either type to use in research is determined by an assessment of psychometric properties and the time and space constraints of the study being undertaken.
Lexical measures use individual adjectives that reflect neurotic traits, such as anxiety, envy, jealousy, and moodiness, and are very space and time efficient for research purposes. Lewis Goldberg (1992) developed a 20-word measure as part of his 100-word Big Five markers. Saucier (1994) developed a briefer 8-word measure as part of his 40-word mini-markers. Thompson (2008) systematically revised these measures to develop the International English Mini-Markers which has superior validity and reliability in populations both within and outside North America. Internal consistency reliability of the International English Mini-Markers for the Neuroticism (emotional stability) measure for native English-speakers is reported as 0.84, and that for non-native English-speakers is 0.77.
Statement measures tend to comprise more words, and hence consume more research instrument space, than lexical measures. Respondents are asked the extent to which they, for example, “Remain calm under pressure”, or “Have frequent mood swings”. While some statement-based measures of neuroticism have similarly acceptable psychometric properties in North American populations to lexical measures, their generally emic development makes them less suited to use in other populations. For instance, statements in colloquial North American English like “Seldom feel blue” and “Am often down in the dumps” are sometimes hard for non-native English-speakers to understand.
Neuroticism has also been studied from the perspective of Gray’s biopsychological theory of personality, using a scale that measures personality along two dimensions: the behavioural inhibition system (BIS) and the behavioural activation system (BAS). The BIS is thought to be related to sensitivity to punishment as well as avoidance motivation, while the BAS is thought to be related to sensitivity to reward as well as approach motivation. Neuroticism has been found to be positively correlated with the BIS scale, and negatively correlated with the BAS scale.
Neuroticism has been included as one of the four dimensions that comprise core self-evaluations, one’s fundamental appraisal of oneself, along with locus of control, self-efficacy, and self-esteem. The concept of core self-evaluations was first examined by Judge, Locke, and Durham (1997), and since then evidence has been found to suggest these have the ability to predict several work outcomes, specifically, job satisfaction and job performance.
There is a risk of selection bias in surveys of neuroticism; a 2012 review of N-scores said that “many studies used samples drawn from privileged and educated populations”.
Neuroticism is highly correlated with the startle reflex in response to fearful conditions and inversely correlated with it in response to disgusting or repulsive stimuli. This suggests that Neuroticism may increase vigilance where evasive action is possible but promote emotional blunting when escape is not an option. A measure of the startle reflex can be used to predict the trait neuroticism with good accuracy; a fact that is thought by some to underlie the neurological basis of the trait. The startle reflex is a reflex in response to a loud noise that one typically has no control over, though anticipation can reduce the effect. The strength of the reflex as well as the time until the reflex ceases can be used to predict neuroticism.
Mental Disorder Correlations
Questions used in many neuroticism scales overlap with instruments used to assess mental disorders like anxiety disorders (especially social anxiety disorder) and mood disorders (especially major depressive disorder), which can sometimes confound efforts to interpret N scores and makes it difficult to determine whether each of neuroticism and the overlapping mental disorders might cause the other, or if both might stem from other cause. Correlations can be identified.
A 2013 meta-analysis found that a wide range of clinical mental disorders are associated with elevated levels of neuroticism compared to levels in the general population. It found that high neuroticism is predictive for the development of anxiety disorders, major depressive disorder, psychosis, and schizophrenia, and is predictive but less so for substance use and non-specific mental distress. These associations are smaller after adjustment for elevated baseline symptoms of the mental illnesses and psychiatric history.
Neuroticism has also been found to be associated with older age. In 2007, Mroczek & Spiro found that among older men, upward trends in neuroticism over life as well as increased neuroticism overall both contributed to higher mortality rates.
Disorders associated with elevated neuroticism include mood disorders, such as depression and bipolar disorder, anxiety disorders, eating disorders, schizophrenia and schizoaffective disorder, dissociative identity disorder, and hypochondriasis. Mood disorders tend to have a much larger association with neuroticism than most other disorders. The five big studies have described children and adolescents with high neuroticism as “anxious, vulnerable, tense, easily frightened, ‘falling apart’ under stress, guilt-prone, moody, low in frustration tolerance, and insecure in relationships with others,” which includes both traits concerning the prevalence of negative emotions as well as the response to these negative emotions. Neuroticism in adults similarly was found to be associated with the frequency of self-reported problems.
These associations can vary with culture: for example, Adams found that among upper-middle-class American teenaged girls, neuroticism was associated with eating disorders and self-harm, but among Ghanaian teenaged girls, higher neuroticism was associated with magical thinking and extreme fear of enemies.
A 2004 meta-analysis attempted to analyse personality disorders in light of the five-factor personality theory and failed to find meaningful discriminations; it did find that elevated neuroticism is correlated with many personality disorders.
Theories of Causation
Studies have found that the mean reaction times will not differ between individuals high in neuroticism and those low in neuroticism, but that, with individuals high in neuroticism, there is considerably more trial-to-trial variability in performance reflected in reaction time standard deviations. In other words, on some trials neurotic individuals are faster than average, and on others they are slower than average. It has been suggested that this variability reflects noise in the individual’s information processing systems or instability of basic cognitive operations (such as regulation processes), and further that this noise originates from two sources: mental preoccupations and reactivity processes.
Flehmig et al. (2007) studied mental noise in terms of everyday behaviours using the Cognitive Failures Questionnaire, which is a self-report measure of the frequency of slips and lapses of attention. A “slip” is an error by commission, and a “lapse” is an error by omission. This scale was correlated with two well-known measures of neuroticism, the BIS/BAS scale and the Eysenck Personality Questionnaire. Results indicated that the CFQ-UA (Cognitive Failures Questionnaire- Unintended Activation) subscale was most strongly correlated with neuroticism (r = .40) and explained the most variance (16%) compared to overall CFQ scores, which only explained 7%. The authors interpret these findings as suggesting that mental noise is “highly specific in nature” as it is related most strongly to attention slips triggered endogenously by associative memory. In other words, this may suggest that mental noise is mostly task-irrelevant cognitions such as worries and preoccupations.
The theory of evolution may also explain differences in personality. For example, one of the evolutionary approaches to depression focuses on neuroticism and finds that heightened reactivity to negative outcomes may have had a survival benefit, and that furthermore a positive relationship has been found between neuroticism level and success in university with the precondition that the negative effects of neuroticism are also successfully coped with. Likewise, a heightened reactivity to positive events may have had reproductive advantages, selecting for heightened reactivity generally. Nettle contends that evolution selected for higher levels of neuroticism until the negative effects of neuroticism outweighed its benefits, resulting in selection for a certain optimal level of neuroticism. This type of selection will result in a normal distribution of neuroticism, so the extremities of the distribution will be individuals with excessive neuroticism or too low neuroticism for what is optimal, and the ones with excessive neuroticism would therefore be more vulnerable to the negative effects of depression, and Nettle gives this as the explanation for the existence of depression rather than hypothesizing, as others have, that depression itself has any evolutionary benefit.
Some research has found that neuroticism, in modern societies, is positively correlated with reproductive success in females but not in males. A possible explanation may be that neuroticism in females comes at the expense of formal education (which is correlated with lower fertility) and correlates with unplanned and adolescent pregnancies.
Terror Management Theory
According to terror management theory (TMT) neuroticism is primarily caused by insufficient anxiety buffers against unconscious death anxiety. These buffers consist of:
Cultural worldviews that impart life with a sense of enduring meaning, such as social continuity beyond one’s death, future legacy and afterlife beliefs, and
A sense of personal value, or the self-esteem in the cultural worldview context, an enduring sense of meaning.
While TMT agrees with standard evolutionary psychology accounts that the roots of neuroticism in Homo sapiens or its ancestors are likely in adaptive sensitivities to negative outcomes, it posits that once Homo sapiens achieved a higher level of self-awareness, neuroticism increased enormously, becoming largely a spandrel, a non-adaptive by-product of our adaptive intelligence, which resulted in a crippling awareness of death that threatened to undermine other adaptive functions. This overblown anxiety thus needed to be buffered via intelligently creative, but largely fictitious and arbitrary notions of cultural meaning and personal value. Since highly religious or supernatural conceptions of the world provide “cosmic” personal significance and literal immortality, they are deemed to offer the most efficient buffers against death anxiety and neuroticism. Thus, historically, the shift to more materialistic and secular cultures – starting in the Neolithic, and culminating in the industrial revolution, is deemed to have increased neuroticism.
Genetic and Environmental Factors
A 2013 review found that “Neuroticism is the product of the interplay between genetic and environmental influences. Heritability estimates typically range from 40% to 60%.” The effect size of these genetic differences remain largely the same throughout development, but the hunt for any specific genes that control neuroticism levels has “turned out to be difficult and hardly successful so far.” On the other hand, with regards to environmental influences, adversities during development such as “emotional neglect and sexual abuse” were found to be positively associated with neuroticism. However, “sustained change in neuroticism and mental health are rather rare or have only small effects.”
In the July 1951 article: “The Inheritance of Neuroticism” by Hans J. Eysenck and Donald Prell it was reported that some 80 per cent of individual differences in neuroticism are due to heredity and only 20 percent are due to environment….the factor of neuroticism is not a statistical artifact, but constitutes a biological unit which is inherited as a whole….neurotic predisposition is to a large extent hereditarily determined.
In children and adolescents, psychologists speak of temperamental negative affectivity that, during adolescence, develops into the neuroticism personality domain. Mean neuroticism levels change throughout the lifespan as a function of personality maturation and social roles, but also the expression of new genes. Neuroticism in particular was found to decrease as a result of maturity by decreasing through age 40 and then levelling off. Generally speaking, the influence of environments on neuroticism increases over the lifespan, although people probably select and evoke experiences based on their neuroticism levels.
The emergent field of “imaging genetics,” which investigates the role of genetic variation in the structure and function of the brain, has studied certain genes suggested to be related to neuroticism, and the one studied so far concerning this topic has been the serotonin transporter-linked promoter region gene known as 5-HTTLPR, which is transcribed into a serotonin transporter that removes serotonin. It has been found that compared to the long (l) variant of 5-HTTLPR, the short (s) variant has reduced promoter activity, and the first study on this subject has shown that the presence of the s-variant 5-HTTLPR has been found to result in higher amygdala activity from seeing angry or fearful faces while doing a non-emotional task, with further studies confirming that the s-variant 5-HTTLPR result greater amygdala activity in response to negative stimuli, but there have also been null findings. A meta-analysis of 14 studies has shown that this gene has a moderate effect size and accounts for 10% of the phenotypic difference. However, the relationship between brain activity and genetics may not be completely straightforward due to other factors, with suggestions made that cognitive control and stress may moderate the effect of the gene. There are two models that have been proposed to explain the type of association between the 5-HTTLPR gene and amygdala activity: the “phasic activation” model proposes that the gene controls amygdala activity levels in response to stress, whereas the “tonic activation” model, on the other hand, proposes that the gene controls baseline amygdala activity. Another gene that has been suggested for further study to be related to neuroticism is the catechol-O-methyltransferase (COMT) gene.
The anxiety and maladaptive stress responses that are aspects of neuroticism have been the subject of intensive study. Dysregulation of hypothalamic-pituitary-adrenal axis and glucocorticoid system, and influence of different versions of the serotonin transporter and 5-HT1A receptor genes may influence the development of neuroticism in combination with environmental effects like the quality of upbringing.
Neuroimaging studies with fMRI have had mixed results, with some finding that increased activity in the amygdala and anterior cingulate cortex, brain regions associated with arousal, is correlated with high neuroticism scores, as is activation of the associations have also been found with the medial prefrontal cortex, insular cortex, and hippocampus, while other studies have found no correlations. Further studies have been conducted trying to tighten experimental design by using genetics to add additional differentiation among participants, as well as twin study models.
A related trait, behavioural inhibition, or “inhibition to the unfamiliar,” has received attention as the trait concerning withdrawal or fear from unfamiliar situations, which is generally measured through observation of child behaviour in response to, for example, encountering unfamiliar individuals. This trait in particular has been hypothesized to be related to amygdala function, but the evidence so far has been mixed.
Age, Gender, and Geographic Patterns
A 2013 review found that groups associated with higher levels of neuroticism are young adults who are at high risk for mood disorders. Research in large samples has shown that levels of neuroticism are higher in women than men. Neuroticism is found to decrease slightly with age. The same study noted that no functional MRI studies have yet been performed to investigate these differences, calling for more research. A 2010 review found personality differences between genders to be between “small and moderate,” the largest of those differences being in the traits of agreeableness and neuroticism. Many personality traits were found to have had larger personality differences between men and women in developed countries compared to less developed countries, and differences in three traits – extraversion, neuroticism, and people-versus-thing orientation – showed differences that remained consistent across different levels of economic development, which is also consistent with the “possible influence of biologic factors.” Three cross-cultural studies have revealed higher levels of female neuroticism across almost all nations.
Geographically, a 2016 review said that in the US, neuroticism is highest in the mid-Atlantic states and southwards and declines westward, while openness to experience is highest in ethnically diverse regions of the mid-Atlantic, New England, the West Coast, and cities. Likewise, in the UK neuroticism is lowest in urban areas. Generally, geographical studies find correlations between low neuroticism and entrepreneurship and economic vitality and correlations between high neuroticism and poor health outcomes. The review found that the causal relationship between regional cultural and economic conditions and psychological health is unclear.
Personality disorders (PD) are a class of mental disorders characterised by enduring maladaptive patterns of behaviour, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual’s culture.
Personality, defined psychologically, is the set of enduring behavioural and mental traits that distinguish individual humans. Hence, PDs are defined by experiences and behaviours that deviate from social norms and expectations. Those diagnosed with a PD may experience difficulties in cognition, emotiveness, interpersonal functioning, or impulse control. In general, PDs are diagnosed in 40-60% of psychiatric patients, making them the most frequent of psychiatric diagnoses.
PDs are characterised by an enduring collection of behavioural patterns often associated with considerable personal, social, and occupational disruption. PDs are also inflexible and pervasive across many situations, largely due to the fact that such behaviour may be ego-syntonic (i.e. the patterns are consistent with the ego integrity of the individual) and are therefore perceived to be appropriate by that individual. In addition, people with personality disorders often lack insight into their condition and so refrain from seeking treatment. This behaviour can result in maladaptive coping skills and may lead to personal problems that induce extreme anxiety, distress, or depression and result in impaired psychosocial functioning. These behaviour patterns are typically recognised by adolescence, the beginning of adulthood or sometimes even childhood and often have a pervasive negative impact on the quality of life.
While emerging treatments, such as dialectical behaviour therapy, have demonstrated efficacy in treating PDs, such as borderline personality disorder, PDs are associated with considerable stigma in popular and clinical discourse alike. Despite various methodological schemas designed to categorise PDs, many issues occur with classifying a personality disorder because the theory and diagnosis of such disorders occur within prevailing cultural expectations; thus, their validity is contested by some experts on the basis of inevitable subjectivity. They argue that the theory and diagnosis of PDs are based strictly on social, or even sociopolitical and economic considerations.
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. For example, the Greek philosopher Theophrastus described 29 ‘character’ types that he saw as deviations from the norm, and similar views have been found in Asian, Arabic and Celtic cultures. A long-standing influence in the Western world was Galen’s concept of personality types, which he linked to the four humours proposed by Hippocrates.
Such views lasted into the eighteenth century, when experiments began to question the supposed biologically based humours and ‘temperaments’. Psychological concepts of character and ‘self’ became widespread. In the nineteenth century, ‘personality’ referred to a person’s conscious awareness of their behaviour, a disorder of which could be linked to altered states such as dissociation. This sense of the term has been compared to the use of the term ‘multiple personality disorder’ in the first versions of the DSM.
Physicians in the early nineteenth century started to diagnose forms of insanity involving disturbed emotions and behaviours 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 ethics, but it was arguably based in part on religious, social and moral beliefs, with a pessimism about medical intervention so social control should take precedence. 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 popularised 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’, theorised 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 judgement. Described as deeply rooted in his Christian faith, his work established the concept of personality disorder as used today.
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:
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 behavioural pathology, he distinguished nine clusters of psychopaths: cycloids (including constitutionally depressive, constitutionally excitable, cyclothymics, and emotionally labile), asthenics (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 behaviour. Hervey M. Cleckley’s 1941 text, The Mask of Sanity, based on his personal categorisation 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 wilful 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 Rorshach, 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 recognised 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 ‘operationalised’ 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 behaviours associated with personality disorders. In the US, the prevailing healthcare system and psychanalytic tradition has been said to provide a rationale for private therapists to diagnose some personality disorders more broadly and provide ongoing treatment for them.
The prevalence of personality disorder in the general community was largely unknown until surveys starting from the 1990s. In 2008 the median rate of diagnosable PD was estimated at 10.6%, based on six major studies across three nations. This rate of around one in ten, especially as associated with high use of services, is described as a major public health concern requiring attention by researchers and clinicians.
The prevalence of individual personality disorders ranges from about 2% to 3% for the more common varieties, such as schizotypal, antisocial, borderline, and histrionic, to 0.5-1% for the least common, such as narcissistic and avoidant.
A screening survey across 13 countries by the WHO using DSM-IV criteria, reported in 2009 a prevalence estimate of around 6% for personality disorders. The rate sometimes varied with demographic and socioeconomic factors, and functional impairment was partly explained by co-occurring mental disorders. In the US, screening data from the National Comorbidity Survey Replication between 2001 and 2003, combined with interviews of a subset of respondents, indicated a population prevalence of around 9% for personality disorders in total. Functional disability associated with the diagnoses appeared to be largely due to co-occurring mental disorders (Axis I in the DSM).
A UK national epidemiological study (based on DSM-IV screening criteria), reclassified into levels of severity rather than just diagnosis, reported in 2010 that the majority of people show some personality difficulties in one way or another (short of threshold for diagnosis), while the prevalence of the most complex and severe cases (including meeting criteria for multiple diagnoses in different clusters) was estimated at 1.3%. Even low levels of personality symptoms were associated with functional problems, but the most severely in need of services was a much smaller group.
Personality disorders (especially Cluster A) are also very common among homeless people.
There are some sex differences in the frequency of personality disorders which are shown below (type of PD/predominant gender):
Paranoid personality disorder: Male.
Schizoid personality disorder: Male.
Schizotypal personality disorder: Male.
Antisocial personality disorder: Male.
Borderline personality disorder: Female.
Histrionic personality disorder: Female.
Narcissistic personality disorder: Male.
Avoidant personality disorder: Male.
Dependent personality disorder: Female.
Depressive personality disorder: Female.
Passive–aggressive personality disorder: Male.
Obsessive-compulsive personality disorder: Male.
Self-defeating personality disorder: Female.
Sadistic personality disorder: Male.
The two relevant major systems of classification are:
The ICD system is a collection of numerical codes that have been assigned to all known clinical disease states, which provides uniform terminology for medical records, billing, and research purposes. The DSM defines psychiatric diagnoses based on research and expert consensus, and its content informs the ICD-10 classifications. Both have deliberately merged their diagnoses to some extent, but some differences remain. For example, ICD-10 does not include narcissistic personality disorder as a distinct category, while DSM-5 does not include enduring personality change after catastrophic experience or after psychiatric illness. ICD-10 classifies the DSM-5 schizotypal personality disorder as a form of schizophrenia rather than as a personality disorder. There are accepted diagnostic issues and controversies with regard to distinguishing particular personality disorder categories from each other.
Both diagnostic systems provide a definition and six criteria for a general personality disorder. These criteria should be met by all personality disorder cases before a more specific diagnosis can be made.
The ICD-10 lists these general guideline criteria:
Markedly disharmonious attitudes and behaviour, generally involving several areas of functioning, e.g. affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others;
The abnormal behaviour pattern is enduring, of long standing, and not limited to episodes of mental illness;
The abnormal behaviour pattern is pervasive and clearly maladaptive to a broad range of personal and social situations;
The above manifestations always appear during childhood or adolescence and continue into adulthood;
The disorder leads to considerable personal distress but this may only become apparent late in its course;
The disorder is usually, but not invariably, associated with significant problems in occupational and social performance.
The ICD adds: “For different cultures it may be necessary to develop specific sets of criteria with regard to social norms, rules and obligations.”
In DSM-5, any personality disorder diagnosis must meet the following criteria:
An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
Cognition (i.e. ways of perceiving and interpreting self, other people, and events).
Affectivity (i.e. the range, intensity, lability, and appropriateness of emotional response).
The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.
The enduring pattern is not attributable to the physiological effects of a substance (e.g. a drug of abuse, a medication) or another medical condition (e.g. head trauma).
Chapter V in the ICD-10 contains the mental and behavioural disorders and includes categories of personality disorder and enduring personality changes. They are defined as ingrained patterns indicated by inflexible and disabling responses that significantly differ from how the average person in the culture perceives, thinks, and feels, particularly in relating to others.
The specific personality disorders are: paranoid, schizoid, dissocial, emotionally unstable (borderline type and impulsive type), histrionic, anankastic, anxious (avoidant) and dependent.
Besides the ten specific PD, there are the following categories:
Other specific personality disorders (involves PD characterised as eccentric, haltlose, immature, narcissistic, passive-aggressive, or psychoneurotic).
Personality disorder, unspecified (includes “character neurosis” and “pathological personality”).
Mixed and other personality disorders (defined as conditions that are often troublesome but do not demonstrate the specific pattern of symptoms in the named disorders).
Enduring personality changes, not attributable to brain damage and disease (this is for conditions that seem to arise in adults without a diagnosis of personality disorder, following catastrophic or prolonged stress or other psychiatric illness).
In the proposed revision of ICD-11, all discrete personality disorder diagnoses will be removed and replaced by the single diagnosis “personality disorder”. Instead, there will be specifiers called “prominent personality traits” and the possibility to classify degrees of severity ranging from “mild”, “moderate”, and “severe” based on the dysfunction in interpersonal relationships and everyday life of the patient.
There are six prominent personality traits/patterns categorised by the ICD-11:
Detachment (“tendency to maintain interpersonal distance (social detachment) and emotional distance (emotional detachment).”).
Dissociality (“disregard for the rights and feelings of others, encompassing both self-centredness and lack of empathy.” Equivalent to the DSM-5 classification of antisocial personality disorder.).
Disinhibition (“tendency to act rashly based on immediate external or internal stimuli (i.e., sensations, emotions, thoughts), without consideration of potential negative consequences.”).
Anankastia (“narrow focus on one’s rigid standard of perfection and of right and wrong, and on controlling one’s own and others’ behaviour and controlling situations to ensure conformity to these standards.” Equivalent to the DSM-5 classification of obsessive-compulsive personality disorder.),
Borderline pattern (“pattern of personality disturbance is characterised by a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity”. Equivalent to the DSM-5 classification of borderline personality disorder.),
The most recent fifth edition of the Diagnostic and Statistical Manual of Mental Disorders stresses that a personality disorder is an enduring and inflexible pattern of long duration leading to significant distress or impairment and is not due to use of substances or another medical condition. The DSM-5 lists personality disorders in the same way as other mental disorders, rather than on a separate ‘axis’, as previously.
DSM-5 lists ten specific personality disorders: paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent and obsessive-compulsive personality disorder.
The DSM-5 also contains three diagnoses for personality patterns not matching these ten disorders, but nevertheless exhibit characteristics of a personality disorder:
Personality change due to another medical condition – personality disturbance due to the direct effects of a medical condition.
Other specified personality disorder – general criteria for a personality disorder are met but fails to meet the criteria for a specific disorder, with the reason given.
Unspecified personality disorder – general criteria for a personality disorder are met but the personality disorder is not included in the DSM-5 classification.
The specific personality disorders are grouped into the following three clusters based on descriptive similarities:
Cluster A (Odd or Eccentric Disorders)
Cluster A personality disorders are often associated with schizophrenia: in particular, schizotypal personality disorder shares some of its hallmark symptoms with schizophrenia, e.g., acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behaviour. However, people diagnosed with odd-eccentric personality disorders tend to have a greater grasp on reality than those with schizophrenia. Patients suffering from these disorders can be paranoid and have difficulty being understood by others, as they often have odd or eccentric modes of speaking and an unwillingness and inability to form and maintain close relationships. Though their perceptions may be unusual, these anomalies are distinguished from delusions or hallucinations as people suffering from these would be diagnosed with other conditions. Significant evidence suggests a small proportion of people with Cluster A personality disorders, especially schizotypal personality disorder, have the potential to develop schizophrenia and other psychotic disorders. These disorders also have a higher probability of occurring among individuals whose first-degree relatives have either schizophrenia or a Cluster A personality disorder.
Paranoid personality disorder: characterised by a pattern of irrational suspicion and mistrust of others, interpreting motivations as malevolent.
Cluster B (Dramatic, Emotional or Erratic Disorders)
Antisocial personality disorder: pervasive pattern of disregard for and violation of the rights of others, lack of empathy, bloated self-image, manipulative and impulsive behaviour.
Borderline personality disorder: pervasive pattern of abrupt emotional outbursts, altered empathy, instability in relationships, self-image, identity, behaviour and affect, often leading to self-harm and impulsivity.
Narcissistic personality disorder: pervasive pattern of superior grandiosity, need for admiration, and a perceived or real lack of empathy. In a more severe expression, narcissistic personality disorder may show evidence of paranoia, aggression, psychopathy, and sadistic personality disorder, which is known as malignant narcissism.
Obsessive-compulsive personality disorder: characterised by rigid conformity to rules, perfectionism, and control to the point of satisfaction and exclusion of leisurely activities and friendships (distinct from obsessive-compulsive disorder).
Other Personality Types
Some types of personality disorder were in previous versions of the diagnostic manuals but have been deleted. Examples include sadistic personality disorder (pervasive pattern of cruel, demeaning, and aggressive behaviour) and self-defeating personality disorder or masochistic personality disorder (characterised by behaviour consequently undermining the person’s pleasure and goals). They were listed in the DSM-III-R appendix as “Proposed diagnostic categories needing further study” without specific criteria. The psychologist Theodore Millon and others consider some relegated diagnoses to be equally valid disorders, and may also propose other personality disorders or subtypes, including mixtures of aspects of different categories of the officially accepted diagnoses.
Psychologist Theodore Millon, who has written numerous popular works on personality, proposed the following description of personality disorders:
Type of Personality Disorder
Guarded, defensive, distrustful and suspicious. Hypervigilant to the motives of others to undermine or do harm. Always seeking confirmatory evidence of hidden schemes. Feel righteous, but persecuted. Experience a pattern of pervasive distrust and suspicion of others that lasts a long time. They are generally difficult to work with and are very hard to form relationships with. They are also known to be somewhat short-tempered.
Apathetic, indifferent, remote, solitary, distant, humourless, contempt, odd fantasies. Neither desire nor need human attachments. Withdrawn from relationships and prefer to be alone. Little interest in others, often seen as a loner. Minimal awareness of the feelings of themselves or others. Few drives or ambitions, if any. Is an uncommon condition in which people avoid social activities and consistently shy away from interaction with others. It affects more males than females. To others, they may appear somewhat dull or humourless. Because they don’t tend to show emotion, they may appear as though they don’t care about what’s going on around them.
Eccentric, self-estranged, bizarre, absent. Exhibit peculiar mannerisms and behaviours. Think they can read thoughts of others. Preoccupied with odd daydreams and beliefs. Blur line between reality and fantasy. Magical thinking and strange beliefs. People with schizotypal personality disorder are often described as odd or eccentric and usually have few, if any, close relationships. They think others think negatively of them.
Impulsive, irresponsible, deviant, unruly. Act without due consideration. Meet social obligations only when self-serving. Disrespect societal customs, rules, and standards. See themselves as free and independent. People with antisocial personality disorder depict a long pattern of disregard for other people’s rights. They often cross the line and violate these rights.
Unpredictable, egocentric, emotionally unstable. Frantically fears abandonment and isolation. Experience rapidly fluctuating moods. Shift rapidly between loving and hating. See themselves and others alternatively as all-good and all-bad. Unstable and frequently changing moods. People with borderline personality disorder have a pervasive pattern of instability in interpersonal relationships.
Hysteria, dramatic, seductive, shallow, egocentric, attention-seeking, vain. Overreact to minor events. Exhibitionistic as a means of securing attention and favours. See themselves as attractive and charming. Constantly seeking others’ attention. Disorder is characterised by constant attention-seeking, emotional overreaction, and suggestibility. Their tendency to over-dramatise may impair relationships and lead to depression, but they are often high-functioning.
Egotistical, arrogant, grandiose, insouciant. Preoccupied with fantasies of success, beauty, or achievement. See themselves as admirable and superior, and therefore entitled to special treatment. Is a mental disorder in which people have an inflated sense of their own importance and a deep need for admiration. Those with narcissistic personality disorder believe that they are superior to others and have little regard for other people’s feelings.
Hesitant, self-conscious, embarrassed, anxious. Tense in social situations due to fear of rejection. Plagued by constant performance anxiety. See themselves as inept, inferior, or unappealing. They experience long-standing feelings of inadequacy and are very sensitive of what others think about them.
Helpless, incompetent, submissive, immature. Withdrawn from adult responsibilities. See themselves as weak or fragile. Seek constant reassurance from stronger figures. They have the need to be taken care of by a person. They fear being abandoned or separated from important people in their life.
Restrained, conscientious, respectful, rigid. Maintain a rule-bound lifestyle. Adhere closely to social conventions. See the world in terms of regulations and hierarchies. See themselves as devoted, reliable, efficient, and productive.
Sombre, discouraged, pessimistic, brooding, fatalistic. Present themselves as vulnerable and abandoned. Feel valueless, guilty, and impotent. Judge themselves as worthy only of criticism and contempt. Hopeless, suicidal, restless. This disorder can lead to aggressive acts and hallucinations.
Resentful, contrary, sceptical, discontented. Resist fulfilling others’ expectations. Deliberately inefficient. Vent anger indirectly by undermining others’ goals. Alternately moody and irritable, then sullen and withdrawn. Withhold emotions. Will not communicate when there is something problematic to discuss.
Explosively hostile, abrasive, cruel, dogmatic. Liable to sudden outbursts of rage. Gain satisfaction through dominating, intimidating and humiliating others. They are opinionated and closed-minded. Enjoy performing brutal acts on others. Find pleasure in abusing others. Would likely engage in a sadomasochist relationship, but will not play the role of a masochist.
Deferential, pleasure-phobic, servile, blameful, self-effacing. Encourage others to take advantage of them. Deliberately defeat own achievements. Seek condemning or mistreatful partners. They are suspicious of people who treat them well. Would likely engage in a sadomasochist relationship.
In addition to classifying by category and cluster, it is possible to classify personality disorders using additional factors such as severity, impact on social functioning, and attribution.
This involves both the notion of personality difficulty as a measure of subthreshold scores for personality disorder using standard interviews and the evidence that those with the most severe personality disorders demonstrate a “ripple effect” of personality disturbance across the whole range of mental disorders. In addition to subthreshold (personality difficulty) and single cluster (simple personality disorder), this also derives complex or diffuse personality disorder (two or more clusters of personality disorder present) and can also derive severe personality disorder for those of greatest risk.
Dimensional System of Classifying Personality Disorders
Level of Severity
Definition by Categorical System
No personality disorder
Does not meet actual or subthreshold criteria for any personality disorder.
Meets sub-threshold criteria for one or several personality disorders.
Simple personality disorder
Meets actual criteria for one or more personality disorders within the same cluster.
Complex (diffuse) personality disorder
Meets actual criteria for one or more personality disorders within more than one cluster.
Severe personality disorder
Meets criteria for creation of severe disruption to both individual and to many in society.
There are several advantages to classifying personality disorder by severity:
It not only allows for but also takes advantage of the tendency for personality disorders to be comorbid with each other.
It represents the influence of personality disorder on clinical outcome more satisfactorily than the simple dichotomous system of no personality disorder versus personality disorder.
This system accommodates the new diagnosis of severe personality disorder, particularly “dangerous and severe personality disorder” (DSPD).
Effect on Social Functioning
Social function is affected by many other aspects of mental functioning apart from that of personality. However, whenever there is persistently impaired social functioning in conditions in which it would normally not be expected, the evidence suggests that this is more likely to be created by personality abnormality than by other clinical variables. The Personality Assessment Schedule gives social function priority in creating a hierarchy in which the personality disorder creating the greater social dysfunction is given primacy over others in a subsequent description of personality disorder.
Many who have a personality disorder do not recognise any abnormality and defend valiantly their continued occupancy of their personality role. This group have been termed the Type R, or treatment-resisting personality disorders, as opposed to the Type S or treatment-seeking ones, who are keen on altering their personality disorders and sometimes clamour for treatment. The classification of 68 personality disordered patients on the caseload of an assertive community team using a simple scale showed a 3 to 1 ratio between Type R and Type S personality disorders with Cluster C personality disorders being significantly more likely to be Type S, and paranoid and schizoid (Cluster A) personality disorders significantly more likely to be Type R than others.
There is a considerable personality disorder diagnostic co-occurrence. Patients who meet the DSM-IV-TR diagnostic criteria for one personality disorder are likely to meet the diagnostic criteria for another. Diagnostic categories provide clear, vivid descriptions of discrete personality types but the personality structure of actual patients might be more accurately described by a constellation of maladaptive personality traits.
Impact on Functioning
It is generally assumed that all personality disorders are linked to impaired functioning and a reduced quality of life (QoL) because that is a basic diagnostic requirement. But research shows that this may be true only for some types of personality disorder.
In several studies, higher disability and lower QoL were predicted by avoidant, dependent, schizoid, paranoid, schizotypal and antisocial personality disorder. This link is particularly strong for avoidant, schizotypal and borderline PD. However, obsessive-compulsive PD was not related to a compromised QoL or dysfunction. A prospective study reported that all PD were associated with significant impairment 15 years later, except for obsessive compulsive and narcissistic personality disorder.
One study investigated some aspects of “life success” (status, wealth and successful intimate relationships). It showed somewhat poor functioning for schizotypal, antisocial, borderline and dependent PD, schizoid PD had the lowest scores regarding these variables. Paranoid, histrionic and avoidant PD were average. Narcissistic and obsessive-compulsive PD, however, had high functioning and appeared to contribute rather positively to these aspects of life success.
There is also a direct relationship between the number of diagnostic criteria and quality of life. For each additional personality disorder criterion that a person meets there is an even reduction in quality of life.
In the Workplace
Depending on the diagnosis, severity and individual, and the job itself, personality disorders can be associated with difficulty coping with work or the workplace – potentially leading to problems with others by interfering with interpersonal relationships. Indirect effects also play a role; for example, impaired educational progress or complications outside of work, such as substance abuse and co-morbid mental disorders, can plague sufferers. However, personality disorders can also bring about above-average work abilities by increasing competitive drive or causing the sufferer to exploit his or her co-workers.
In 2005 and again in 2009, psychologists Belinda Board and Katarina Fritzon at the University of Surrey, UK, interviewed and gave personality tests to high-level British executives and compared their profiles with those of criminal psychiatric patients at Broadmoor Hospital in the UK. They found that three out of eleven personality disorders were actually more common in executives than in the disturbed criminals:
Histrionic personality disorder: including superficial charm, insincerity, egocentricity and manipulation
Narcissistic personality disorder: including grandiosity, self-focused lack of empathy for others, exploitativeness and independence.
Obsessive-compulsive personality disorder: including perfectionism, excessive devotion to work, rigidity, stubbornness and dictatorial tendencies.
According to leadership academic Manfred F.R. Kets de Vries, it seems almost inevitable that some personality disorders will be present in a senior management team.
Early stages and preliminary forms of personality disorders need a multi-dimensional and early treatment approach. Personality development disorder is considered to be a childhood risk factor or early stage of a later personality disorder in adulthood. In addition, in Robert F. Krueger’s review of their research indicates that some children and adolescents do suffer from clinically significant syndromes that resemble adult personality disorders, and that these syndromes have meaningful correlates and are consequential. Much of this research has been framed by the adult personality disorder constructs from Axis II of the Diagnostic and Statistical Manual. Hence, they are less likely to encounter the first risk they described at the outset of their review: clinicians and researchers are not simply avoiding use of the PD construct in youth. However, they may encounter the second risk they described: under-appreciation of the developmental context in which these syndromes occur. That is, although PD constructs show continuity over time, they are probabilistic predictors; not all youths who exhibit PD symptomatology become adult PD cases.
Versus Mental Disorders
The disorders in each of the three clusters may share with each other underlying common vulnerability factors involving cognition, affect and impulse control, and behavioural maintenance or inhibition, respectively. But they may also have a spectrum relationship to certain syndromal mental disorders:
Paranoid, schizoid or schizotypal personality disorders may be observed to be premorbid antecedents of delusional disorders or schizophrenia.
Borderline personality disorder is seen in association with mood and anxiety disorders, with impulse-control disorders, eating disorders, ADHD, or a substance use disorder.
Avoidant personality disorder is seen with social anxiety disorder.
Versus Normal Personality
The issue of the relationship between normal personality and personality disorders is one of the important issues in personality and clinical psychology. The personality disorders classification (DSM-5 and ICD-10) follows a categorical approach that views personality disorders as discrete entities that are distinct from each other and from normal personality. In contrast, the dimensional approach is an alternative approach that personality disorders represent maladaptive extensions of the same traits that describe normal personality.
Thomas Widiger and his collaborators have contributed to this debate significantly. He discussed the constraints of the categorical approach and argued for the dimensional approach to the personality disorders. Specifically, he proposed the Five Factor Model of personality as an alternative to the classification of personality disorders. For example, this view specifies that Borderline Personality Disorder can be understood as a combination of emotional lability (i.e. high neuroticism), impulsivity (i.e. low conscientiousness), and hostility (i.e. low agreeableness). Many studies across cultures have explored the relationship between personality disorders and the Five Factor Model. This research has demonstrated that personality disorders largely correlate in expected ways with measures of the Five Factor Model and has set the stage for including the Five Factor Model within DSM-5.
In clinical practice, individuals are generally diagnosed by an interview with a psychiatrist based on a mental status examination, which may take into account observations by relatives and others. One tool of diagnosing personality disorders is a process involving interviews with scoring systems. The patient is asked to answer questions, and depending on their answers, the trained interviewer tries to code what their responses were. This process is fairly time-consuming.
As of 2002, there were over fifty published studies relating the five factor model (FFM) to personality disorders. Since that time, quite a number of additional studies have expanded on this research base and provided further empirical support for understanding the DSM personality disorders in terms of the FFM domains. In her seminal review of the personality disorder literature published in 2007, Lee Anna Clark asserted that “the five-factor model of personality is widely accepted as representing the higher-order structure of both normal and abnormal personality traits”.
The five factor model has been shown to significantly predict all 10 personality disorder symptoms and outperform the Minnesota Multiphasic Personality Inventory (MMPI) in the prediction of borderline, avoidant, and dependent personality disorder symptoms.
Research results examining the relationships between the FFM and each of the ten DSM personality disorder diagnostic categories are widely available. For example, in a study published in 2003 titled “The five-factor model and personality disorder empirical literature: A meta-analytic review”, the authors analysed data from 15 other studies to determine how personality disorders are different and similar, respectively, with regard to underlying personality traits. In terms of how personality disorders differ, the results showed that each disorder displays a FFM profile that is meaningful and predictable given its unique diagnostic criteria. With regard to their similarities, the findings revealed that the most prominent and consistent personality dimensions underlying a large number of the personality disorders are positive associations with neuroticism and negative associations with agreeableness.
Openness to Experience
At least three aspects of openness to experience are relevant to understanding personality disorders: cognitive distortions, lack of insight (means the ability to recognise one’s own mental illness here) and impulsivity. Problems related to high openness that can cause problems with social or professional functioning are excessive fantasising, peculiar thinking, diffuse identity, unstable goals and nonconformity with the demands of the society.
High openness is characteristic to schizotypal personality disorder (odd and fragmented thinking), narcissistic personality disorder (excessive self-valuation) and paranoid personality disorder (sensitivity to external hostility). Lack of insight (shows low openness) is characteristic to all personality disorders and could help explain the persistence of maladaptive behavioural patterns.
The problems associated with low openness are difficulties adapting to change, low tolerance for different worldviews or lifestyles, emotional flattening, alexithymia and a narrow range of interests. Rigidity is the most obvious aspect of (low) openness among personality disorders and that shows lack of knowledge of one’s emotional experiences. It is most characteristic of obsessive-compulsive personality disorder; the opposite of it known as impulsivity (here: an aspect of openness that shows a tendency to behave unusually or autistically) is characteristic of schizotypal and borderline personality disorders.
Currently, there are no definitive proven causes for personality disorders. However, there are numerous possible causes and known risk factors supported by scientific research that vary depending on the disorder, the individual, and the circumstance. Overall, findings show that genetic disposition and life experiences, such as trauma and abuse, play a key role in the development of personality disorders.
Child abuse and neglect consistently show up as risk factors to the development of personality disorders in adulthood. A study looked at retrospective reports of abuse of participants that had demonstrated psychopathology throughout their life and were later found to have past experience with abuse. In a study of 793 mothers and children, researchers asked mothers if they had screamed at their children, and told them that they did not love them or threatened to send them away. Children who had experienced such verbal abuse were three times as likely as other children (who did not experience such verbal abuse) to have borderline, narcissistic, obsessive-compulsive or paranoid personality disorders in adulthood. The sexually abused group demonstrated the most consistently elevated patterns of psychopathology. Officially verified physical abuse showed an extremely strong correlation with the development of antisocial and impulsive behaviour. On the other hand, cases of abuse of the neglectful type that created childhood pathology were found to be subject to partial remission in adulthood.
Socioeconomic status has also been looked at as a potential cause for personality disorders. There is a strong association with low parental/neighbourhood socioeconomic status and personality disorder symptoms. In a 2015 publication from Bonn, Germany, which compared parental socioeconomic status and a child’s personality, it was seen that children who were from higher socioeconomic backgrounds were more altruistic, less risk seeking, and had overall higher IQs. These traits correlate with a low risk of developing personality disorders later on in life. In a study looking at female children who were detained for disciplinary actions found that psychological problems were most negatively associated with socioeconomic problems. Furthermore, social disorganisation was found to be inversely correlated with personality disorder symptoms.
Evidence shows personality disorders may begin with parental personality issues. These cause the child to have their own difficulties in adulthood, such as difficulties reaching higher education, obtaining jobs, and securing dependable relationships. By either genetic or modelling mechanisms, children can pick up these traits. Additionally, poor parenting appears to have symptom elevating effects on personality disorders. More specifically, lack of maternal bonding has also been correlated with personality disorders. In a study comparing 100 healthy individuals to 100 borderline personality disorder patients, analysis showed that BPD patients were significantly more likely not to have been breastfed as a baby (42.4% in BPD vs. 9.2% in healthy controls). These researchers suggested this act may be essential in fostering maternal relationships. Additionally, findings suggest personality disorders show a negative correlation with two attachment variables: maternal availability and dependability. When left unfostered, other attachment and interpersonal problems occur later in life ultimately leading to development of personality disorders.
Currently, genetic research for the understanding of the development of personality disorders is severely lacking. However, there are a few possible risk factors currently in discovery. Researchers are currently looking into genetic mechanisms for traits such as aggression, fear and anxiety, which are associated with diagnosed individuals. More research is being conducted into disorder specific mechanisms.
Research shows a malfunctioning inner brain: hippocampus up to 18% smaller, a smaller amygdala, malfunctions in the striatum-nucleus accumbens and the cingulum neural pathways connecting them and taking care of the feedback loops on what to do with all the incoming information from the multiple senses; so what comes out is anti-social – not according to what is the social norm, socially acceptable and appropriate.
There are many different forms (modalities) of treatment used for personality disorders:
Individual psychotherapy has been a mainstay of treatment. There are long-term and short-term (brief) forms.
Family therapy, including couples therapy.
Group therapy for personality dysfunction is probably the second most used.
Psychological-education may be used as an addition.
Self-help groups may provide resources for personality disorders.
Psychiatric medications for treating symptoms of personality dysfunction or co-occurring conditions.
Milieu therapy, a kind of group-based residential approach, has a history of use in treating personality disorders, including therapeutic communities.
The practice of mindfulness that includes developing the ability to be non-judgementally aware of unpleasant emotions appears to be a promising clinical tool for managing different types of personality disorders.
There are different specific theories or schools of therapy within many of these modalities. They may, for example, emphasize psychodynamic techniques, or cognitive or behavioural techniques. In clinical practice, many therapists use an ‘eclectic’ approach, taking elements of different schools as and when they seem to fit to an individual client. There is also often a focus on common themes that seem to be beneficial regardless of techniques, including attributes of the therapist (e.g. trustworthiness, competence, caring), processes afforded to the client (e.g. ability to express and confide difficulties and emotions), and the match between the two (e.g. aiming for mutual respect, trust and boundaries).
Response of Patients with Personality Disorders to Biological and Psychosocial Treatments
Evidence for Brain Dysfunction
Response to Biological Treatments
Response to Psychosocial Treatments
Evidence for relationship to schizophrenia; otherwise none known.
Schizotypal patients may improve on antipsychotic medication; otherwise not indicated.
Poor. Supportive psychotherapy may help.
Evidence for relationship to bipolar disorder; otherwise none known.
Antidepressants, antipsychotics, or mood stabilizers may help for borderline personality; otherwise not indicated.
Poor in antisocial personality. Variable in borderline, narcissistic, and histrionic personalities.
Evidence for relationship to generalized anxiety disorder; otherwise none known.
No direct response. Medications may help with comorbid anxiety and depression.
Most common treatment for these disorders. Response variable.
The management and treatment of personality disorders can be a challenging and controversial area, for by definition the difficulties have been enduring and affect multiple areas of functioning. This often involves interpersonal issues, and there can be difficulties in seeking and obtaining help from organisations in the first place, as well as with establishing and maintaining a specific therapeutic relationship. On the one hand, an individual may not consider themselves to have a mental health problem, while on the other, community mental health services may view individuals with personality disorders as too complex or difficult, and may directly or indirectly exclude individuals with such diagnoses or associated behaviours. The disruptiveness that people with personality disorders can create in an organisation makes these, arguably, the most challenging conditions to manage.
Apart from all these issues, an individual may not consider their personality to be disordered or the cause of problems. This perspective may be caused by the patient’s ignorance or lack of insight into their own condition, an ego-syntonic perception of the problems with their personality that prevents them from experiencing it as being in conflict with their goals and self-image, or by the simple fact that there is no distinct or objective boundary between ‘normal’ and ‘abnormal’ personalities. There is substantial social stigma and discrimination related to the diagnosis.
The term ‘personality disorder’ encompasses a wide range of issues, each with a different level of severity or disability; thus, personality disorders can require fundamentally different approaches and understandings. To illustrate the scope of the matter, consider that while some disorders or individuals are characterised by continual social withdrawal and the shunning of relationships, others may cause fluctuations in forwardness. The extremes are worse still: at one extreme lie self-harm and self-neglect, while at another extreme some individuals may commit violence and crime. There can be other factors such as problematic substance use or dependency or behavioural addictions. A person may meet the criteria for dissociative identity disorder (formerly “multiple personality disorder”) diagnoses and/or other mental disorders, either at particular times or continually, thus making coordinated input from multiple services a potential requirement.
Therapists in this area can become disheartened by lack of initial progress, or by apparent progress that then leads to setbacks. Clients may be perceived as negative, rejecting, demanding, aggressive or manipulative. This has been looked at in terms of both therapist and client; in terms of social skills, coping efforts, defence mechanisms, or deliberate strategies; and in terms of moral judgments or the need to consider underlying motivations for specific behaviours or conflicts. The vulnerabilities of a client, and indeed a therapist, may become lost behind actual or apparent strength and resilience. It is commonly stated that there is always a need to maintain appropriate professional personal boundaries, while allowing for emotional expression and therapeutic relationships. However, there can be difficulty acknowledging the different worlds and views that both the client and therapist may live with. A therapist may assume that the kinds of relationships and ways of interacting that make them feel safe and comfortable have the same effect on clients. As an example of one extreme, people who may have been exposed to hostility, deceptiveness, rejection, aggression or abuse in their lives, may in some cases be made confused, intimidated or suspicious by presentations of warmth, intimacy or positivity. On the other hand, reassurance, openness and clear communication are usually helpful and needed. It can take several months of sessions, and perhaps several stops and starts, to begin to develop a trusting relationship that can meaningfully address a client’s issues.
Personality disorder not otherwise specified (PDNOS) is a diagnostic classification for some DSM-IV Axis II personality disorders not otherwise listed in DSM-IV.
The DSM-5 does not have an equivalent to Personality Disorder NOS. However Personality disorder-trait specified (PD-TS) remains under consideration for future revisions. The DSM 5 “Unspecified Disorder” is not a personality disorder, it is used to enhance specificity of an existing disorder or it is an emergency diagnosis unto itself (i.e. Unspecified Mental Disorder, 300.9), without being attached to another disorder.
Not to be confused with PDD-NOS (Pervasive Developmental Disorder Not Otherwise Specified).
This diagnosis may be given when no other personality disorder defined in the DSM fits the patient’s symptoms.
Four personality disorders were excluded from the main body of the DSM-IV-TR but this diagnosis may be used instead. The four excluded personality disorders are:
Haltlose personality disorder is a personality disorder in which affected individuals possess psychopathic traits built upon short-sighted selfishness and irresponsible hedonism, combined with an inability to anchor one’s identity to a future or past. The symptoms of Haltlose are characterised by a lack of inhibition.
Refer to Hysteroid Dysphoria. Other names have included Willenloser Psychopath, Unstable Psychopath, Unstable Drifter, and Disinhibited Personality.
Described by Emil Kraepelin and Gustav Aschaffenburg in the early twentieth century, and further distinguished by Karl Jaspers, Eugen and Manfred Bleuler, it has been colloquially dubbed psychopathy with an “absence of intent or lack of will”.
With other hyperthymics, Haltlose personalities were considered to make up “the main component of serious crime”, and are studied as one of the strains of psychopathy relevant to criminology as they are “very easily involved in the criminal history” and may become aggressors or homicidal. Their psychopathy is difficult to identify as a shallow sense of conformity is always present. A 2020 characterisation of mental illnesses noted of the Haltlose that “these people constantly need vigilant control, leadership, authoritarian mentor, encouragement and behavior correction” to avoid an idle lifestyle, involvement in antisocial groups, crime and substance abuse. The marked tendencies towards suggestibility are off-set by demonstrations of “abnormal rigidity and intransigence and firmness”.
After discovering a guilty conscience due to some act or omission they have committed, “they then live under constant fear of the consequences of their action or inaction, fear of something bad that might strike them” in stark opposition to their apparent carelessness or hyperthymic temperament, which is itself frequently a subconscious reaction to overwhelming fear. They frequently withdraw from society. Given their tendency to “exaggerate, to embroider their narratives, to picture themselves in ideal situations, to invent stories”, this fear then manifests as being “apt to blame others for their offences, frequently seeking to avoid responsibility for their actions”. They do not hold themselves responsible for their failed life, instead identifying as an ill-treated martyr.
They were characterised as Dégénérés supérieurs, demonstrating normal or heightened intellect but degraded moral standards. Of the ten types of psychopaths defined by Schneider, only the Gemütlose (compassionless) and the Haltlose “had high levels of criminal behavior” without external influence, and thus made up the minority of psychopaths who are “virtually doomed to commit crimes” by virtue only of their own constitution. Frequently changing their determined goals, a haltlose psychopath is “constantly looking for an external hold, it doesn’t really matter whether they join occult or fascist movements”. The ability to moderate external influence was considered one of three characteristics necessary to form an overall personality, thus leaving Haltlose patients without a functional personality of their own. A study of those with haltlose personality disorder concludes “In all of those cases, the result was a continuous social decline that ended in asocial-parasitic existence or an antisocial-criminal life”.
Haltlose has one of the most unfavourable prognoses of psychopathies. To exist safely, such a psychopath requires “a harsh lifestyle” and constant supervision.
Etymology and Criticism
“Haltlos” is a German word that contextually refers to a floundering, aimless, irresponsible lifestyle, and the diagnosis is named “Haltlose” using the feminine variation on the word. They are commonly clinically termed an “unstable psychopath”, which is differentiated from emotionally unstable personality disorder (an alternative name for borderline personality disorder). It was remarked in early studies that England, the United States and northern European countries did not use the same typology, not distinguishing between those psychopaths who were unstable and those who were “Unstable Psychopaths”.
It has been dubbed a part of “German-speaking psychiatry”. The term “Haltlose” is more common in the study of psychiatry, while “Willenlose” is preferred in sociology. Some like Karl Birnbaum prefer the term “Haltlose”, while others like Kurt Schneider prefer “Willenlos” shifting focus off their lack of self-control and opposed to the moralist tones of those like Birnbaum who had described the Haltlose as unable to grasp “important ideal values such as honor and morality, duty and responsibility, as well as material ones such as prosperity and health”. In 1928, Eugen Kahn argued Willenlose was a misnomer, as the patients demonstrated plenty of “will” and simply lacked the ability to translate it into action. Historically, researchers such as Schneider argued that instability is the symptom, whereas lack of volition is the underlying cause. It is not included in the Diagnostic and Statistical Manual of Mental Disorders (DSM), possibly due to a modern belief that the concept of volition is outdated and overshadowed by the concepts of motivation and arousal or drive.
In 1963, Karl Jaspers defined the term as “those who have no willpower at all, the drifters, simply echoing any influence that impinges on them”. However, in 1976, the Government of Canada listed the alternate term “Unstable drifter” in a psychiatric criminology context as a problematic term for which they could not readily offer a French translation in accordance with their bilingualism laws. Similar issues have arisen trying to translate it to other languages, including Turkish. Ultimately the diagnosis was handicapped by the issues of translation, leading to criticism of “the impoverishment of psychiatric vocabulary” that led to declining research and use.
In the early 20th century, Aschaffenburg distanced himself from accusations that the diagnosis was intended to protect criminals from punishment, emphasizing instead that those with Haltlose personality disorder “generally cannot be exculpated”.
Dr. Friedrich Stumpfl cautioned against what he saw as a trend of diagnosing haltlose personality disorder without investigating comorbidities that may be even more pronounced. In condemning the idea of personality disorders generally, Joachim-Ernst Meyer suggested in 1976 that Schneider’s early description of the Haltlose personality disorder, as a lack of determination in aspects of life including parenting, could just as easily be described as an example of a neurosis rather than a psychopathy if studied only by its aetiology rather than its symptoms, and used it as an example of the nature versus nurture debate that surrounded all personality disorders. Critics ceded that the term “Haltlose” remained of value in educational and therapeutic contexts, while suggesting future collaboration between psychiatric research and sociologists would allow further definition.
Recently, it has been criticised as a “diagnosis of convenience [that] avoids all further deliberations about a psychopathic personality”. Dr. DM Svrakic and Dr. M Divac-Jovanovic suggested the ICD-10 explanations of Haltlose, Immature and Psychoneurotic personality disorders appeared “dubious”, and sociologist James Cosgrave found psychiatric use to represent a “fringe figure”. A graduate student at Bochumer Stadt & Studierendenzeitung condemned the historical diagnosis from an LGBT perspective, opining that “incredibly oppressive language” had been used by the psychiatrists studying it such as “pathological femininity”.
It may be that the evolution of test-batteries have minimised diagnoses of Haltlosen, differentiating it from some newer models in psychiatry.
Described as bearing a “pronounced heredity burden”, the propensity for Haltlose has also been suggested to be passed only through the maternal genes. Only able to offer “primitive reactions” and “poor and immature judgement”, they are noted to display an absolute lack of purpose in their lives “except for the simple biological need to continue living”.
Gustav von Bergmann, a specialist in internal medicine rather than psychiatry, wrote in 1936 that Haltlose personality disorder was entirely biological rather than fostered through psychological experiences. Indeed, Dr. Hans Luxenburger proposed in 1939 that a toxin in the metabolism, when present with Haltlose personality disorder, might be responsible for asthenic difficulties such as shortness of breath, nausea, and cluster headaches. Dr. E.H. Hughes noted that two-thirds of Huntington’s disease patients had previously been diagnosed as Haltlose or Gemütlose psychopaths.
A study in 1949 of different psychopathies under examination by electroencephalography recordings showed that borderline personalities and haltlose personalities had increased levels of dysrhythmia, whereas other subtypes of psychopathy did not show variation. An individual in 1931 was noted as having initially improved but relapsed “because of encephalitis”. As with other personality disorders, a 1923 article suggests it can also be acquired through encephalitis. In 2006, an Essex warehouse employee who suffered head injuries was awarded £3 million compensation on the basis it had caused him to develop Haltlose personality disorder, seeking out prostitutes and pornography which destroyed his marriage.
Mistakes cannot be fully avoided when placing children under care. even an experienced specialist often cannot distinguish between a blossoming hebephrenia and a Gemutlose or Haltlose personality disorder. Even with weeks of institutional observation, the certainty of our diagnostic aids can remain doubtful…under certain circumstances a doctor will advise medical care even at the risk of learning the patient cannot improve as a result of mental illness and will end up in a madhouse. Kurt Schneider.
Dr. W. Blankenburg posited in 1968 that those with haltlose personality disorder exhibited less categorical orientation than those patients who were simply unstable. By 1962, lobotomy was being tested as a possible means to limit the chaotic thinking of the Haltlose personality.
Kraepelin, in noting “an increased risk of criminal behavior”, estimated that 64% of men and 20% of women with Haltlose descended into alcoholism in the early twentieth century. The frequent intersection between HLPD and alcoholism means modern clinical researchers may use “haltlose” as a grouping when separating subjects by disposition. Research in 1915 noted an increased propensity for lavish spending, and overconsumption of coffee, tea and medication.
One 1954 study suggested female Haltlose patients may experience “manic excitement” during their menses. According to 1949 research, they have a higher rate of homosexuality, and 1939 evidence suggested that masturbation is more prevalent in Haltlose and Gemütlose (compassionless) psychopaths than in other disorders, and Haltlose erethics leave them “usually very sexually excited” and seeking out “atypical, irregular and unusual” debauchery whether in brothels, adultery or destroying marriages.
They demonstrate similarities to hysteroid dysphoria. In 1928, it was proposed that Fantasy prone personality was likely a subset of Haltlose personalities, suffering from maladaptive daydreaming and Absorption.
According to 1968 research, haltlose personality disorder is frequently comorbid with other mental health diagnoses, and rarely appears isolated on its own. Hans Heinze focused on his belief that Haltlose ultimately stemmed from a sense of inferiority, while Kramer held there was a battling inferiority complex and superiority complex.
The Haltlose were said to have a dynamic instinctual drive to “cling” to others, to avoid a horrible loneliness they fear – but they will always represent a “lurking danger” because they were unable to actually maintain the necessary relationship and were in a class with the “forever abandoned”. According to 1926 research, they view all interaction as a means of winning “indulgence from some people, help from other people”.
One early study indicated that 7.5% of psychopaths were Haltlose, and Kraepelin estimated that his own practice determined fewer than 20% of psychopaths he saw were Haltlose. However more recent studies, after differentiating out newer diagnoses, have suggested that it may be fewer than 1% of psychopaths who are truly Haltlose.
Described in 1922 as both “moody” and “passive”, they quickly switch from over-confidence in victory to sullen defiance.
Their emotional lability means they alternate between projecting an optimistic and competent image claiming they are “destined to do great things”, and a more honest cynicism and depression. Research in 1925 indicates they display “great emotional irritability, which may result in violent loss of temper…and interpret every limitation as an undeserved insult” and have a “pronounced lust for argument”. The symptoms are considered to worsen if patients are granted greater independence “in the home and in their work”.
Their self schema only encompasses the immediate present. They are described as “living in a random location and moment”. A common pitfall in therapy is that they proved in 1917 to be “very superficial, they easily acquire knowledge but do not apply it in any way and soon forget it”.
The essence of these people…playthings of external influences, allowing themselves to be carried away by events like a leaf in the wind! …Impermanence is everything. In one hour, they are happy and excited with the whole world lying open for them in the splendor of the joy of life, but the next hour casts aside this optimism and the future now seems bleak, gray on gray…sympathies and antipathies quickly replace each other, what was worshipped yesterday is burned today, and despite all oaths of eternal loyalty, the best friend is transformed into the deeply-loathed enemy overnight.” Dr. L. Scholz, Anomale Kinder, Berlin, 1919.
Those with HLPD display “a number of endearing qualities, charming with an apparent emotional warmth, but also an enhanced suggestibility and a superficiality of affect”, which can lead to unrealistic optimism. and “wandering through life without ever taking firm root”. They are also noted as “absolutely indifferent to others…likes to live for [their] pleasure today, does not make plans not only for the future but even for tomorrow, studying and working are not for them”. Persons with HLPD typically lack any deep knowledge, and “look for easy life and pleasures”. They have been described as “conquerers with an appearance of emotional warmth”.
Persons with HLPD were noted as struggling with hypochondria in 1907. They also struggle with alcoholism, and identify with antisocial personality disorder.
Kraepelin said they were “apt to take senseless journeys, perhaps even becoming vagabonds”. Kraepelin argued only lifelong wanderlust was tied to Haltlose, whereas Kahn argued that the Haltlose often lost their wanderlust as they aged and preferred to settle into mediocrity. Some make their fortune, but the disappearance of less fortunate travelers is not mentioned by their families who considered them to have been burdensome.
To early twentieth-century researchers, they appeared amiable, well-spoken, self-confident and to be making strong efforts to improve their weaknesses, thus making a misleading first impression and endearing themselves to superiors. The lack of a sense of identity, or internal support, was thought to a lack of resistance to both external and internal impulses in 1927. Their “gradual deterioration in the swamp of neediness and immorality” still does not make a lasting impression on the patients. Thus Haltlose patients who recognize their shortcomings were thought to possibly be overwhelmed by a subconscious fear about participating in the world without restraints in a 1924 account. Similarly, researchers in the early twentieth-century believed that the inauthenticity of their projected self and superficiality of knowledge means that when “someone who is really superior to [them]”, after a period of stiffly asserting themselves hoping to avoid submission, will ultimately and without explanation fully embrace the position of the other.
Pathological lying is closely linked to Haltlose personality disorder, with Arthur Kielholz noting “They lie like children…this activity always remains just a game which never satisfies them and leaves them with a guilty conscious because neither the super ego nor the Id get their due…Since they are offering such a daydream as a gift, they consider themselves entitled to extract some symbolic gift in return through fraud or theft”. Adler maintained “Memory is usually poor and untrustworthy…often they seem to have no realization of the truth”, while Homburger felt they held “no sense of objectivity, no need for truth or consistency”.
According to early accounts, choices are made, often in mirroring others around them, but “do not leave even a passing imprint on the person’s identity”. Thus, they can “behave properly for a while under good leadership”, and are not to be trusted in leadership positions themselves. Gannushkin noted they must be urged, scolded or encouraged “with a stick, as they say”. They demonstrate poor mood control and “react quickly to immediate circumstances” since “mood variation can be extreme and fluctuate wildly”, which led to the denotation “unstable psychopath”.
They have been described as “cold-blooded”, but must be differentiated from dependent personality disorder, as the two can appear similar, due to the artifice of the Haltlose patient, despite having starkly opposing foundations. Persons with Dependent Personality Disorder are defined by a tendency to embarrassment, and submissiveness which are not genuine facets of those with Haltlose even if they mimic such. Haltlose was thus deemed the “more troublesome” personality in 1955.
Childhood Origins, and Later Role of Family
“Whomever is abandoned in youth to the inexorable misery of existence, and at the same time is exposed to all manner of seductions, will find it very difficult to curb their constantly incited desires, and to instead force themselves through to the lofty vantage of moral self-assertion. Kraepelin speaking about the Haltlose, 1915.
It has been proposed that haltlose personality disorder may arise from “traumatization through maternal indolence” or institutionalisation in early life, although without definite conclusion. It may present in childhood simply as a hypomanic reaction to the loss of a parent or incest object. They often display a fear of abandonment that appeared in childhood, a common borderline personality disorder symptom. Male Haltlose personalities may come out of families with a pampering, over-protective and domineering mother with a weak father. Homburger noted the “childhood and youth of the Haltlose are extraordinarily sad”. It is possible, but rare, for Haltlose personalities to develop within healthy family structures.
Gerhardt Nissen referenced the possibility of intrauterine factors in the shaping of anti-social behaviours in Haltlose psychopaths, while noting the concept of psychopathy had been so weakened in modern psychopathology as to be indistinguishable from other conditions. Others have suggested there is a strong heredity correlation, as the parents often also display Haltlose personality disorder, especially the mother. Raising a haltlose child can, in some cases, destroy the family structure by forcing relatives to take opposing positions, provoking disagreement and creating an atmosphere of bitterness and dejection. They have been clinically described as disappointments to their families, and are unable to feel actual love for their parents and are indifferent to the hardships of relatives – since all relationships are seen only as potential means towards acquiring pleasure.
Care must be taken in making Haltlose diagnoses of children, since “the traits of instability of purpose, lack of forethought, suggestibility, egoism and superficiality of affect…are to some extent normal in childhood”. Children with haltlose personality disorder demonstrate a marked milieu dependency, which may be a cause rather than effect of the Haltlose. It is of great importance that only children with Haltlose have peers and friends to surround themselves to try and learn associations and behaviours. They often become sexually active at a young age but delayed sexual maturity, and as adults retain a psychophysical infantilism. Regressive addictions amongst Haltlose psychopaths typically are infantile, and seek to replace the lost “dual union” arising from their parents’ rejection, and later morph into a focus on subjects including vengeance or sado-masochism.
The age at which parents or professionals exhibited concern about psychopathy ranged; rarely even at a preschool age. Haltlose children confusingly tend to appear very strong-willed and ambitious, it is only as they age and the lack of perseverance becomes manifest that caretakers become puzzled by their “naughtiness” as it contradicts what had earlier appeared. This arises principally due to their rigid demands for short-term wishes being mistakenly interpreted as having a fixed purpose and persistence. Some patients later shown to be Haltlose, had shown neuropathic traits in childhood such as bedwetting and stuttering. They were also more likely to run away from their home, begin drinking before the socially acceptable age, and were afraid of punishment. Although struggling to make friends in young childhood, they find it easier as they age.
Kraepelin contended the disorder was “based on a biological predisposition” but also affected by factors such as childrearing practises, social position and state of the parental home. His analysis showed that 49% of diagnosed Haltlose had obvious parental issues such as alcoholism or personality disorders. A 1944 study of children produced by incest by Dr. Alfred Aschenbrenner found a high rate of Haltlose personality disorder, which he suggested might be explained as inherited from overly suggestive mothers. It is possible, although difficult, to diagnose from the age of five and presents one of the stronger psychiatric difficulties if present at such young age. It may be possible to prevent social failure “through welfare measures” akin to early intervention. Italian courts stressed mimicry of positive role models as a means to combat Haltlose youth who had fallen afoul of the law.
Haltlose can cause educational difficulties, and if parents do not understand the peculiarities of their haltlose child, they may try to through good intentions to force the child into an educational regimen inappropriate for them, which then creates a feeling of isolation in the child which grows into a rebellious tendencies, “which turns out to be disastrous for further development”. Students with Haltlose personalities may prefer the arts over the sciences, since the former does not require a consistent sense of truth and entails less disciplined study. Given their inability to anchor a self-schema and tendency to play-act roles, the theatre and film have great attraction and influence over them.
With proper leadership and controls from teachers, they are able to become “model pupils” in terms of behaviour, although Schneider opined that it was worthless to educate an inability to learn from mistakes prevented actual education, and bemoaned that the late onset of anti-social behaviours kept the Haltlose in school when they might otherwise be removed. Walter Moos believed that Haltlose personality disorder and hyperthymia had shown itself to be contagious in rare cases, wherein classmates developed the same disorder from interaction with patients. Homburger argued for removing a Haltlose child from their family of origin as soon as the disorder was confirmed, to resettle in a rural educational centre.
Adolescence, Young Adulthood and Efforts to Intervene
When required to live independently, they “soon lose interest, become distracted and absent-minded, and commit gross errors and negligence”. Ruth von der Leyen noted that “every care provider, teacher and doctor knows the Haltlose Psychopath from their practice”, and remarked that caring for such a patient was made more difficult because of the need to lecture and intervene to enlist the psychopath’s cooperation in short-term improvements, despite being aware the psychiatric reports have determined such efforts are ultimately useless but should be practised regardless.
The tendency to accumulate debts while seeking pleasure or escaping responsibility is often the attributed cause for their descent into crime, although Kramer noted those who displayed “extreme dexterity, sufficient talent for imagination, and a tendency towards dishonesty” were able to find alternative sources of income without necessarily becoming criminal, although warned that “again and again, their debts have to be paid until the parents no longer can, or want to, do this and leave them to their selves”.
Gannushkin noted “Such people involuntarily evoke sympathy and a desire to help them, but the assistance rendered to them rarely lasts, so it is worth abandoning such people for a short while”. The wasted good intentions resulted in the summary:
“probably the most important function of the psychiatrist when dealing with these patients is to protect their relatives and friends from ruining themselves in hopeless attempts at reclamation. With most of these patients a time comes when the relatives will be best advised…to allow the patient to go to prison, or otherwise suffer unsheltered the consequences of his deeds.”
By contrast, others have advanced the “rather optimistic” belief that “a suitable [spouse]” or similar “strong-willed” relative could drastically improve the outcome of Haltlosen patients. This was echoed by Andrey Yevgenyevich Lichko who, while preferring the term “accentuation of character” to describe the psychopathy rather than “personality disorder”, noted “if they fall into the hands of a person with a strong will, for example a wife or husband, they can they live quite happily…but the guardianship must be permanent.”
While some Haltlose have risen to the level of dangerous offenders multiple times over, it is more frequent that they attract attention early from their “vagabond” nature.
Heinrich Schulte, a wartime medical judge and consulting psychiatrist for the military, continued advocating for the sterilization of Haltlose and other “Schwachsinnigen” after the war’s end. In 1979, the Neue Anthropologie publication referred to a need to sterilize those like alcoholics, “who are often Haltlose psychopaths”, from bearing children, to reduce crime.
Although Kraepelin believed those with Haltlose personality disorder represented the antithesis of morality, there is not necessarily a tendency towards deliberate amorality among the demographic despite its frequent criminal violations since they may lack the ability to premeditate. But their demonstrated lack of self-control is “especially manifested in the sphere of morality”.
In 1935, it was estimated that 58% of recidivist criminals were diagnosed with Haltlose personality disorder, higher than any other personality disorder. More recently, Haltlose and Histrionic were the most common personality disorders found in female juvenile delinquents by forensic psychologists in Russia in the year 2000.
Domestic Violence, Incest and Molestation of Children
“[Patients resembling Haltlose] as a rule show little insight into the peculiarities of their conduct. They do not understand how they could have done these things, or they blame their relatives, neighbors and so forth”. Dr. Herman Morris Adler, 1917.
Although they enter relationships easily, Andrey Yevgenyevich Lichko contends they are not capable of actual loyalty or selfless love, and sex is treated as a form of entertainment rather than intimacy. They are therefore described as acting as “family tyrants”.
Although they may not qualify as “true” pedophiles, Haltlose personalities demonstrate an increased risk of sexually molesting children, since other potential victims would require the realisation of greater planning, but children are suggestible and easily overwhelmed.
A 1967 German study had suggested over 90% of adult-child incest offenders were diagnosed with Haltlose Personality Disorder. Female patients may also live vicariously through encouraging and directing the sexual lives of their daughters.
Drunk Driving, Hit-and-Run
Some Haltlose personalities are drawn towards dangerous driving habits “as a source of almost hedonist pleasure”. In 1949 the Automobil Revue proposed that additional tests should be necessary for Haltlose personalities to obtain a driver’s license. They have been known to steal cars to joyride at high speeds if they are not otherwise able to find satisfy their urge.
The American Journal of Psychiatry published a study of hit and run drivers in 1941, which showed 40% of drivers who fled the scene of a traffic accident tested positive for haltlose personality disorder. This was consistent with the earlier finding that Haltlose Personalities were among the most likely to attempt to flee if caught in commission of any crime.
Suicidality and Murder-Suicide
Research in the early twentieth century on suicidality among the Haltlose indicated several things: they chafe at the notion of any religion as it introduces unwanted inhibitions, especially against parasuicidal demonstrations; women Haltlose most frequently indicated suicidality was based upon fear of punishment or reproach, as well as the “excitement” of being institutionalised; and although frequently planning or attempting suicide, including through suicide pacts or murder suicide, Haltlose typically do not succeed since they lacked courage and were easily distracted.
Haltlose patients respond very well to institutionalization where their influences can be controlled, becoming “model inmates” of sanitariums even within hours of first arriving despite a chaotic life outside of the regimen, “but if you leave them, through good intentions, to their own devices – they don’t last long before collapsing their current state and being seduced back onto the wrong track”. Schneider recommended warning them “through punishing them” as it was the only control on their action. Bleuler said the court system needed to understand such persons were in “urgent need of inhibitions”.
Pyotr Gannushkin noted they joined military service due to peer pressure but given the lack of alcohol and stern, hard work required of them were able to function without their normal impairment. A 1942 study of the Wehrmacht found that only Haltlose and Schizoid were not measurable among soldiers despite their presence in the civilian population. A 1976 Soviet naval study came to similar conclusions.
Roth and Slater concluded “the treatment of such a personality is almost hopeless under the present ordering of society. Any treatment would…present difficulties…beyond the powers of these patients. The prospects of psychotherapy are forlorn and the best that can be obtained will be reached through social control.”
Some researchers suggest their moods and insufficient motivation will lead them to “vague feelings of fear and calamity…turning every little thing into big things, excitement, misinterpreting every harmless word, criticizing everything and commiting hostile acts”, and in some cases they look back with hindsight and regret the injustices they did. However Kramer held that when caught in wrongdoing, “we find them contrite, self-accusing and assuring that they will improve – but on closer inspection it is feigned and not sincere”.
Upon being confronted with their misdeeds, the Haltlose respond “with more or less superficial reasons to excuse them, they claim that their parents treated them incorrectly, that they were the victim of adverse circumstances, seduced by other people and misled. Other Haltlose, especially those with a strong intellect, make up a theoretical schema that would justify their actions.”
Kielholz, Arthur, Internationale Zeitschrift für Psychoanalyse XIX 1933 Heft 4, “Weh’dem der lugt! Beitrag zum problem der pseudologia phantastica”, an article on pathological lying in the Haltlose patients Max Specke, a Swiss charlatan with a penchant for melodramatic flair and Emil Schuldling, a habitual criminal with childhood sexual perversions
Story of Robert Wenger, who was diagnosed Haltlose and spent 54 years between institutions and prison for minor crimes until the documentary series Quer exposed his case, leading to an apology from politician Samuel Bhend in 1999.
Karl Hager, a habitual criminal diagnosed Haltlose who was frequently jailed for homosexual acts and was ultimately killed in Sachsenhausen concentration camp (in German)