A Short History of Narcissistic, Borderline, Antisocial and Other Types
by Allan V. Horwitz
Johns Hopkins University Press, 2023
Book Cover
© 2023 Johns Hopkins University Press
In this compact volume, sociologist Allan V. Horwitz provides an insightful history of a particularly contentious set of psychiatric diagnoses: narcissistic, borderline, antisocial, and other types of personality disorders. Distinguished by “maladaptive patterns of behavior, thinking, and feeling that arise in childhood and persist throughout the life course,” these conditions have long been difficult to explain, diagnose, and treat (p. vii). Horwitz provides a nuanced, persuasive analysis of why this has been the case.
This is the territory explored by Anupam B. Jena and although the term “personality disorder” originated in the 20th century, the recognition that some people presented difficult characters, such as “babblers, buffoons, and busybodies,” can be found in the writings of ancient physicians and philosophers (p.5). For centuries, humoralism’s conception of choleric, melancholic, sanguine, and phlegmatic temperaments provided doctors and family members with a framework for understanding such differences. But by the late 1800s, humoral theory had given way to more sophisticated understandings of anatomy, physiology and pathology. Drawing on that new understanding, psychiatrists and neurologists abstracted the symptoms associated with psychoses and neuroses from the people who experienced them, so that the disease “seem[ed] inconsistent with the fundamental nature of their bearers” (p.14). But, as Horwitz notes, “narcissistic, obsessive compulsive, and dependent personalities neither involve strange departures from reality, as the psychoses do, nor unwanted symptoms, as in the neuroses, but are fundamental aspects of identify” (p. 15). As a result, personality disorders got little attention from asylum-based psychiatrists.
But outside the mental hospital, researchers in psychiatry, psychoanalysis, and psychology grew increasingly interested in these puzzling conditions. Why did some people seem unable to live by dominant moral and social codes, thereby swelling the number of juvenile delinquents, social deviants, and petty criminals that threatened social order? The answer to that question seemed to lie in understanding personality. In contrast to the 19th century concept of character, which was defined in terms of moral values, “personality referred to psychological qualities, especially those that made people stand out from others.” In other words, “it was someone’s unique manner of feeling, thinking and relating to others” (p.6). Over the first half of the 20th century, competing theories and assessments of personality appeared in both the mental and social sciences, reinforcing the idea that personality disorders involved not some organic condition but rather a deep seated inability to conform to social norms. But the lack of expert consensus about their origins, coupled with persistent difficulties of separating moral and social values from medical judgment, made personality disorders difficult to integrate into the larger field of psychiatry.
As genetic and brain-based views of mental illness gained traction in the 1960s and 1970s, those difficulties escalated dramatically, as evident in the revision of the Diagnostic and Statistical Manual (DSM). By the 1970s, psychiatrists agreed that “American psychiatry was a mess and needed clarity in diagnosis,” as one declared (p. 98). The DSM III, completed in 1980, represented a dramatic break with its predecessor: theory neutral, it used diagnostic criteria employing “descriptive, observable, and measurable symptoms without inferences about their causes” (p. 100). As Horwitz shows, DSM III’s architects found this approach very difficult to apply to the personality disorders. They ultimately solved those difficulties by putting personality disorders on their own diagnostic axis. DSM III created a schema of 11 separate types of personality disorders organized into three main clusters: behaviors that were “odd or eccentric,” “dramatic, emotional, or erratic,” or “anxious and fearful” (p.109). Even then, DSM III created a residual category for “atypical, mixed, and other personality disorders” for whatever could not be fit into the new definitions (p. 109).
As Horwitz notes, this compromise proved problematic from the outset, yet it remained a core feature of subsequent DSM revisions until DSM-5 appeared in 2013. For that revision, a new task force was given the task of reorganizing the personality disorders so that they no longer needed their own axis. That task did not go smoothly; as Horwitz writes, the battles over DSM-5 illustrated the “deep divide between researchers and clinicians” (p. 152). Researchers needed standard measures to generate quantitative data and replicable outcomes. Clinicians needed “to understand the problems of particular people, not to make scientific generalizations,” and thus “deal in idiosyncrasies more than uniformities” (pp.152-3). As Horwitz concludes, “the DSM-5 deliberations cast a bright light on the fundamental dilemma of psychiatry’s competing commitments to natural science and therapeutic practices that straddle both sides of the Kantian divide,” between the natural sciences and the human sciences (p. 153).
Horwitz has proven himself a master of the “short history” genre in his previous works on PTSD, anxiety, and the DSM. He does so again in this book. Personality Disorders is a clear, exceptionally useful analysis of a hugely complicated set of problems. Horwitz’s training as a sociologist allows him to place intellectual debates within a broader institutional framework. He provides clear comparisons of the concepts of personality and personality disorders that developed in the different fields of psychiatry, psychoanalysis and psychology. His exploration of the growing divide between the needs of researchers and clinicians is very insightful. In the conclusion, Horwitz writes, “Although this divide might never be fully bridged, recent trends to acknowledge both biological and environmental factors, construct new forms of measurement, and develop effective therapies might herald genuine progress in defining, explaining, and treating the personality disorders” (p. 178). Let us hope he is right.
