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THE AMERICAN PSYCHIATRIC PUBLISHING
TEXTBOOK OF
PERSONALITY
DISORDERS
S E C O N D E D I T I O N
This page intentionally left blank
THE AMERICAN PSYCHIATRIC PUBLISHING
TEXTBOOK OF
PERSONALITY
DISORDERS
S E C O N D E D I T I O N
EDITED BY
John M. Oldham, M.D., M.S.

Andrew E. Skodol, M.D.
Donna S. Bender, Ph.D., FIPA
Washington, DC
London, England
Note. The authors have worked to ensure that all information in this book is accu-
rate at the time of publication and consistent with general psychiatric and medical
standards, and that information concerning drug dosages, schedules, and routes of
administration is accurate at the time of publication and consistent with standards set
by the U.S. Food and Drug Administration and the general medical community. As
medical research and practice continue to advance, however, therapeutic standards
may change. Moreover, specific situations may require a specific therapeutic response
not included in this book. For these reasons and because human and mechanical er-
rors sometimes occur, we recommend that readers follow the advice of physicians di-
rectly involved in their care or the care of a member of their family.
Books published by American Psychiatric Publishing (APP) represent the findings,
conclusions, and views of the individual authors and do not necessarily represent the
policies and opinions of APP or the American Psychiatric Association.
If you would like to buy between 25 and 99 copies of this or any other American Psy-
chiatric Publishing title, you are eligible for a 20% discount; please contact Customer
Service at [email protected] or 800–368–5777. If you wish to buy 100 or more copies of
the same title, please e-mail us at [email protected] for a price quote.
Copyright © 2014 American Psychiatric Association
ALL RIGHTS RESERVED
Manufactured in the United States of America on acid-free paper
18 17 16 15 14 5 4 3 2 1
Second Edition
Typeset in Adobe’s Helvetica Std and Palatino Std.
American Psychiatric Publishing
A Division of American Psychiatric Association
1000 Wilson Boulevard
Arlington, VA 22209-3901
www.appi.org
Library of Congress Cataloging-in-Publication Data
The American Psychiatric Publishing textbook of personality disorders / edited by
John M. Oldham, Andrew E. Skodol, Donna S. Bender. — Second edition.
p. ; cm.
Textbook of personality disorders
Includes bibliographical references and index.
ISBN 978-1-58562-456-0 (hardcover : alk. paper)
I. Oldham, John M., editor. II. Skodol, Andrew E., editor. III. Bender, Donna S.,
editor. IV. American Psychiatric Publishing, issuing body. V. Title: Textbook of person-
ality disorders.
[DNLM: 1. Personality Disorders—therapy. 2. Personality Disorders—diagnosis.
3. Personality Disorders—etiology. WM 190]
RC554
616.85c81—dc23
2014008220
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
To our families, who have supported us:
Karen, Madeleine, and Michael Oldham;
Laura, Dan, and Ali Skodol; and
John and Joseph Rosegrant.
To our colleagues, who have helped us.
To our patients, who have taught us.
And to each other, for the friendship that has

enriched our work together.
Contents
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xv
Steven E. Hyman, M.D.
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix
John M. Oldham, M.D., M.S., Andrew E. Skodol, M.D., and
1 Personality Disorders: Recent History

and New Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Part I
Clinical Concepts and Etiology
2 Theories of Personality and Personality Disorders. . . . . 13
Amy K. Heim, Ph.D., and Drew Westen, Ph.D.
3 Articulating a Core Dimension of

Personality Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Leslie C. Morey, Ph.D., and Donna S. Bender, Ph.D., FIPA
4 Development, Attachment, and Childhood

Experiences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Peter Fonagy, Ph.D., Anthony W. Bateman, M.A., FRCPsych,
Nicolas Lorenzini, M.Sc., M.Phil., and Chloe Campbell, Ph.D.
5 Genetics and Neurobiology . . . . . . . . . . . . . . . . . . . . . . . 79

Harold W. Koenigsberg, M.D., Antonia S. New, M.D.,
Larry J. Siever, M.D., and Daniel R. Rosell, M.D., Ph.D.
6 Prevalence, Sociodemographics, and

Functional Impairment . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Svenn Torgersen, Ph.D.
7 Manifestations, Assessment, and

Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
8 Course and Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

Carlos M. Grilo, Ph.D., Thomas H. McGlashan, M.D.,
and Andrew E. Skodol, M.D.
Part II
Treatment
9 Therapeutic Alliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
10 Psychodynamic Psychotherapies and

Psychoanalysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Frank E. Yeomans, M.D., John F. Clarkin, Ph.D.,
and Kenneth N. Levy, Ph.D.
11 Cognitive-Behavioral Therapy I:
Basics and Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Martin Bohus, M.D.
12 Cognitive-Behavioral Therapy II:

Specific Strategies for Personality Disorders. . . . . . . . . 261
J. Christopher Fowler, Ph.D., and John M. Hart, Ph.D.
13 Group, Family, and Couples Therapies . . . . . . . . . . . . . 281

John S. Ogrodniczuk, Ph.D., Amanda A. Uliaszek, Ph.D.,
Jay L. Lebow, Ph.D., and William E. Piper, Ph.D.
14 Psychoeducation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
Alan E. Fruzzetti, Ph.D., John G. Gunderson, M.D.,
and Perry D. Hoffman, Ph.D.
15 Somatic Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321

S. Charles Schulz, M.D., and Katharine J. Nelson, M.D.
16 Collaborative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . 345

Abigail B. Schlesinger, M.D., and Kenneth R. Silk, M.D.
17 Boundary Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369

Thomas G. Gutheil, M.D.
Part III
Special Problems,
Populations, and Settings
18 Assessing and Managing Suicide Risk. . . . . . . . . . . . . . 385
Paul S. Links, M.Sc., M.D., FRCPC, Paul H. Soloff, M.D., and
Francesca L. Schiavone, B.Sc.
19 Substance Use Disorders . . . . . . . . . . . . . . . . . . . . . . . 407
Seth J. Prins, M.P.H., Jennifer C. Elliott, Ph.D.,
Jacquelyn L. Meyers, Ph.D., Roel Verheul, Ph.D.,
and Deborah S. Hasin, Ph.D.
20 Antisocial Personality Disorder and Other

Antisocial Behavior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
Donald W. Black, M.D., and Nancee S. Blum, M.S.W.
21 Personality Disorders in the Medical Setting . . . . . . . . 455

Randy A. Sansone, M.D., and Lori A. Sansone, M.D.
22 Personality Disorders in the Military

Operational Environment . . . . . . . . . . . . . . . . . . . . . . . . 475
Ricky D. Malone, M.D., Col., M.C., U.S.A., and
David M. Benedek, M.D., Col., M.C., U.S.A.
Part IV
Future Directions
23 Translational Research in Borderline
Personality Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
Christian Schmahl, M.D., and Sabine Herpertz, M.D.
24 An Alternative Model for Personality Disorders:

DSM-5 Section III and Beyond. . . . . . . . . . . . . . . . . . . . 511
Andrew E. Skodol, M.D., Donna S. Bender, Ph.D., FIPA
and John M. Oldham, M.D., M.S.
Appendix: Alternative DSM-5 Model for

Personality Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . 545
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 569
Contributors
Anthony W. Bateman, M.A., FRCPsych Medical College of Cornell University,
Professor, Halliwick Unit, St Ann’s Hos- New York, New York
pital; Research Department of Clinical,
Jennifer C. Elliott, Ph.D.
Educational, and Health Psychology, Uni-
versity College London, London, United Postdoctoral Fellow, Substance Use Dis-
Kingdom orders Training Program, Department of
Epidemiology, Columbia University, New
Donna S. Bender, Ph.D., FIPA York, New York
Director, Counseling and Psychological
Services, Tulane University, New Orleans, Peter Fonagy, Ph.D.
Louisiana Professor and Head, Research Department
of Clinical, Educational, and Health Psy-
David M. Benedek, M.D., Col., M.C., chology, University College London; Anna
U.S.A. Freud Centre, London, United Kingdom
Department of Psychiatry, Uniformed Ser-
vices University of the Health Sciences, J. Christopher Fowler, Ph.D.
Bethesda, Maryland Associate Professor, Menninger Depart-
ment of Psychiatry and Behavioral Sci-
Donald W. Black, M.D.
ences, Baylor College of Medicine,
Professor and Vice-Chair for Education, Houston, Texas
Department of Psychiatry, University of
Iowa Roy J. and Lucille A. Carver Col- Alan E. Fruzzetti, Ph.D.
lege of Medicine, Iowa City, Iowa Professor of Psychology and Director,
Dialectical Behavior Therapy and Re-
Nancee S. Blum, M.S.W.
search Program, University of Nevada,
Adjunct Instructor, Department of Psy-
Reno, Nevada
chiatry, University of Iowa Roy J. and
Lucille A. Carver College of Medicine, Carlos M. Grilo, Ph.D.
Iowa City, Iowa Professor of Psychiatry, Department of
Martin Bohus, M.D. Psychiatry, Yale University School of
Chair in Psychosomatic Medicine and Medicine, New Haven, Connecticut
Psychotherapy, Heidelberg University, John G. Gunderson, M.D.
Germany; Director, Department of Psy-
Professor of Psychiatry, Harvard Medi-
chosomatic Medicine and Psychothera-
cal School; Director, Psychosocial and
py, Central Institute of Mental Health,
Personality Research, McLean Hospital,
Mannheim, Germany
Boston, Massachusetts
Chloe Campbell, Ph.D.
Thomas G. Gutheil, M.D.
Research Department of Clinical, Educa-
Professor of Psychiatry, Harvard Medi-
tional, and Health Psychology, University
cal School, and Co-Founder, Program in
College London, London, United Kingdom
Psychiatry and the Law, Beth Israel-
John F. Clarkin, Ph.D. Deaconess Medical Center and the Mas-
Professor of Clinical Psychology in Psy- sachusetts Mental Health Center, Boston,
chiatry, Department of Psychiatry, Weill Massachusetts
xi
xii The American Psychiatric Publishing Textbook of Personality Disorders
John M. Hart, Ph.D. Paul S. Links, M.Sc., M.D., FRCPC

Cognitive and Behavioral Therapy Spe- Professor and Chair, Department of Psy-
cialist, Menninger Department of Psy- chiatry, Schulich School of Medicine and
chiatry and Behavioral Sciences, Baylor Dentistry, The University of Western
College of Medicine, Houston, Texas Ontario; Chief of Psychiatry, London
Health Sciences Centre and St. Joseph’s
Deborah S. Hasin, Ph.D. Health Care, London, Ontario, Canada
Professor of Clinical Epidemiology (in
Psychiatry), Columbia University, New Nicolas Lorenzini, M.Sc., M.Phil.
York, New York Research Department of Clinical, Educa-
tional, and Health Psychology, Universi-
Amy K. Heim, Ph.D. ty College London; Anna Freud Centre,
Private Practice, Lexington, Massachusetts London, United Kingdom
Sabine Herpertz, M.D. Ricky D. Malone, M.D., Col., M.C., U.S.A.
Medical Director, Department of Gener- Center for Forensic Behavioral Sciences,
al Psychiatry, Centre of Psychosocial Walter Reed National Military Medical
Medicine, Heidelberg, Germany Center, Bethesda, Maryland
Perry D. Hoffman, Ph.D. Thomas H. McGlashan, M.D.
President and Co-Founder, National Ed- Professor of Psychiatry, Department of
ucation Alliance for Borderline Person- Psychiatry, Yale University School of
ality Disorder, Rye, New York Medicine, New Haven, Connecticut
Steven E. Hyman, M.D. Jacquelyn L. Meyers, Ph.D.
Director, Stanley Center for Psychiatric Postdoctoral Fellow, Psychiatric Epidemi-
Research at the Broad Institute of MIT ology, Department of Epidemiology, Co-
and Harvard; Harvard University Dis- lumbia University, New York, New York
tinguished Service Professor of Stem
Cell and Regenerative Biology, Harvard Leslie C. Morey. Ph.D.
University, Cambridge, Massachusetts George T. and Gladys H. Abell Profes-
sor, Department of Psychology, Texas
Harold W. Koenigsberg, M.D. A&M University, College Station, Texas
Professor of Psychiatry and Co-Director,
Mood and Personality Disorders Pro- Katharine J. Nelson, M.D.
gram, Icahn School of Medicine at Assistant Professor of Psychiatry and
Mount Sinai, New York, New York; Staff Medical Director of the Borderline Per-
Psychiatrist, James J. Peters VA Medical sonality Disorder Program, Department
Center, Bronx, New York of Psychiatry, University of Minnesota
Medical School, Minneapolis, Minnesota
Jay L. Lebow, Ph.D.
Clinical Professor of Psychology, Family In- Antonia S. New, M.D.
stitute at Northwestern, Evanston, Illinois Professor of Psychiatry, Icahn School of
Medicine at Mount Sinai, New York,
Kenneth N. Levy, Ph.D. New York
Assistant Professor, Department of Psy-
chology, Pennsylvania State University, John S. Ogrodniczuk, Ph.D.
University Park, Pennsylvania; Adjunct Professor, Department of Psychiatry,
Assistant Professor of Psychology, De- University of British Columbia, Vancou-
partment of Psychiatry, Joan and San- ver, British Columbia, Canada
ford I. Weill Medical College of Cornell
University, New York, New York John M. Oldham, M.D., M.S.
Senior Vice President and Chief of Staff,
The Menninger Clinic; Barbara and Cor-
Contributors xiii
bin Robertson Jr. Endowed Chair for Endowed Chair, Department of Psychia-
Personality Disorders, and Professor try, University of Minnesota Medical
and Executive Vice Chair, Menninger School, Minneapolis, Minnesota
Department of Psychiatry and Behavior-
al Sciences, Baylor College of Medicine, Larry J. Siever, M.D.
Houston, Texas; Past President, Ameri- Professor of Psychiatry, Icahn School of
can Psychiatric Association Medicine at Mount Sinai, New York,
New York; Director Mental Illness Re-
William E. Piper, Ph.D. search, Education and Clinical Centers,
Professor Emeritus, Department of Psy- James J. Peters VA Medical Center,
chiatry, University of British Columbia, Bronx, New York
Vancouver, British Columbia, Canada
Kenneth R. Silk, M.D.
Seth J. Prins, M.P.H. Professor, University of Michigan School
Predoctoral Fellow, Psychiatric Epide- of Medicine, Ann Arbor, Michigan
miology Training Program, Department Andrew E. Skodol, M.D.
of Epidemiology, Columbia University, Research Professor of Psychiatry, Depart-
Mailman School of Public Health, New ment of Psychiatry, University of Arizona
York, New York College of Medicine, Tucson, Arizona
Daniel R. Rosell, M.D., Ph.D. Paul H. Soloff, M.D.
Fellow, James J. Peters VA Medical Cen- Professor of Psychiatry, Department of
ter, Bronx, New York Psychiatry, School of Medicine, Universi-
ty of Pittsburgh, Pittsburgh, Pennsylvania
Lori A. Sansone, M.D.
Civilian Family Medicine Physician and Svenn Torgersen, Ph.D.
Medical Director, Family Health Clinic, Professor, Department of Psychology,
Wright-Patterson Air Force Base, Day- University of Oslo, Blindern, Norway
ton, Ohio
Amanda A. Uliaszek, Ph.D.
Randy A. Sansone, M.D. Assistant Professor, Department of Psy-
Professor, Departments of Psychiatry and chology, University of Toronto Scarbor-
Internal Medicine, Wright State Universi- ough, Toronto, Ontario, Canada
ty School of Medicine, Dayton, Ohio; Di-
Roel Verheul, Ph.D.
rector of Psychiatry Education, Kettering
Medical Center, Kettering, Ohio Professor of Personality Disorders, Uni-
versity of Amsterdam; Chief Executive
Francesca L. Schiavone, B.Sc. Officer/President of de Viersprong, Neth-
Medical Student, Schulich School of Medi- erlands Center for Personality Disorders,
cine and Dentistry, The University of West- Halsteren, The Netherlands
ern Ontario, London, Ontario, Canada
Drew Westen, Ph.D.
Abigail B. Schlesinger, M.D. Professor, Department of Psychology and
Assistant Professor, University of Pitts- Department of Psychiatry and Behav-
burgh School of Medicine, Pittsburgh, ioral Sciences, Emory University, Atlan-
Pennsylvania ta, Georgia
Christian Schmahl, M.D. Frank E. Yeomans, M.D.

Department of Psychosomatic Medicine Clinical Associate Professor of Psychiatry,
and Psychotherapy, Central Institute of Department of Psychiatry, Weill Medical
Mental Health, Mannheim, Germany College of Cornell University; Adjunct
Associate Professor, Columbia University
S. Charles Schulz, M.D. Center for Psychoanalytic Training and
Professor and Head, Donald W. Hastings Research, New York, New York
xiv The American Psychiatric Publishing Textbook of Personality Disorders
Disclosures of Competing Interests

The following contributors to this book have The following contributors to this book have
indicated a financial interest in or other affili- indicated no competing interests to disclose
ation with a commercial supporter, a manu- during the year preceding manuscript sub-
facturer of a commercial product, a provider of mission:
a commercial service, a nongovernmental or-
Anthony W. Bateman, M.A., FRCPsych
ganization, and /or a government agency, as
Donna S. Bender, Ph.D.
listed below:
David M. Benedek, M.D., Col., M.C.,
Donald W. Black, M.D.—Research grant: U.S.A.
AstraZeneca. Royalties: American Psychi- Martin Bohus, M.D.
atric Publishing; Oxford University Press Chloe Campbell, Ph.D.
Nancee S. Blum, M.S.W.—Royalties: Level John F. Clarkin, Ph.D.
One Publishing (publisher of STEPPS, Jennifer C. Elliott, Ph.D.
STEPPS UK, and STAIRWAYS treatment Peter Fonagy, Ph.D.
manuals, as first author). Consultant: Iowa J. Christopher Fowler, Ph.D.
Department of Corrections Carlos M. Grilo, Ph.D.
John G. Gunderson, M.D.
Thomas G. Gutheil, M.D.—More than
John M. Hart, Ph.D.
300 publications in national and interna-
Deborah S. Hasin, Ph.D.
tional professional literature, some of
Amy K. Heim, Ph.D.
which generate income
Sabine Herpertz, M.D.
Paul S. Links, M.Sc., M.D., FRCPC— Harold W. Koenigsberg, M.D.
Honorarium: Lundbeck Canada 2012 Jay L. Lebow, Ph.D.
Antonia S. New, M.D.—The author has Nicolas Lorenzini, M.Sc., M.Phil.
been a consultant for Alkermes. Other- Ricky D. Malone, M.D., Col., M.C.,
wise, no conflicts of interest to report. U.S.A.
The author believes consultation with Thomas H. McGlashan, M.D.
Alkermes is not a conflict of interest. She Jacquelyn L. Meyers, Ph.D.
has consulted on pharmacology in per- Leslie C. Morey
sonality disorders with Alkermes. She John S. Ogrodniczuk, Ph.D.
did not include any Alkermes product in John M. Oldham, M.D.
authoring of her chapter. William E. Piper, Ph.D.
S. Charles Schulz, M.D.—Consultant: Eli Seth J. Prins, M.P.H.
Lilly, Genentech; Grant/research support: Daniel R. Rosell, M.D., Ph.D.
AstraZeneca, Otsuka, Myriad/RBM, Na- Lori A. Sansone, M.D.
tional Institute of Mental Health Randy A. Sansone, M.D.
Francesca L. Schiavone, B.Sc.
Kenneth R. Silk, M.D.—Consultant:
Abigail B. Schlesinger, M.D.
One time consultancy on potential drug
Christian Schmahl, M.D.
development; Royalties: American Psy-
Larry J. Siever, M.D.
chiatric Press, Cambridge University
Press, Up-to-Date, Wiley Blackwell
Paul H. Soloff, M.D.
Svenn Torgersen, Ph.D.
Amanda A. Uliaszek, Ph.D.
Roel Verheul, Ph.D.
Frank E. Yeomans, M.D.
Foreword
Personality disorders occupy polygenic risk with diverse developmen-

an important and particularly challeng- tal and environmental factors; as a result
ing place in psychiatry. There is broad these disorders would be better concep-
recognition that for affected individuals, tualized in dimensional terms that are
personality disorders cause significant continuous with health and that recog-
distress, impairment, and disproportion- nize shared features within and across
ate health care utilization. In addition, families of disorders (Sullivan et al. 2012).
several personality disorders, most no- The clinical and scientific problems cre-
tably borderline, narcissistic, and anti- ated by the imposition of a nosology based
social, often produce significant adverse on discontinuous categories are perhaps
effects on families, in workplaces, and, greater for the study and treatment of
more broadly, for society. The clinical and personality disorders than for any other
societal significance of these disorders area of psychiatry. Personality represents
notwithstanding, there remains consid- a complex set of attributes that mediate
erable disagreement on how best to de- how each human being experiences his
fine them and how to make reliable, clin- or her self and understands and interacts
ically useful, and ultimately scientifically with the external world, especially the so-
valid diagnoses. cial but also the nonsocial world. As de-
The challenges facing the field of per- scribed in several chapters of this textbook,
sonality disorders, as well documented it is an intensely active area of investiga-
in this textbook, arise partly from difficul- tion to find the scientifically strongest—
ties that are common to the study of all and at the same time clinically useful—
psychiatric disorders: a lack of objective approaches to capturing and enumerat-
medical or neuropsychological diagnos- ing personality traits. In the study of per-
tic tests or of biomarkers that track sever- sonality disorders, however, this task is
ity or reflect improvement with treatment. further complicated by the need to iden-
As for essentially all psychiatric disor- tify boundaries among personality traits
ders, the personality disorders are poorly (and trait clusters) that are adaptive, mal-
captured by the categorical diagnostic adaptive, or disordered, a scientific task
approach that has been the hallmark of complicated by the need to account for the
DSM since its third edition (American context dependence of what can be judged
Psychiatric Association 1980). Personal- adaptive versus pathological.
ity disorders, like almost all psychiatric As is documented within this textbook,
disorders, are heterogeneous syndromes serious attempts were made in the pro-
that result from the interaction of highly cess of developing DSM-5 (American
xv
xvi The American Psychiatric Publishing Textbook of Personality Disorders
Psychiatric Association 2013) to create di- the science by facilitating better cluster-
mensional alternatives to the problematic ing of patients for study.
contemporary categorical treatment of The challenges taken on by the authors
the personality disorders. The end result of this textbook might frighten all but the
of this process is represented by an alter- most stalwart clinicians and investiga-
native diagnostic model contained within tors, especially when combined with the
DSM-5, but not within the main section of task of treating such a demanding popu-
the manual. This alternative model, de- lation. In a field that finds itself in a
tailed by the editors of this textbook in period of serious, but hopefully construc-
Chapter 24, “An Alternative Model for tive disagreement, it is particularly im-
Personality Disorders: DSM-5 Section III portant to have a textbook such as this
and Beyond,” was rightly or wrongly one. It presents the clinical wisdom and
judged too complex for the clinical com- scientific data that should be expected of
munity and too radical a departure from a comprehensive volume. More impor-
the status quo. Unfortunately, the prob- tantly, it does not push the current con-
lems with the status quo remain quite se- troversies into the background, but ad-
vere: these are described throughout the dresses them head-on with many very
textbook, but perhaps most saliently in interesting chapters written by protago-
Chapter 3, “Articulating a Core Dimen- nists in the attempts to advance better sci-
sion of Personality Pathology.” Thus, for entific understandings. Despite the un-
example, the current DSM-5 personality settled nature of the classification, many
disorder categories discussed in the main chapters contained within this textbook
text of the manual have the peculiar prop- bear powerful witness to advances in the
erties of being too broad and too narrow understanding of personality disorders
at the same time. In short, each personal- and to a very solid body of treatment re-
ity disorder category is too broad in that search. Over the last decade it has been
it selects a highly heterogeneous group of recognized that the course of many per-
individuals but also too narrow as evi- sonality disorders, including the most
denced by the remarkably high fre- researched disorder, borderline personal-
quency of co-occurrence with other per- ity disorder, is not as fixed and mono-
sonality disorders and other DSM-5 tonic as had previously been believed.
disorders. As a result of the arbitrary and Especially when treated with evidence-
narrow diagnostic silos, the majority of based psychosocial interventions and ju-
patients with any personality disorder di- dicious use of medications, many patients
agnosis receive more than one diagnosis, can achieve reasonably good outcomes.
and often many. Despite the challenges that remain, there
Of course, it is far easier to identify has been significant and meaningful prog-
problems than to propose solutions that ress. Overall, I commend this textbook to
will aid the clinicians who treat this chal- mental health professionals as extremely
lenging population or facilitate scientific useful and as capturing the excitement of
advances aimed at better understandings this field.
and treatments. Perhaps the disagree-
ments that surfaced in the development Steven E. Hyman, M.D.
of DSM-5 can be taken as a starting point Director, Stanley Center for Psychiatric
for progress in classification, which would Research Broad Institute of MIT and
represent a step toward strengthening Harvard, Cambridge, Massachusetts
Foreword xvii
American Psychiatric Association: Diag-

References nostic and Statistical Manual of Mental
Disorders, 5th Edition. Arlington, VA,
American Psychiatric Association, 2013
American Psychiatric Association: Diag-
Sullivan PF, Daly MJ, O’Donovan M: Genetic
nostic and Statistical Manual of Mental
architecture of psychiatric disorders: the
Disorders, 3rd edition. Washington, DC,
emerging picture and its implications.
American Psychiatric Association, 1980
Nat Rev Genet 13:537-551, 2012
Introduction
There is a vast and rich literature in also critically important—these range

science, medicine, philosophy, and the from health-promoting, highly nurturing
arts reflecting worldwide fascination environments to stressful and neglectful
with the subject of personality—what environments from which only the most
makes each of us unique and different resilient emerge unscathed. We are
from each other, and what determines the steadily learning more about complex
ways in which we are alike. The tradi- polygenic risk factors that confer vul-
tional mandate of medicine, however, is nerability to the development of most
to understand illness—how to identify it, psychiatric disorders. The importance of
how to treat it, and how to prevent it. This epigenetics is increasingly recognized,
new edition of the Textbook of Personality clarifying the capacity of stressful en-
Disorders brings to its pages the wisdom vironmental experience to activate risk
and guidance of some of the world’s ex- genes and launch a cascade of events re-
perts to teach us about the illnesses we sulting in the emergence of psychopathol-
call personality disorders. Particularly in ogy, including the personality disorders.
the realm of personality, there are not clear With the advent of standardized di-
categorical distinctions differentiating in- agnostic systems, empirical and clinical
dividuals with “normal” personalities research on the personality disorders
from those who suffer from impairments has expanded. Semistructured research
in personality functioning. Personality interviews are being used to study clinical
functioning and personality traits exist and community-based populations to
along continuous spectra, from healthy to provide better data about the epidem-
unhealthy and from adaptive to maladap- iology of these disorders. Overall, per-
tive. There are variations in the degree of sonality disorders occur in over 10% of
disturbance in a person’s sense of self and the general population, and their public
in interpersonal relationships (central de- health significance has been well docu-
fining aspects of personality disorders), mented, reflecting sometimes extreme
but significant impairment in these areas impairment in functioning and high
of functioning plus the prevalence of health care utilization. As clinical popu-
pathological traits can impede a person’s lations are becoming better defined, new
effective navigation in the world. and more rigorous treatment studies are
For decades, it was widely thought that being carried out, with increasingly prom-
some severely disturbed individuals just ising results. In addition, longitudinal
seemed to have been “born that way,” a naturalistic studies have shown surpris-
view resulting from cases with signifi- ing patterns of improvement in patients
cant genetic loading or risk. We know, of with selected personality disorders, chal-
course, that environments in early life are lenging the assumption that these dis-
xix
xx The American Psychiatric Publishing Textbook of Personality Disorders
orders are almost always “stable and en-

during” over time. Genetic and neurobi- Part I: Clinical Concepts
ological studies have clarified that the
personality disorders, like other psychi-
and Etiology
atric disorders, emerge developmentally
The first section of this textbook might
based on the combination of heritable
be thought of as the foundation for the
risk factors and environmental stress.
parts that follow. In Chapter 2, Heim and
Fundamental challenges remain, such
Westen review the major theories that
as clarifying the relationship between nor-
have influenced thinking about the na-
mal personality and personality disor-
ture of personality and personality disor-
ders themselves. A strong consensus has
ders. The next chapter, by Morey and
developed among personality experts
Bender, follows naturally from the previ-
that the personality disorders are best
ous one, emphasizing the fundamental
conceptualized dimensionally, and Sec-
roles of self and interpersonal function-
tion III, “Emerging Measures and Mod-
ing as core components of personality
els,” of the recently published DSM-5
and as defining features of impairment in
contains an alternative model for the per-
personality disorders. These concepts are
sonality disorders, a hybrid dimensional
central components of the alternative
and categorical model that is extensively
model for personality disorders in DSM-5,
referenced and discussed in this volume
described in more detail in Chapters 7 and
(see particularly Chapter 7, “Manifesta-
24. Fonagy and colleagues, in Chapter 4,
tions, Assessment, and Differential Diag-
then present a developmental perspec-
nosis,” and Chapter 24, “An Alternative
tive, stressing the importance of healthy
Model for Personality Disorders: DSM-5
attachment experiences as building blocks
Section III and Beyond”).
for effective adult personality functioning.
In light of the continuing and increased
Disruptions in attachment, conversely, set
activity and progress in the field of per-
the stage for future impairment, and they
sonality studies and personality disor-
correlate strongly with the development
ders, we judged the time to be right to de-
of the neurobiological dysregulation that
velop this new edition of the Textbook of
is present in many patients with personal-
Personality Disorders, with an emphasis on
ity disorders, described in Chapter 5 by
updating information we believe to be es-
Koenigsberg and colleagues. New data on
sential to clinicians. First, in Chapter 1,
prevalence, sociodemographics, and lev-
Oldham presents a brief overview of the
els of functional impairment are described
recent history of the personality disor-
by Torgersen in Chapter 6. Although
ders, along with a summary look at the
there are relatively few well-designed
evolution of the personality disorders
population-based studies, Torgersen re-
component in successive editions of DSM.
views important contributions, including
Then, this new volume is organized into
his own Norwegian study, and he tabu-
four parts: 1) Clinical Concepts and Etiol-
lates prevalence ranges and averages for
ogy; 2) Treatment; 3) Special Problems,
individual DSM-defined personality dis-
Populations, and Settings; and 4) Future
orders as well as for all personality disor-
Directions.
ders taken together.
Introduction xxi
In Chapter 7, Skodol reviews the de- ing this conceptual overview by Bohus,
fining features of DSM-5 Section II and Fowler and Hart summarize several spe-
Section III personality disorder assess- cific cognitive-behavioral therapy strate-
ment models, discusses complementary gies, including traditional cognitive-
approaches to the clinical assessment of a behavioral therapy itself, schema-focused
patient with possible personality psychotherapy, and dialectical behavior therapy,
pathology, provides guidance on general as applied in working with patients with
problems encountered in the routine clin- personality disorders.
ical evaluation, and outlines differential Apart from the realm of individual
diagnosis according to the alternative treatments, there are other venues for
DSM-5 model for personality disorders. therapeutic interventions. In Chapter 13,
Throughout, Skodol provides expert guid- Ogrodniczuk and colleagues demonstrate
ance to introduce readers to the new the application of group, family, and cou-
model, clarifying the differences in the ples therapies to personality disorders.
application of this new dimensional Fruzzetti and colleagues, in Chapter 14,
hybrid system compared with the tradi- review the important role of psychoedu-
tional DSM-IV categorical approach. In cation in the treatment of personality
Chapter 8, Grilo and colleagues provide disorders, as well as the growing impor-
an overview of the clinical course and tance of family involvement in treatment
outcome of personality disorders, syn- and of peer support programs. Schulz and
thesizing the empirical literature on the Nelson then take up the issue, in Chap-
long-term course of personality disorder ter 15, of pharmacotherapy and other so-
psychopathology, including the impor- matic treatments, because many patients
tance of comorbidity and continuity of with personality disorders may benefit
psychopathology over time. from complementing their psychosocial
treatments with evidence-based, symp-
tom-targeted, adjunctive medications.
Part II: Treatment Schlesinger and Silk, in Chapter 16, pro-
vide recommendations about the best way
Chapters 9–17 offer a range of treatment of negotiating collaborative treatments,
options and considerations. The treatment because many patients with personality
section begins with Chapter 9, in which disorders are engaged in several treatment
Bender underscores the necessity of ex- modalities with several clinicians at the
plicitly considering aspects of alliance same time. In the final chapter in this sec-
building with various styles of personal- tion, Gutheil cautions practitioners about
ity psychopathology across all treatment dynamics that can lead to boundary viola-
modalities. Yeomans and colleagues, in tions when working with certain patients
Chapter 10, summarize the salient fea- with personality disorders.
tures of psychodynamic psychotherapies
and psychoanalysis, including mecha-
nisms of change and empirical validation, Part III: Special
as applied to patients with personality pa-
thology. In Chapter 11, Bohus outlines the
Problems, Populations,
core elements of cognitive-behavioral and Settings
therapies, approaches that have increas-
ingly been shown to be effective in the In recognition of the fact that patients
treatment of a number of different per- with personality disorders can be partic-
sonality disorders. In Chapter 12, follow- ularly challenging, we have included
xxii The American Psychiatric Publishing Textbook of Personality Disorders
five chapters devoted to special issues ognized but can eventually lead to sig-
and populations. Of prime importance is nificant impairment in functioning. The
the risk for suicide. In Chapter 18, Links armed services are increasingly alert to
and colleagues provide evidence on the the accurate recognition of personality
association of suicidal behavior and per- disorders within their ranks, and to the
sonality disorders, examine modifiable not uncommon co-occurrence of post-
risk factors, and discuss clinical ap- traumatic stress disorder, traumatic brain
proaches to the assessment and manage- injury, major depression, and suicide
ment of suicide risk. In Chapter 19, Prins risk.
and colleagues focus on pathways to
substance abuse in patients with person-
ality disorders, and they discuss issues Part IV: Future
of differential diagnosis and treatment.
Substance use and abuse is common in
Directions
many patients with personality dis- In the first of two chapters in the final
orders, perhaps particularly in patients section of this textbook, Schmahl and
with antisocial personality disorder. Black Herpertz focus on the increasing useful-
and Blum, in Chapter 20, present the lat- ness of translational research to deepen
est findings regarding antisocial behav- understanding of the biopsychosocial
ior. Of the personality disorders, antiso- nature of the personality disorders. To
cial personality disorder is one of the most close, the book’s editors Skodol, Bender,
costly to society, and it can be associated and Oldham summarize current contro-
with serious personal consequences. Un- versies about and present a detailed
fortunately, far too little is available to of- chronicle of the evidence supporting the
fer at this point in terms of effective treat- alternative DSM-5 model for personality
ment, and many of these individuals end disorders, and the complex process of its
up in correctional and forensic settings. development.
In Chapter 21, Sansone and Sansone
discuss the substantial prevalence of per- We are grateful to all of the chapter
sonality disorders within general medi- authors for their careful and thoughtful
cal settings, demonstrating that physical contributions, and we hope that we have
conditions frequently coexist with and succeeded in providing a current, defin-
are complicated by personality pathol- itive review of the field. We would par-
ogy and that patients with personality ticularly like to thank Liz Golmon for
disorders often seek treatment from pri- her organized and steadfast administra-
mary care or family medicine physicians. tive support, without which this volume
In the final chapter in this section, Chap- would not have been possible.
ter 22, Malone and Benedek focus on an
important population that often gets
overlooked: soldiers on active duty in the
U.S. military. In military settings, person- Andrew E. Skodol, M.D.
ality disorders can be masked or unrec- Donna S. Bender, Ph.D., FIPA
CHAPTER 1
Personality Disorders
Recent History and New Directions
cess is also bidirectional, so that the “in-

Personality Types and born” behavior of the infant can elicit be-
havior in parents or caretakers that can, in
Personality Disorders turn, reinforce infant behavior: placid,
happy babies may elicit warm and nur-
People are different, and what makes us turing behaviors; irritable babies may
different from each other has a lot to do elicit impatient and neglectful behaviors.
with something called personality, the But even-tempered, easy-to-care-for
phenotypic patterns of thoughts, feelings, babies can have bad luck and land in a
and behaviors that uniquely define each nonsupportive or even abusive environ-
of us. In many important ways, we are ment, which may set the stage for a per-
what we do. At a school reunion, for ex- sonality disorder, and difficult-to-care-
ample, recognition of classmates not seen for babies can have good luck, protected
for decades derives as much from famil- from future personality pathology by spe-
iar behavior as from physical appearance. cially talented and attentive caretakers.
To varying degrees, heritable tempera- Once these highly individualized dynam-
ments that differ widely from one indi- ics have had their main effects and an indi-
vidual to another determine an amazing vidual has reached late adolescence or
range of human behavior. Even in the young adulthood, his or her personality
newborn nursery, one can see strikingly will often have been pretty well estab-
different infants, ranging from cranky ba- lished. This is not an ironclad rule, how-
bies to placid ones. Throughout life, each ever; there are “late bloomers,” and high-
individual’s temperament remains a key impact life events can derail or reroute any
component of that person’s developing of us. How much we can change if we
personality, added to by the shaping and need to and want to is variable, but change
molding influences of family, caretakers, is possible. How we define the differences
and environmental experiences. This pro- between personality styles and personal-
1
2 The American Psychiatric Publishing Textbook of Personality Disorders
ity disorders (PDs), how the two relate to ery edition of the APA’s Diagnostic and
each other, what systems best capture the Statistical Manual of Mental Disorders
magnificent variety of nonpathological (DSM). Largely driven by the need for
human behavior, and how we think about standardized psychiatric diagnoses in the
and deal with extremes of thoughts, feel- context of World War II, the U.S. War De-
ings, and behaviors that we call PDs are partment, in 1943, developed a document
spelled out in great detail in the chapters labeled Technical Bulletin 203, represent-
that follow in this textbook. In this first ing a psychoanalytically oriented system
chapter, I briefly describe how the Ameri- of terminology for classifying mental ill-
can Psychiatric Association (APA) has ap- ness precipitated by stress (Barton 1987).
proached the definition and classification The APA charged its Committee on No-
of the PDs, building on broader interna- menclature and Statistics to solicit expert
tional concepts and theories of psychopa- opinion and to develop a diagnostic man-
thology. ual that would codify and standardize
Although personality pathology has psychiatric diagnoses. This diagnostic
been well known for centuries, it is often system became the framework for the
thought to reflect weakness of character first edition of DSM (American Psychiat-
or willfully offensive behavior, produced ric Association 1952). This manual has
by faulty upbringing, rather than to be a subsequently been revised on several oc-
type of “legitimate” psychopathology. In casions, leading to new editions: DSM-II
spite of these common attitudes, clini- (American Psychiatric Association 1968),
cians have long recognized that patients DSM-III (American Psychiatric Associa-
with personality problems experience sig- tion 1980), DSM-III-R (American Psychi-
nificant emotional distress, often accom- atric Association 1987), DSM-IV (Ameri-
panied by disabling levels of impairment can Psychiatric Association 1994), DSM-
in social or occupational functioning. IV-TR (American Psychiatric Association
General clinical wisdom has guided treat- 2000), and DSM-5 (American Psychiatric
ment recommendations for these patients, Association 2013).
at least for those who seek treatment, plus Figure 1–1 (Skodol 1997) portrays the
evidence-based treatment guidelines ontogeny of diagnostic terms relevant to
have been developed for patients with the PDs, from the first edition of DSM
borderline PD. Patients with paranoid, through DSM-5. DSM-IV-TR involved
schizoid, or antisocial patterns of think- only text revisions but retained the same
ing and behaving often do not seek treat- diagnostic terms as DSM-IV, and DSM-5
ment. Others, however, seek help for (in its main diagnostic component, Sec-
problems ranging from self-destructive tion II, “Diagnostic Criteria and Codes”)
behavior to anxious social isolation to just includes the same PD diagnoses as DSM-
plain chronic misery, and many of these IV except that the two provisional diag-
patients have specific or mixed PDs, often noses, passive-aggressive and depres-
coexisting with other conditions such as sive, listed in DSM-IV Appendix B, “Cri-
mood or anxiety disorders. teria Sets and Axes Provided for Further
Study,” have been deleted. Additionally,
Section III, “Emerging Measures and Mod-
The DSM System els,” of DSM-5 includes an alternative
model for personality disorders, which
Contrary to assumptions commonly en- is reviewed extensively throughout this
countered, PDs have been included in ev- book.
Personality Disorders 3
DSM-I (1952) DSM-II (1968) DSM-III (1980) DSM-IV (1994)/

DSM-5 (2013)
Personality pattern Axis I cyclothymic Axis I cyclothymic
disturbance disorder disorder
Inadequate Inadequate Cluster A Cluster A
Paranoid Paranoid Paranoid Paranoid
Cyclothymic Cyclothymic
Schizoid Schizoid Schizoid Schizoid
Schizotypal Schizotypal
Personality trait
disturbance Cluster B Cluster B
Emotionally unstable Hysterical Histrionic Histrionic
Passive-aggressive Antisocial Antisocial
dependent type Borderline Borderline
aggressive type Passive- Narcissistic Narcissistic
aggressive
Cluster C Cluster C
Compulsive Obsessive- Compulsive Obsessive-compulsive
compulsive Avoidant Avoidant
Dependent Dependent
Passive-aggressive
Sociopathic personality
disturbance Asthenic
Antisocial Antisocial
Dyssocial Explosive Axis I intermittent
explosive disorder
Indicates that category was discontinued.
FIGURE 1–1. Ontogeny of personality disorder classification.

Note. No changes were made to the personality disorder classification in DSM-III-R except for
the inclusion of self-defeating and sadistic personality disorders in Appendix A. These two cate-
gories were not included in DSM-IV, DSM-IV-TR, or DSM-5. Passive-aggressive and depressive
personality disorders were present in Appendix B of DSM-IV and DSM-IV-TR but have been
removed for DSM-5. An alternative model for the personality disorders (not shown in Figure 1–1)
is included in Section III, “Emerging Measures and Models,” of DSM-5.
Source. Modified from Skodol AE: “Classification, Assessment, and Differential Diagnosis of Person-
ality Disorders.” Journal of Practical Psychiatry and Behavioral Health 3:261–274, 1997.
Although not explicit in the narrative issues such as how to differentiate PDs
text, the first edition of DSM reflected from personality styles or traits, which re-
the general view of PDs at the time, ele- main actively debated today, were clearly
ments of which persist to the present. identified.
Generally, PDs were viewed as more or In the first edition of DSM, PDs were
less permanent patterns of behavior and generally viewed as deficit conditions,
human interaction that were established reflecting partial developmental arrests,
by early adulthood and were unlikely to or distortions in development secondary
change throughout the life cycle. Thorny to inadequate or pathological early care-
taking. The PDs were grouped primarily By the mid 1970s, greater emphasis
into personality pattern, personality trait, was placed on increasing the reliability of
and sociopathic personality. Personality all diagnoses. DSM-III defined PDs (and
pattern disturbances were viewed as the all other disorders) by explicit diagnostic
most entrenched conditions, likely to be criteria and introduced a multiaxial eval-
recalcitrant to change, even with treat- uation system. Disorders classified on
ment; these conditions included inade- Axis I included those generally seen as
quate personality, schizoid personality, episodic “symptom disorders” charac-
cyclothymic personality, and paranoid terized by exacerbations and remissions,
personality. Personality trait disturbances such as psychoses, mood disorders, and
were thought to be less pervasive and dis- anxiety disorders. Axis II was established
abling, so in the absence of stress these to include the PDs as well as specific de-
patients could function relatively well. If velopmental disorders; both groups were
under significant stress, however, pa- seen as composed of early-onset, persis-
tients with emotionally unstable, pas- tent conditions, but the specific develop-
sive-aggressive, or compulsive person- mental disorders were understood to be
alities were thought to show emotional “biological” in origin, in contrast to the
distress and deterioration in functioning, PDs, which were generally regarded as
and they were variably motivated for and “psychological” in origin. The decision to
amenable to treatment. The category of place the PDs on Axis II led to greater rec-
sociopathic personality reflected what ognition of the PDs and stimulated ex-
were generally seen as types of social de- tensive research and progress in our un-
viance; it included antisocial reaction, derstanding of these conditions. (New
dyssocial reaction, sexual deviation, and data, however, have called into question
addiction (subcategorized into alcohol- the rationale to conceptualize the PDs as
ism and drug addiction). fundamentally different from other types
The primary stimulus leading to the of psychopathology, such as mood or
development of a new, second edition of anxiety disorders, and in any event the
DSM was the publication of the eighth multiaxial system of DSM-III and IV has
revision of the International Classifica- been removed in DSM-5.)
tion of Diseases (World Health Organi- As shown in Figure 1–1, the DSM-II
zation 1967) and the wish of the APA to diagnoses of inadequate PD and asthenic
reconcile its diagnostic terminology with PD were discontinued in DSM-III. Also
this international system. In the DSM re- in DSM-III, the DSM-II diagnosis of ex-
vision process, an effort was made to plosive PD was changed to intermittent
move away from theory-derived diag- explosive disorder, cyclothymic PD was
noses and to attempt to reach consensus renamed cyclothymic disorder, and both
on the main constellations of personality of these diagnoses were moved to Axis I.
that were observable, measurable, endur- Schizoid PD was felt to be too broad a
ing, and consistent over time. The earlier category in DSM-II and therefore was re-
view that patients with PDs did not expe- crafted into three PDs: schizoid PD, re-
rience emotional distress was discarded, flecting “loners” who are uninterested in
as were the subcategories described close personal relationships; schizotypal
above. One new PD was added, called as- PD, understood to be on the schizophre-
thenic PD, only to be deleted in the next nia spectrum of disorders and character-
edition of DSM. ized by eccentric beliefs and nontradi-
Personality Disorders 5
tional behavior; and avoidant PD, typified In addition, on the basis of prior clinical
by self-imposed interpersonal isolation recommendations to the DSM-III-R PD
driven by self-consciousness and anxi- subcommittee, two PDs were included
ety. Two new PD diagnoses were added in DSM-III-R in Appendix A, “Proposed
in DSM-III: borderline PD and narcissis- Diagnostic Categories Needing Further
tic PD. In contrast to initial notions that Study”: self-defeating PD and sadistic
patients called “borderline” were on the PD. These diagnoses were considered
border between the psychoses and the provisional.
neuroses, the criteria defining borderline DSM-IV was developed after an exten-
PD in DSM-III emphasized emotion dys- sive process of literature review, data anal-
regulation, unstable interpersonal rela- ysis, field trials, and feedback from the
tionships, and loss of impulse control profession. Because of the increase in re-
more than persistent cognitive distor- search stimulated by the criteria-based
tions and marginal reality testing, which multiaxial system of DSM-III, more evi-
were more characteristic of schizotypal dence existed to guide the DSM-IV pro-
PD. Among many scholars whose work cess. As a result, the threshold for ap-
greatly influenced and shaped the con- proval of revisions for DSM-IV was a
ceptualization of borderline pathology higher one than that used in DSM-III or
introduced in DSM-III were Kernberg DSM-III-R. DSM-IV introduced, for the
(1975) and Gunderson (1984). Although first time, a set of general diagnostic crite-
concepts of narcissism had been described ria for any PD, underscoring qualities
by Sigmund Freud, Wilhelm Reich, and such as early onset, long duration, inflex-
others, the essence of the current views ibility, and pervasiveness. These general
of narcissistic PD emerged from the work criteria, however, were developed by ex-
of Millon (1969), Kohut (1971), and Kern- pert consensus and were not derived em-
berg (1975). pirically. Diagnostic categories and di-
DSM-III-R was published in 1987 after mensional organization of the PDs into
an intensive process to revise DSM-III, in- clusters remained the same in DSM-IV as
volving widely solicited input from re- in DSM-III-R, with the exception of the
searchers and clinicians and following relocation of passive-aggressive PD from
similar principles to those articulated in the “official” diagnostic list to Appendix
DSM-III, such as assuring reliable diag- B, “Criteria Sets and Axes Provided for
nostic categories that were clinically Further Study.” Passive-aggressive PD,
useful and consistent with research find- as defined by DSM-III and DSM-III-R,
ings, thus minimizing reliance on theory. was thought to be too unidimensional and
In DSM-III-R, no changes were made in generic; it was tentatively retitled “nega-
diagnostic categories of PDs, although tivistic PD” and the criteria were revised.
some adjustments were made in certain In addition, the two provisional Axis II
criteria sets—for example, they were diagnoses in DSM-III-R, self-defeating
made uniformly polythetic instead of PD and sadistic PD, were dropped, be-
defining some PDs with monothetic cri- cause of insufficient research data and
teria sets (i.e., with all criteria required), clinical consensus to support their reten-
such as for dependent PD, and others tion. One other PD, depressive PD, was
with polythetic criteria sets (i.e., with proposed and added to Appendix B. Al-
some minimum number, but not all cri- though substantially controversial, this
teria required), such as for borderline PD. provisional diagnosis was proposed as a
pessimistic cognitive style, presumably height might be better conceptualized di-

distinct from passive-aggressive PD or mensionally because there is no exact
dysthymic disorder. definition of “tall” or “short,” notions of
The diagnostic terms and criteria of tallness or shortness may vary among
DSM-IV were not changed in DSM-IV-TR, different cultures, and all gradations of
published in 2000. The intent of DSM- height exist along a continuum.
IV-TR was to revise the descriptive, nar- We know, of course, that the DSM sys-
rative text accompanying each diagnosis tem is referred to as categorical and is
where it seemed indicated and to update contrasted with any number of systems
the information provided. Only minimal referred to as dimensional, such as the in-
revisions were made in the text material terpersonal circumplex (Benjamin 1993;
accompanying the PDs. Kiesler 1983; Wiggins 1982), the three-fac-
Since the publication of DSM-IV, new tor model (Eysenck and Eysenck 1975),
knowledge has rapidly accumulated several four-factor models (Clark et al.
about the PDs, and discussions about 1996; Livesley et al. 1993, 1998; Watson et
controversial areas have intensified. Al- al. 1994; Widiger 1998), the “Big Five”
though DSM-IV had an increased empir- model (Costa and McCrae 1992), and the
ical basis compared with previous ver- seven-factor model (Cloninger et al.
sions of DSM, a number of limitations of 1993). How fundamental is the difference
the categorical approach were apparent, between the two types of systems? Ele-
and many unanswered questions re- ments of dimensionality already exist in
mained. Are the PDs fundamentally dif- the traditional DSM categorical system,
ferent from other categories of major represented by the organization of the
mental illness such as mood disorders or PDs into Cluster A (odd or eccentric),
anxiety disorders? What is the relation- Cluster B (dramatic, emotional, or er-
ship of normal personality to PD? Are the ratic), and Cluster C (anxious or fearful).
PDs best conceptualized dimensionally In addition, a patient can just meet the
or categorically? What are the pros and threshold for a PD or can have all of the
cons of polythetic criteria sets, and what criteria, presumably a more extreme ver-
should determine the appropriate num- sion of the disorder. Certainly, if a patient
ber of criteria (i.e., threshold) required for is one criterion short of being diagnosed
each diagnosis? Which PD categories with a PD, clinicians do not necessarily
have construct validity? Which dimen- assume that there is no element of the dis-
sions best cover the full scope of normal order present; instead, prudent clinicians
and abnormal personality? Many of these would understand that features of the
discussions overlap with and inform disorder need to be recognized if present
each other. and may need attention. Busy clinicians,
Among these controversies, one stands however, often think categorically, decid-
out with particular prominence: whether ing what disorder or disorders a patient
a dimensional approach or a categorical “officially” has. In practice, when a pa-
one is preferred to classify the PDs. Much tient is thought to have a PD, clinicians
of the literature poses this topic as a de- generally assign only one PD diagnosis,
bate or competition, as if one must choose whereas systematic studies of clinical
sides. Dimensional structure implies con- populations utilizing semistructured in-
tinuity, whereas categorical structure im- terviews show that patients with person-
plies discontinuity. For example, being ality psychopathology generally have
pregnant is a categorical concept, whereas multiple PD diagnoses (Oldham et al.
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Title: Profili e paesaggi della Sardegna
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Language: Italian
Original publication: Milano: Brigola, 1869
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*** START OF THE PROJECT GUTENBERG EBOOK PROFILI E

PAESAGGI DELLA SARDEGNA ***
PROFILI E PAESAGGI
DELLA
SARDEGNA
PROFILI E PAESAGGI
DELLA
SARDEGNA
DI
PAOLO MANTEGAZZA
MILANO
PER L’EDITORE G. BRIGOLA.
1869
Proprietà Letteraria.
Milano. — Ditta Wilmant.
INDICE
Man möchte glauben, dass
diese Insel gar nicht in Europa
läge, so wenig kümmert man
sich um sie.
Si potrebbe credere che
quest’isola non fosse in
Europa, tanto poco ce ne
occupiamo.
Barone di Maltzan.
UNA PAROLA AL LETTORE
Questo scritterello tirato giù alla buona, più col cuore che colla
squadra, era destinato ad uscire modestamente in qualche rivista:
ma in questi nostri tempi anche le riviste hanno i loro regolamenti, le
loro frontiere, le loro dogane; e il mio lavoro, già piccino per sè, fece
il caparbio e il superbuzzo, nè volle rassegnarsi a comparir pei
giornali tagliato a fette, nè ci son riuscito a condurlo a più modesti
consigli. Ecco perchè un libro, che non è un libro, vi compare
impaginato, col suo frontispizio e il suo indice, col nome dell’editore
nella prima pagina e colla triste parola di fine nell’ultima. Non badate
però alla veste superba, perchè sotto la scorza c’è un galantuomo,
che chiacchiera con voi senza pretensione di scrittore che voglia dir
cose nuove o ripeter cose vecchie meglio degli altri.
Amando il vero più che il brevetto d’invenzione, io godrò assai di
ripetere sulla Sardegna cose già dette da altri; ma ad un patto solo,
ch’io sia riuscito cioè a farvi amare un’isola bellissima e infelicissima,
che noi altri italiani abbiamo il torto di dimenticar troppo e di amar
troppo poco.
Io poi vorrei dirvi un’altra parola che mi riguarda, e per farmela
perdonare voglio rubarla al nostro Giusti. Voi sapete che l’Io è come
le mosche, più le scacci e più ti ronzan d’intorno; sicchè devo
confessare che ho scritto questo libro non libro per amor mio, per
pagare almeno in parte un debito di riconoscenza verso i Sardi così
cortesi, così ospitali, così delicatamente generosi. Mi parve che a
saldare il conto non dovesse bastare quel po’ di lavoro utile che
potrò fare in Palazzo Vecchio come membro della Commissione
d’inchiesta e come deputato. Mi parve che fosse mio dovere scrivere
una parola calda d’affetto per la Sardegna, farla conoscere anche a
quei molti italiani che non possono leggere e studiare le grandi opere
che son privilegio delle biblioteche e dei pochi signori che comprano
i libri grossi e costosi.
Può darsi che la mia parola riesca qua e là severa od acerba; ma
son sicuro che i miei amici di Sardegna non vi troveranno ombra di
fiele. Chi molto ama, molto castiga; ed io amo fortemente quell’isola,
così povera di presente, così ricca d’avvenire; e in nome di questo
affetto fraterno, confido che l’asprezza sarà interpretata come
burbera tenerezza d’un galantuomo, come rabbuffo amoroso
d’amico ad amico.
Rimini, 2 agosto 1869.
CAPITOLO I.
La Sardegna vuol essere amata. — Le città della

Sardegna. — Cagliari. — I giardinetti e un pazzo di San
Bartolomeo. — Sassari e una lezione di storia. — Le
grandi e le piccole borgate della Sardegna. — I villaggi e
gli stazzi.
Ho messo il piede in Sardegna con viva curiosità e dopo un lungo

giro ho lasciato quell’isola con caldo amore: prima di conoscerla, era
per me cosa curiosa; dopo averla conosciuta era per me cosa cara.
Gli Italiani della penisola hanno un grave torto di dimenticare questa
gemma del Mediterraneo; essi devono studiarla ed amarla; gli Italiani
di Sardegna hanno il grave torto di spegnere la loro energia in
queruli lamenti, cercando fuor di sè stessi l’origine e il rimedio dei
loro mali. Or conviene che isola e penisola si perdonino a vicenda i
loro peccati, e stringendosi in un potente amplesso, si preparino a
tempi nuovi, e si mettano con forze comuni a fecondare una terra
quasi deserta e che ha dinanzi a sè un avvenire senza confini, più
splendido del suo passato ai tempi di Roma. Io sento nel cuore molti
debiti verso la Sardegna e i suoi cortesi abitanti: come membro della
Commissione d’inchiesta farò coi colleghi quanto sta in me, perchè il
nostro lavoro non riesca infecondo; come operaio della penna vorrei
con queste poche pagine far amare la Sardegna da tutti gli Italiani,
invitarli a studiarla, ad accarezzarla. Io ho viaggiato gran parte del
nostro pianeta e ho portato il piede in regioni quasi ignote a calcagno
europeo: eppure ho trovato in questa italianissima nostra isola molte
cose nuove, e belle e originali; e più d’una volta coi miei cari
compagni di viaggio ho dovuto esclamare in coro: Oh perchè mai gli
Italiani ignorano queste bellezze della loro patria? Oh perchè mai
non vi portano i loro occhi per ammirare, le loro braccia per lavorare,
il loro oro per raddoppiarlo?
La Sardegna è pur terra feconda e originale! Quasi ignota alle
invasioni germaniche, è tesoro per l’etnografo e l’archeologo; e
altrove non si saprebbero trovare alcuni tipi che in quell’isola
rimasero purissimi, segregati dall’incrociamento moltiforme del
medio evo. Un filologo e un antropologo troverebbero nello studio
comparato dei dialetti e dei cranii sardi tali tesori da farne una
scienza nuova e da ricostruire con facile e feconda fatica la fisiologia
delle più antiche stirpi italiane. L’amante del bello trova in Sardegna
paesaggi svariatissimi: coste dentellate come le foglie delle mimose;
vergini foreste; pianure e stagni; colli e vere Alpi, dove il granito
mostra i più bei fianchi ch’io m’abbia veduti al mondo. Costumi
pittoreschi intatti da più secoli: tipi umani profondamente scolpiti;
poesia popolare, passioni calde; rozze e ardenti nature poco o nulla
mutate dagli attriti sociali, nè lisciate dalla pialla della moda francese;
scene della natura geologica e umana, quali è difficile trovare altrove
e ai tempi nostri; tutta una tavolozza di colori vivi e svariati che può
dare materia d’opere immortali al poeta, allo scrittore, all’artista.
E poi in questo secolo affamato d’oro, tu trovi in Sardegna monti
solcati da cento e mille filoni di piombo e sul piombo strati di zinco; e
presso il piombo e lo zinco altri metalli che non aspettano che la
mano del minatore per versare una larga vena di ricchezza nel
sangue italiano. E su quei monti una terra che scalda e profuma i
pampini delle vigne di Spagna e di Portogallo e promette in epoca
non lontana una mina a fior di terra più ricca di quella metallica che
s’addensa nelle viscere dei monti. E nel piano una terra che per
ritornare ad essere granaio d’Italia, non aspetta che la magia d’una
parola, il drenaggio.
Su questa terra benedetta dal sole, ricca di metalli, e di vino; di biade
e di poesia, batte l’ali fuligginose un triste vampiro, la malaria; ma
questa può e deve esser vinta dall’uomo, purchè il voglia. Nelle vene
dei Sardi, intelligenti e morali, serpeggia un veleno più infesto della
malaria alla salute di un popolo, ed è l’inerzia: malaria ed inerzia, le
due grandi malattie della Sardegna; ma malattie curabili, perchè
l’organismo è robusto e malgrado la ricca storia, ancor giovine;
perchè quest’isola dà già segni di reazione della natura medicatrice;
perchè quest’isola incomincia a voler essere medico di sè stessa.
Anche Londra aveva la malaria e per opera dell’uomo è fra le città
più salubri del mondo: anche i Tedeschi furono per anni e secoli
inerti; ma l’inerzia fu vinta; e la Germania, dopo essersi messa a
capo della scienza, ha fatto Sadowa.
Cagliari e Sassari son le due gemme della Sardegna, e son gemme

rivali, e di un’antica rivalità, come già lo scrisse Cattaneo col suo
scalpello da scultore. «Il solo vincolo che unisce le città sarde, era
quello della rivalità anzi dell’odio. La stessa mano che fomentava
altrove i rancori tra Palermo e Messina, tra Milano e Pavia,
opponeva studiosamente Cagliari e Sassari, Sassari e Alghero. In
Alghero si fece statuto, che i Sassaresi non vi si potessero mostrare
colla spada al fianco; e in Sassari vi si rispose argutamente,
ordinando che li Algheresi non potessero venire a Sassari se non
cinti di due spade. La vita delle nazioni era concentrata nei pochi
municipi. Cagliari fondava un’Università, e Sassari non rimaneva
indietro, e ne fondava un’altra.» — Ed io aggiungerò, che al dì d’oggi
la rivalità fra le due prime città dell’isola non è astiosa, e va
assottigliandosi di giorno in giorno coi contatti cresciuti; finchè le
ferrovie la facciano sparire del tutto.
Del resto Cagliari non può essere confrontata a Sassari, così come
una bella bruna non può compararsi con una bella bionda. Cagliari
ha più pittoresca posizione e s’adagia in un panorama più grandioso;
Sassari è più lieta e si circonda di più amena cornice di colli e di
oliveti. La prima città è più severa, più accigliata e più sporca;
Sassari è più vivace, più rumorosa, più pulita. Cagliari è città
ufficiale, burocratica, con tinta soffusa di orientale e di spagnolesco;
Sassari è città più italiana, d’aspetto più moderno, di tinta siciliana; e
mi si perdoni il pericoloso confronto in nome dell’amor grandissimo
che porto alla Sardegna. L’Italia è così ricca di belle e svariate città,
che si dovrebbe poter ragionar senza fiele di ogni gemma che
adorna il nostro ricco diadema.
Quando si contempla il golfo di Cagliari dall’alto del bellissimo
giardino pubblico, o del castello, o meglio ancora dalla torre di San
Pancrazio, si gode d’uno dei bellissimi fra i belli spettacoli che
offrono al viaggiatore le cento città d’Italia. Un golfo ampio, dinanzi a
cui l’uomo deve arrossire col microscopico porto che offre alle navi;
e il faro lontano, e le saline, colle loro piramidi bianchissime, quasi
tende di un guerresco accampamento; e gli stagni vicini, veri laghi,
popolati da grosse borgate; e il promontorio di Sant’Elia col Bagno di
San Bartolomeo; e la città che dal Castello scende a Stampace e
alla Marina, quasi volesse imbarcarsi sul mare, e la vasta fascia di
agavi americane che cingono il Castello d’una fortezza primitiva; e i
lontani gruppi di palme e i tamarischi e le altre piante tropicali danno
all’occhio infinita ricchezza di sensazioni; e l’occhio beato si riposa
lungamente e amorosamente su quelle mille incantevoli bellezze.
Il Castello è il quartiere più alto e più salubre della città, e
s’arrampica sopra un alto colle: ha vie dirette da nord a sud, poco
larghe, ripide, con case alte. E strette sono anche le vie di Cagliari
alla Marina: vecchia abitudine dei nostri padri, che, vivendo giorni e
mesi all’aria libera, volevano nelle loro case ombra e frescura più
che aria e luce. Nel quartiere del Castello avete la Cattedrale
dedicata a Santa Cecilia e sette altre chiese.
Discendendo dal Castello per la piccola porta del Balice, vi trovate
nel quartiere di Stampace, che è il centro del commercio e degli
affari. Se per la via di Yenne vi dirigete verso il mare, guardando a
destra e a manca le migliori botteghe della città, giungerete alla
piazza di San Carlo, che si continua in quella del mercato; e là vi
convien sorridere, ma di un sorriso senza amarezza, guardando
sopra un gran piedestallo di granito, un re Carlo Felice, fatto di
bronzo, con elmo, corazza e paludamento; graniti e bronzi e vesti
romane che, davvero, poco convengono ad un re pacifico; due volte
pacifico.
Quando siete in Stampace non avete a dimenticare il mercato, che è
sempre uno dei quadri più importanti di una città. Vi troverete molto
pesce; montagne di arancie dorate e profumate raccolte sotto
capanne pittoresche, quasi indiane; vedrete il ricco e svariato
selvaggiume della Sardegna. Vi offriranno una pernice per una lira,
una beccaccia per dieci soldi; filze di otto tordi polputi e grassi,
lessati nelle montagne e ravvolti nel mirto: filze degne di Nembrodde
e di Lucullo e che i Sardi chiamano taccole. Fra le capanne dei
venditori d’arancie, e le botteghe a ciel sereno dei pesciajuoli, dei
salumieri e dei beccai vedrete aggirarsi la gente minuta coi suoi
costumi variopinti, quasi sempre pieni di gusto.
Le case di Cagliari son popolate da cento balconi e in molte di esse
ogni finestra è un balcone, ciò che non è bello a vedersi, ma è
comodo assai per le fanciulle e le signore, che escono assai poco di
casa e da quei loro osservatorii studiano il mondo esterno e fanno
all’amore. L’amore onesto si fa anzi da una signora che guarda dal
balcone e da un giovinotto che impavido e instancabile passa le ore
inchiodato nella via come una statua, contemplando la fiamma del
suo cuore. E come sia cosa seria il far l’innamorato in Sardegna, lo
vedremo più innanzi.
Se dalle vie principali della città vi addentrate nei viottoli e più ancora
se cercate i più poveri quartieri, il naso si arriccia e l’igiene pubblica
fa sentire i suoi lamenti. Nel quartiere di Villanuova ho veduto le vie
convertite in fogne, e anche in alcune case di Stampace ho veduto
atrii che devono essere molto pericolosi agli uomini di corta vista. In
Villanuova la vita del povero è pubblica nel senso più preciso della
parola. Le case per lo più non hanno finestre; e l’aria, la luce e gli
sguardi dei curiosi entrano liberissimamente a spiare i costumi degli
abitanti. Quando il tempo è buono, non fa bisogno neppure di
spinger lo sguardo oltre la soglia delle case, perchè tutta la famiglia
si rovescia nella via, dove si lavora, si chiacchiera e si mangia. In
Villanuova io mi credevo davvero in Africa, e le donne che mi
parevan tutte sorelle, avean gli occhi orizzontali e piccoli, il colorito
terreo e quella fisonomia di obelisco che ci hanno tramandati i
monumenti egiziani.
E quella gente dal volto egiziano è cortese e sorride al forestiero.
Colle migliori grazie del mondo mi lasciarono entrare in casa e mi
accorsi che molte di quelle abitazioni sembravan fatte per una cosa
sola, adatte ad una sola industria, quella del mugnaio. Le sedie son
poche e spesso brillano per la loro assenza, e così dei tavoli e degli
altri mobili; ma la nostra attenzione è tutta attratta da un asinello
grullo grullo, arruffato, poco più grosso d’un mastino e che così poco
rassomiglia a cosa viva da sembrar di legno, quando si arresta nel
suo monotono, sempiterno giro intorno alla macina che muove.
Quell’animaluccio, il dio penate, la prima ricchezza della casa, costa
da cinque a dieci lire, è più parco di un arabo; e divide il tetto col
padrone e i suoi figliuoli. Fabbrica il pane alla famiglia e produce
spesso il piccolo frutto di macinar il grano ai vicini, industria rovinosa
che speriamo veder scomparire dalle classi povere della Sardegna.
Le donne della casa son occupate per tre e fin quattro giorni della
settimana a fabbricare la farina che stacciano e raffinano con infinite
cure per mezzo di crivelli e stacci puliti, fini ed eleganti, intrecciati a
varii colori con cannucce di paglia e fibre di palma e che vedete
appiccati al muro della casa, di cui insieme a qualche immagine di
Santo formano l’unico ornamento.
Il mulino casalingo della Sardegna è la mola asinaria o machinaria
degli antichi: poco diversa dalla χειρομύλη dei Greci. Potete vedere
in Vaticano sopra un bassorilievo una mola machinaria romana,
dove anche il cavallo che la muove ha gli occhi coperti come i
rachitici asinelli macinatori della Sardegna. Se son rachitici e nani,
son però valenti e pazienti, perchè lavoran fin quindici e diciassette
ore al giorno, e Matzan aggiunge, ridendo a proposito, che quei
somarelli devono esser anche grandi filosofi, dacchè Pittaco di
Mitilene passava molte ore, macinando colla χειρομύλη, movimento
che aveva trovato favorevole alla meditazione.
Quando si pensa però che tutte le donne e spesso anche i fanciulli
d’una famiglia sono occupati in null’altro che a far pane, è a
desiderarsi che la legge del macinato abbia almeno in Sardegna
questo vantaggio di far sparir la falsa e fatale industria dei mulini
casalinghi.
Cagliari può vantarsi di possedere nel suo Museo un vero tesoro
archeologico, a nessuno secondo e che è opera quasi intiera di un
solo uomo, il Canonico Giovanni Spano, una delle prime glorie della
Sardegna; più che instancabile, miracoloso nella sua attività e
ardentissimo e innamoratissimo illustratore del suo paese.
L’Università di Cagliari e la sua minore sorella di Sassari sono una
vera vergogna per l’Italia. Non è lecito ad un governo, per quanto
povero, lasciare queste larve di insegnamento superiore, dove la
povertà dei mezzi concessi alla scienza fiacca e avvilisce i migliori
ingegni e la volontà dei buoni è spesso impotente e rabbiosa contro
le lesinerie burocratiche dell’alta sfera governativa. Speriamo che
per onor nostro questo obbrobrio sarà cancellato. Ho conosciuto a
Cagliari e a Sassari ottimi uomini che pur vorrebbero studiare;
giovani intelligenti e operosi che pur potrebbero far avanzare la
scienza, ma li ho veduti aggirarsi come larve irrequiete per quei muti
corridoj e quelle aule deserte che con superba parola si chiamano
Università: veri idalghi spagnuoli che domandano l’elemosina con
piglio altero e i vestiti laceri.
La penna irata mi richiama alla mente un tristo ricordo di Cagliari, ed
è la mia visita all’Ergastolo di San Bartolomeo; primo passo in una
via crucis che dovetti percorrere in Sardegna, visitando tutte le
carceri e tutte le galere.
A San Bartolomeo si sta assai bene, molti assassini vi ingrassano a
meraviglia, nel lavoro salubre delle saline, negli ampii dormitorii e
con sani alimenti. In altre carceri però e specialmente a San
Pancrazio in Cagliari e a Sassari e altrove sentii il tanfo di una lenta
asfissia e mi si inchiodò nel capo un pensiero che non mi abbandona
mai, ed è questo che la società si vendica col suo codice delle pene
assai più spesso di quel che si difende; incrudelisce assai più di
quello che educa.
Nell’Ergastolo di San Bartolomeo si fondò una colonia agricola
penitenziaria che promette assai per l’avvenire. Dinanzi al palazzo
della vendetta vedete giardini fioriti che appartengono agli impiegati
della galera: ho veduto bambine rosee nel volto, coi nastri rosei
pendenti da un lindo cappellino di paglia di Firenze correre per
quelle aiuole fiorite dietro le farfalle; mentre uomini dalla faccia
patibolare passavano dinanzi a quei giardinetti e coi loro sguardi
contaminavano quelle bambine.
E quei galeotti avevano diversi berretti, dacchè anche fra essi v’ha
una gerarchia. L’uomo è un animale da gerarchia e pur che ne
abbiate tre riuniti avete subito: plebe, aristocrazia e mezzo ceto; è
privilegio di tutte le bestie sociali e socievoli e possiamo menarne
vanto. Il berretto rosso vuol dire condanna a tempo, berretto verde
condanna a vita, fiocco nero omicidio e così via. Le bambine dai
nastri rosei conoscono tutte queste differenze e ve le spiegano; e il
Procuratore del re, passeggiando col sorriso sul volto mi diceva:
stanno benissimo: la è gente fortunata, che mangia e lavora e gode
di ottima salute. Nell’ultima epidemia di febbri miasmatiche in
Cagliari ebbero tutti la febbre e questi galeotti si serbarono
sanissimi; ed egli rideva.
Io però, passeggiando nelle sale destinate ai malati, mi fermai
dinanzi ad un volto che parea impietrito nel dolore; un Laocoonte del
cuore; sempre vivo e sempre tormentato. Era melanconico e
tormentato tratto tratto da accessi di delirio di persecuzione credeva
che tutti lo volessero ammazzare. Era divorato dai rimorsi. Era un
povero muratore, che, trovandosi senza pane, andò dal suo antico
padrone, chiedendogli lavoro. Gli fu negato; ritornò più volte e
sempre invano. Un giorno la fame era maggiore del solito: era
rabbiosa; egli insiste nell’implorare il lavoro: Ho sei figliuoli; signor
padrone. — Oh va all’inferno, tu e i tuoi figliuoli. — Una mazza era
sul suolo fra vari attrezzi di muratore e un momento dopo il padrone
era steso al suolo cadavere: e il povero muratore condannato nella
galera di San Bartolomeo è pazzo di dolore e di rimorsi [1]. —
A San Bartolomeo però si sta bene e si ingrassa; e i giardinetti degli
impiegati sono fioriti. Io vi ho vedute le più belle viole del mondo e vi
ho colta una rosa più profumata di quelle d’Arabia; i bambini vi
acchiappano le più brillanti farfalle; ma a due passi v’è un uomo
pazzo di dolore, perchè la società si vendica più di quel che si
difende. I nostri figliuoli, però, ne son sicuro, prepareranno ai posteri
una giustizia più umana.
Quando voi avete percorso le noiose, lunghe e tristi lande sterili che
separano Bosa da Macomer e avete attraversati i paesaggi poco
interessanti di Torrealba e i rari boschi di quercie che trovate nella
monotona pianura; voi vi accorgete di esser vicini a Sassari, quando
la natura diviene ridente; quando i monti, rizzandosi più alti intorno a
voi, frastagliano il cielo e la terra in modo da formare quadri svariati
e pittoreschi. Ascendete un monte tutto pieno di magnifici olivi,
coltivati colla stessa sollecitudine e tenerezza con cui si coltiva un
orto cittadino. Io percorsi quei boschi d’argento nel tempo della
raccolta e vidi liete schiere di fanciulle e di ragazzi che raccoglievano
il frutto in lindi canestri, e a quando a quando interrompevano il
lavoro per cantare e ballare. Parevano stormi di passerotti vivaci e
protervi; e raccoglievano le olive colla stessa cura e lo stesso amore
con cui si farebbe bottino di cosa carissima e preziosissima. E
davvero che l’olivo è per Sassari una mina d’argento: mi si diceva
che in quest’anno, fortunato fra gli altri, si farebbero 200,000 barili
d’olio, che è quanto dire una bella cifra rotonda di sette ad otto
milioni di lire. Di questa ricchezza mi accorsi anche entrando in
Sassari, dove molte case nuove si stavano rizzando ed erano le
olive trasformate in muri e marmi. L’olio di Sassari potrebbe esser
fatto meglio: se ne manda a Nizza, dove raffinato cresce di valore e
piglia un nome che per la sua squisitezza nativa ben si ha meritato.
L’olivo dovrebbe anche esser difeso nei dintorni di Sassari dai
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Handbook of Personality Disorders Theory Research and

Personality Jerry M. Burger

Songs of love and horror collected lyrics of Will Oldham

John M. Oldham, M.D., M.S.

To our colleagues, who have helped us.

To our patients, who have taught us.

And to each other, for the friendship that has

1 Personality Disorders: Recent History

3 Articulating a Core Dimension of

4 Development, Attachment, and Childhood

5 Genetics and Neurobiology . . . . . . . . . . . . . . . . . . . . . . . 79

6 Prevalence, Sociodemographics, and

7 Manifestations, Assessment, and

8 Course and Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

10 Psychodynamic Psychotherapies and

12 Cognitive-Behavioral Therapy II:

13 Group, Family, and Couples Therapies . . . . . . . . . . . . . 281

15 Somatic Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321

16 Collaborative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . 345

17 Boundary Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369

20 Antisocial Personality Disorder and Other

21 Personality Disorders in the Medical Setting . . . . . . . . 455

22 Personality Disorders in the Military

24 An Alternative Model for Personality Disorders:

Appendix: Alternative DSM-5 Model for

John M. Hart, Ph.D. Paul S. Links, M.Sc., M.D., FRCPC

Christian Schmahl, M.D. Frank E. Yeomans, M.D.

Disclosures of Competing Interests

Personality disorders occupy polygenic risk with diverse developmen-

American Psychiatric Association: Diag-

There is a vast and rich literature in also critically important—these range

orders are almost always “stable and en-

cess is also bidirectional, so that the “in-

DSM-I (1952) DSM-II (1968) DSM-III (1980) DSM-IV (1994)/

Indicates that category was discontinued.

FIGURE 1–1. Ontogeny of personality disorder classification.

pessimistic cognitive style, presumably height might be better conceptualized di-

Title: Profili e paesaggi della Sardegna

Author: Paolo Mantegazza

Release date: January 5, 2024 [eBook #72631]

Original publication: Milano: Brigola, 1869

Credits: Barbara Magni and the Online Distributed Proofreading

*** START OF THE PROJECT GUTENBERG EBOOK PROFILI E

La Sardegna vuol essere amata. — Le città della

Ho messo il piede in Sardegna con viva curiosità e dopo un lungo

Cagliari e Sassari son le due gemme della Sardegna, e son gemme

Let us accompany you on the journey of exploring knowledge and

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