Allan V. Horwitz, Personality Disorders: A Short History of Narcissistic, Borderline, Antisocial, and Other Types

Allan V. Horwitz, Personality Disorders: A Short History of Narcissistic, Borderline, Antisocial, and Other Types (Baltimore, MD: Johns Hopkins University Press, 2023), Hb $35, 227 pages, ISBN: 9781421446103

Horwitz’s book unravels the messy social history of the concept of ‘personality disorders’ as it has been developed by multiple disciplines over the course of the last two centuries. The book follows a loosely chronological structure: the first half narrates the emergence of the ‘personality disorder’ in nineteenth-century psychoanalysis, psychiatry and psychology. The second half details the medical community’s failure to clearly define the personality disorder, resulting in the implementation of inefficient diagnostic resources which continue to impact the treatment of sufferers.

Chapter One traces the evolution of the terms ‘character’ and ‘personality’ from the works of ancient philosophers such as Theophrastus, Aristotle, Hippocrates and Galen. In sketching their arguments, Horwitz brings into focus the interrelating factors which shape personality: natural disposition, innate temperament, biological imbalances, cultivation of habits, social roles and cultural influences. In the subsequent discussion of nineteenth- and twentieth-century theories of the personality, he illustrates how this mixture of biological and cultural factors remain central to modern discourse about personality formation. To this end, he surveys the formation of different disciplines – psychiatry, neurology, psychoanalysis, psychology, sociology and anthropology – and how they sought to address fundamental questions: what is personality? Is it comprised of isolated traits or is it a holistic organization? An inner quality or an interactional process? Part of the natural or the cultural world?

The formation of these various disciplines is discussed in greater detail in the second chapter, starting with the foundation of Freudian psychoanalysis. Without devaluing concepts such as the anal, oral and genital character styles, which are generally considered outdated by modern analysts, Horwitz evaluates their contributions to current understandings of the personality with an evenness and objectivity that is maintained throughout the book. In contrast to the extensive discussion of Freud, Carl Jung is mentioned only fleetingly in a note, indicating his views on introversion and extroversion in Psychological Types (1921) and its impact on the Myers-Briggs personality tests. Yet Jung has much more to offer here: his background in philosophy, religion and literature, which enriched his insights into personhood and informed other works such as Aion: Researches into the Phenomenology of the Self (1951), might have enhanced Horwitz’s argument by contributing both to the earlier sections on the ancient philosophers, and to the later sections on DSM-5’s dimensional models of holistic, integrated personalities.

Chapter Two concludes by describing the emergence of ‘psychology’ as a discipline which attempted to objectively and quantitatively study personality, and constituted a critical response to psychoanalysis’s more subjective, speculative approach to the mind. Horwitz’s detailed account of how personality tests were designed to evaluate potential recruits for the US military is especially illuminating because it shows just how socially, economically and politically motivated the development of these disciplines has been.

In like manner, Chapter Three compares the methods of psychologists who sought to analyse quantitatively the abstracted personality traits of large social groups with those of anthropologists, neo-Freudian psychoanalysts and culture and personality schools that studied environmental determinants in communities and individuals. The comparison elucidates how problematic the concept of the ‘personality disorder’ is, by detailing the far from objective cultural conditions in which it is developed.  

In Chapter Four, Horwitz explains how the rapidly-changing social structures, cultural values and political systems in the decades prior to and following the Second World War affected not only perceptions of what a ‘disordered’ personality was, but also the symptoms being presented to clinicians. He then provides a detailed account of how psychiatric diagnostic manuals, Medical 203, DSM-I and -II were developed, acknowledging the ways that moralistic, misogynistic and homophobic views pathologized traits which are considered normal by modern standards.  

Chapter Five focusses mostly on the development of DSM-III and the clarity of distinctions between the personality types it defines. It features short discussions of Antisocial Personality Disorder (112-116), Borderline Personality Disorder (116-120) and Narcissistic Personality Disorder (120), which were described clearly for the first time in DSM-III. These involve interesting and informative histories of how each disorder was constructed, and the cultural and social conditions which informed those perceptions. It is a shame that similarly detailed descriptions of each of the other personality disorders do not feature in the following chapter on DSM-III-R, -IV and -5.

In Chapter Six, Horwitz provides a highly detailed narrative account of the challenges and controversies faced by the teams developing DSM-5 (2013), in which personality disorders featured as ‘the major concern’ (147) for the first time. He weighs up the advantages and disadvantages of implementing a multiaxial system (discrete subdivisions of traits) and dimensional model (gradients of severity of traits) of the personality in diagnostic procedures. The historical context of the contending methodological approaches of psychiatry, psychology, psychoanalysis, anthropology and sociology, laid out in the previous chapters, here culminates in a discussion of the conflicts between researchers and clinicians in the development and implementation of the DSM-5 models in their respective settings. These conflicts are yet to be resolved and – as Horwitz emphasises – continue to impact the diagnosis and treatment of personality disorders. 

The long and complex history of the emergence of personality disorders into diagnostic terminology, and the wide range of social and cultural issues encountered in the process, are summarised in the final chapter. In doing so, Horwitz directs the attention of readers to the questions which need to be addressed most urgently. Personality Disorders concludes on a hopeful note: encouraging students to reintegrate intuitive understandings of the personal and cultural aspects of identity formation into their anatomical, chemical and neurological studies, which would better reflect the nature of the personality itself, and ‘herald genuine progress in defining, explaining and treating the personality disorders’ (178).

Laura Blunsden, University of Liverpool.