Journal of Affective Disorders 68 (2002) 143158 www.elsevier.

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Millennial article

Development of an integrated model of personality, personality disorders and severe axis I disorders, with special reference to major affective disorders
Detlev von Zerssen*
Max Planck Institute of Psychiatry, Munich, Germany Received 19 May 2000; accepted 26 March 2001

Abstract A unidimensional model of the relationships between normal temperament, psychopathic variants of it and the two main forms of so-called endogenous psychoses (major affective disorders and schizophrenia) was derived from Kretschmers constitutional typology. It was, however, not conrmed by means of a biometric approach nor was Kretschmers broad concept of cyclothymia as a correlate of physical stoutness on the one hand and major affective disorders on the other supported by empirical data. Yet the concept of the melancholic type of personality of patients with severe unipolar major depression (melancholia) which resembles descriptions by psychoanalysts could be corroborated. This was also true for the manic type of personality as a (premorbid) correlate of predominantly manic forms of a bipolar I disorder. As predicted from a spectrum concept of major affective disorders, the ratio of traits of either type co-varied with the ratio of the depressive and the manic components in the long-term course of such a disorder. The two types of premorbid personality and a rare variant of the manic type, named relaxed, easy-going type, were conceived as affective types dominating in major affective disorders. They are opposed to three neurotoid types prevailing in so-called neurotic disorders as well as in schizophrenic psychoses. The similarity among the types can be visualized as spatial relationships in a circular, i.e. a two-dimensional, model (circumplex). Personality disorders as maladapted extreme variants of personality are, by denition, located outside the circle, mainly along its neurotoid side. However, due to their transitional nature, axis I disorders cannot be represented adequately within the plane which represents (adapted as well as maladapted) forms of habitual behaviour (personality types and disorders, respectively). To integrate them into the spatial model of similarity interrelations, a dimension of actual psychopathology has to be added to the two-dimensional plane as a third (orthogonal) axis. The distance of a case from the ground level of habitual behaviour corresponds with the severity of the actual psychopathological state. The specic form of that state (e.g. manic or depressive), however, varies along one the axes which dene the circumplex of habitual behaviour. This three-dimensional model is, by its very nature, more complex than the unidimensional one derived from Kretschmers typological concept, but it is clearly more in accordance with empirical data. 2002 Elsevier Science B.V. All rights reserved.
Keywords: Premorbid personality; Personality disorders; Melancholia; Mania; Spectrum concept

*Dipl. Psych., Ottostr. 11, D-82319 Starnberg, Germany. Tel.: 1 49-8151-4168; fax: 1 49-8151-4116. 0165-0327 / 02 / $ see front matter 2002 Elsevier Science B.V. All rights reserved. PII: S0165-0327( 02 )00045-9

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1. Introduction This is an overview of research concerning the premorbid personality (PP) in patients with affective and other mental state (axis I) disorders conducted during the nal third of the last century (von Zerssen, 1996b). The respective investigations started with an attempt to test the validity of the then widely accepted constitutional typologies (Mayer-Gross et al., 1969) proposed by Kretschmer (1921) in Germany and Sheldon (1940, 1942) in the USA. Finally, it resulted in a comprehensive taxonomic model which integrated the empirical ndings regarding associations between personality and personality disorders (PDs) on the one hand and personality and axis I disorders on the other. The emphasis of this report is on the relationships of PP to PDs and major affective disorders (unipolar melancholia and bipolar disorder). However, other axis I disorders are used for comparison, particularly with respect to the specicity of the relationships under review. A terminological and conceptual discussion on how temperament, personality, and personality disorder are viewed in Germany, Europe at large, and the United States is beyond the scope of the present paper. To the extent possible, the author has used such terminology and concepts as commonly understood in the literature. The interested reader may wish to consult several recent papers that have dealt with most of these issues in the international literature (Brieger and Marneros, 1997; von Zerssen and Akiskal, 1998; Akiskal, 2001).

2. Historical background The conceptual framework of our research is rooted in Kraepelins description of the personal disposition of patients with manic-depressive insanity (Kraepelin, 1913), i.e. a depressive, irritable, manic or cyclothymic disposition which he related to the predominant clinical manifestation of the disorder (von Zerssen and Akiskal, 1998). He regarded these trait patterns as fundamental states of the episodes of severe depression and / or mania. Kretschmer (1921) unied the different fundamental states according to Kraepelin to the broad concept of cyclothymia to which he later added syntonia, a

habitually balanced mood state, described by Bleuler (1922) as typical for the PP of manic-depressives sensu Kraepelin. Kretschmer considered cyclothymia in this broad sense as a normal variant of temperament (the part of the psyche that is correlated with body build), which was associated with a stout (pyknic) physical habitus. Akiskal et al. (1977, 1998) have also used cyclothymia in the sense of mildly symptomatic bipolar, as well as widely distributed traits in the population at large which might predispose to bipolar disorder. This temperament was contrasted by Kretschmer with schizothymia, a temperament closely resembling the personal disposition to dementia praecox described by Kraepelin (1913) and the schizoid personality of schizophrenics according to Bleuler (1911). Kretschmer assumed a strong association of schizothymia with a slender (asthenic or leptosome) physique and, in addition, with a muscular (athletic) habitus as well as abnormal (dysplastic) variants of body build. (For the sake of simplicity, these additional variants will not be considered here.) The respective types of physique and temperament were found by Kretschmer and many of his followers to predominate in manic-depressives (bipolar patients as well as unipolar melancholics: pyknic habitus and cyclothymic temperament) and schizophrenia (leptosome habitus and schizothymic temperament). The mental disorder, whether affective or schizophrenic, was conceived as an exaggerated form of normal temperamental traits. Psychopathic variants (named cycloidia and schizoidia, respectively) were regarded by Kretschmer as kinds of intermediate states between temperamental types and the related disorders. Several authors, among them Conrad (1941), one of Kretschmers scholars, argued that the leptosome and pyknic types of body build represented opposite poles of a normal variation in physique between slenderness and stoutness and that the same was true for the respective temperaments. A similar view was held by Sheldon (1940, 1942) who developed a dimensional system of physique and temperament. Kretschmers typological concept of relationships between temperament, psychopathic variants of it and the two main forms of so-called endogenous psychoses according to Kraepelin could thus be reduced to a unidimensional model (Fig. 1).

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Fig. 1. Unidimensional model of temperament, psychopathic variants of it and the two main forms of endogenous psychoses as derived from the writings of Kretschmer and others.

A basically different picture of the predominant personality traits of patients suffering from melancholia, i.e. a severe form of depression, emerged from the work of psychoanalysts (Mendelson, 1976) and several other psychiatrists (von Zerssen, 1996a), among them Tellenbach (1961) who coined the term melancholic type of personality. These traits were most often observed in involutional (late onset) melancholia (Titley, 1936). According to these authors particularly characteristic features of the patients were orderliness and rigidity, often in combination with a close binding to a few signicant others (Nietzel and Harris, 1990). However, some of the authors, e.g. Tellenbach and the psychoanalysts Cohen et al. (1954) and Arieti (1959), noted hypomanic traits, corresponding to the manic disposition sensu Kraepelin, in the PP of a certain proportion of patients with a bipolar disorder, i.e. traits almost opposite to those of the melancholic type of personality. This historical situation was the background of research of my own which was performed in several stages described in Sections 39 of this paper.

3. Testing the validity of the unidimensional model of variations in physique, personality and so-called endogenous psychoses Our research on the PP of patients with major affective disorders (unipolar melancholia and bipolar disorder) started with an attempt to test the validity of the respective concepts of constitutionalists as outlined above. For this purpose, a series of new self-rating questionnaires were derived from Kretschmers writings and then combined with selfconstructed scales for the measurement of mental

vitality (i.e. a vigorous temperament with high levels of activity and self-condence; for references see von Zerssen, 1973, 1977) and with already existing self-rating instruments, e.g. Eysencks Maudsley Personality Inventory (MPI: Eysenck, 1959) and a questionnaire for the assessment of Sheldons temperamental types (Child, 1950). These instruments, together with anthropometric measurements, were applied in samples of healthy young men, healthy students of both sexes and psychiatric patients aged between 20 and 60 years. The main results of a large number of statistical analyses are described in von Zerssen, 1976. Variations in physique and their relationships to variations in personality traits can be most adequately described in a dimensional framework. Of three main dimensions of body buildgeneral skeleton size, sturdiness and development of fatty tissue only sturdiness is correlated signicantly with personality traits. However, this correlation is rather weak (r 0.2) and restricted to males. Finally, it resembles Sheldons description of an association between a mesomorphic (sturdy) physical constitution and somatotonia (extraverted activity) rather than Kretschmers description of an association between a pyknic body build and cyclothymia in a broad sense: males of a sturdy physical habitus tend to be more active and assertive and less sensitive than their physically less robust counterparts. We have named this trait pattern, i.e. extraverted tendencies in combination with emotional stability, mental vitality because it correlated highly with the respective scales (see above). A score composed of questionnaire items that correlate signicantly with physical sturdiness in males can be used as a measure of this higher order dimension of personality or temperament (according to Kretschmers denition; see

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Section 2). Yet this score does not discriminate patients with major affective disorders (mainly unipolar melancholia) from schizophrenics, neither in females nor in males (von Zerssen, 1966). The same is true for pyknic versus leptosome physique ascertained by means of anthropometric indices if age is comparable in the two groups of patients. On the other hand, the same indices do show signicant differences between younger patients (age below the mean of | 40 years) and older ones (above that age), the latter displaying a comparatively more pyknic habitus, irrespective of the clinical diagnosis (von Zerssen, 1969a). It can be concluded that (1) differences in physique between patients with major affective disorders and the usually younger schizophrenics are mainly age dependent and (2) the socalled endogenous psychoses can hardly be regarded as exaggerated forms of temperament, at least not in the way Kretschmer had conceived such a relationship.

4. Comparison of cyclothymia sensu Kretschmer and the melancholic type of personality in major affective disorders In a next step (von Zerssen, 1969b), we carried out a comparison of Kretschmers broad concept of cyclothymia (embracing Kraepelins fundamental states of manic-depressive insanity plus syntonia according to Bleuler) with the psychoanalytic concept of the personality of melancholics and Tellenbachs similar concept of the melancholic type of personality, neglecting associations of body build and personality as probably unimportant in this context. The analyses included expert ratings of questionnaire items derived from the respective literature. A Q-factor analysis of these ratings conrmed the consistency of the three concepts, the close resemblance of the psychoanalytic concept and that described, although in different terms, by Tellenbach and the independence of these concepts from cyclothymia sensu Kretschmer. In a preliminary case control study (von Zerssen, 1969b), scales for retrospective self-rating of personality traits (Kendell and DiScipio, 1968), constructed on the basis of the expert ratings, were applied in a small sample of patients with so-called

endogenous depression (melancholia) and two control groups of equal size (n 5 10 for each group) and equal composition with respect to gender, age and verbal IQ. One control group consisted of psychiatric patients with either schizophrenia or a non-depressive neurotic disorder, the other one of neurological cases with no obvious mental disorder. The cyclothymia scale revealed a signicant difference between these two control groups only, in that the psychiatric patients achieved markedly lower values than the physically ill. However, the typus melancholicus scale discriminated the melancholic group by signicantly higher values from both control groups. Informants ratings by close relatives of patients (melancholics and and a mixed control group of psychiatric and neurological cases only) showed trends in similar directions without reaching signicance. It could be argued that the negative ndings regarding cyclothymic traits of melancholics might be due to an inadequate operationalization of Kretschmers concept and the small sample sizes. Therefore, a replication study (von Zerssen et al., 1970) was carried out with new expertises and with larger samples (n 5 30 per group). In this investigation, the second control group consisted of patients with various physical disorders. Informants ratings could be obtained for subgroups of patients in all three samples. The new expertises correlated highly with the older ones that the scaling of the questionnaire items had not to be changed. The group comparisons by means of these scales not only conrmed the differences found in the preceding study but disclosed, in addition, signicantly lower values in the self-ratings of melancholics concerning cyclothymia compared with the physically ill controls and signicantly higher values regarding the melancholic type compared with both control groups in the patients self-ratings as well as in the ratings by their relatives. The basic concordance between the two different kinds of rating is a strong argument in favour of the validity of the results (von Zerssen, 2001b). In order to exclude an inuence of the patients mental states on the results, an investigation with the same questionnaires and a newly developed hypomania scale was performed in other samples (Hofmann, 1973). The main objective of this study was,

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however, to nd out whether Kretschmers concept of cyclothymia might rather apply to bipolar forms of an affective disorder than to unipolar melancholia. For this purpose, former inpatients fully recovered from either disorder (n 5 10 each) were compared with each other and with a matched control group of physically and mentally healthy subjects using selfratings for all 30 subjects and, in addition, relatives ratings for the two groups of former patients. In the comparison of self-ratings, the melancholics scored signicantly higher on the typus melancholicus scale and lower on the scales assessing cyclothymia as well as hypomanic personality traits than the two other groups. The bipolar patients, however, did not differ from the healthy controls in any scale. The ratings by relatives indicated qualitatively similar differences between the two groups of (former) patients as the self-ratings, yet not reaching signicance. It was concluded that Kretschmers concept of cyclothymia tted neither the premorbid characteristics of patients with affective disorders in general nor that of bipolar manic-depressives in particular and that it was questionable whether this subgroup differed premorbidly from the average personality in the general population. These conclusions were later conrmed by research of other authors, e.g. with respect to cyclothymia in affective disorders by a study in unipolar depressives, healthy probands and rst degree relatives conducted by Wetzel et al. (1980) and regarding the rather inconspicuous PP of bipolar manic-depressives by the prospective eld study of J. Angsts group at Zurich, Switzerland (Clayton et al., 1994).

5. The concept of the manic type of personality and the spectrum concept of affective disorders The search for differences in PP between patients with severe unipolar depression and bipolar disorder beyond those attributable to features of the melancholic type was continued in our group at Munich. As no denite hypotheses regarding such differences could be formulated yet, an exploratory case history analysis was conducted (Tellenbach, 1975). This analysis was based on biographical data concerning patients with either melancholia or a bipolar disorder

and, for controlling the specicity of eventual differences, patients with a schizophrenic disorder. (Regarding the advantages of a biographical approach to the assessment of PP, see von Zerssen et al., 1998a; von Zerssen, 2001b.) By this individual-oriented approach, it became evident that the bipolar group was heterogeneous with respect to PP. While the group of unipolar patients could rather uniformly be described in terms of the melancholic type, the bipolar group was composed of individuals resembling this type, others who displayed partially opposite traits, such as habitually increased activity, socially as well as sexually, and a strong striving for independence; others showed neither constellation of traits. Both groups of patients with major affective disorders differed fundamentally from the schizophrenics whose premorbid development resembled the description of schizoid or schizotypal features in the psychiatric literature. These ndings could be conrmed by a diagnostically blind analysis of case notes from which all data concerning clinical aspects had been erased by another investigator. From these results, reports in the literature (from Kraepelin, 1913, to Arieti, 1959) and casual observations, it was inferred that premorbidly bipolar patients displayed a mixture of traits of the melancholic type and partially opposite traits, summarized (in analogy to the term melancholic type) under the heading of the manic type of personality (von Zerssen, 1977; see also von Zerssen, 1988, 1996a). It was postulated that the major affective disorders formed a spectrum from a purely depressive pole (unipolar melancholia) to a predominantly manic pole and that the premorbid traits indicated a patients position within this spectrum: the more pronounced the features of the melancholic type, the higher the probability of a purely or, at least predominantly, depressive course of the disorder, the more pronounced features of the manic type, the higher the probability of a predominantly manic course. In the majority of (prospectively) bipolar patients, a kind of indiscernible mixture of traits of both types would have to be expected (von Zerssen, 1996a). In a rst attempt to empirically test this rather speculative working hypothesis and, simultaneously, the specicity of the postulated relationships (von Zerssen, 1982), we analysed deviations of ques-

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tionnaire scores of several groups of psychiatric patients (retrospective self-ratings and informants ratings) from the scores obtained in healthy subjects. As the patients in the various diagnostic groups could not be matched with the healthy subjects with respect to gender, age etc. and the selection of the non-patients was possibly biased towards normality, the degree of deviations of the patients test scores may have been accentuated, at least in some of the diagnostic subgroups. All the same, it seems noteworthy that bipolar patients, except those with a predominantly manic course of the disorder, did not markedly deviate in their scores from the healthy subjects, quite in line with our spectrum concept. This was in sharp contrast to all other diagnostic subgroups, in particular the various personality disorders. The deviations differed more in extent than in content. In general, they were more pronounced with respect to the various aspects of neuroticism with elevated scores for all subgroups, than for extraversive tendencies where, however, most of the subgroups displayed decreased values on our cyclothymia scale. Thus, they represented the opposite of mental vitality (i.e. the combination of extraversive tendencies with emotional stability; see Section 3). Exceptions from this overall picture of PP were only found in the subgroups of typical bipolar patients with almost no deviations from healthy controls, and bipolar patients with a predominantly manic course of the disorder. Opposite to all other subgroups, the latter showed an increase in cyclothymia rated by relatives, concordant with selfrated extraversion. Furthermore, hysterical character traits were as pronounced in the self-ratings as in that of patients with a hysterical (in modern terms: histrionic) personality disorder. This ts in well with the picture of the manic type of personality. Regarding various aspects of rigidity, the unipolar melancholics, irrespective of an early or late onset of the disorder, were the only patients who exhibited consistently elevated scores on almost every subscale, self-rated or rated by relatives. This agrees well with the picture of the melancholic type of personality. Thus, only the subgroups supposed to represent the ends of a spectrum of major affective disorders showed relatively specic deviations from normal values. All other deviations could be sub-

sumed under the heading of a general syndrome of premorbid abnormality (the opposite of mental vitality; see above). It is in good agreement with our spectrum concept that this syndrome is but weakly, if at all, present in bipolar patients. It cannot be discussed here to what extent the ndings are inuenced by the patients mental states. However, the fact that the retrospective rating of PP by the patients relatives concorded generally very well with the patients self-ratings is a strong argument against the hypothesis that such an inuence can sufciently explain the ndings. The results regarding the manic type of personality in predominantly manic forms of a bipolar disorder were later conrmed by the analysis of self-ratings of 14 such patients and several groups of patients with other mental disorders, all of them matched for gender and age, as well as 13 of the manics in comparison with matched patients with a physical disorder (von Zerssen, 1988). Again, the manics exceeded the others in extraversion and hysterical traits. A cyclothymia scale was not applied in this study. In order to test the validity of the spectrum concept on another methodological ground than the questionnaire approach, the analysis of biographical data from psychiatric case notes was elaborated further with respect to both the manic and the melancholic types (Possl and von Zerssen, 1990a). This method was then applied to case records from which all clinical data and all data concerning the time from the rst indications of the respective disorder had been eliminated (von Zerssen and Possl, 1990). A total of 42 records had been carefully selected without any knowledge of the rater (J.P.). Selection criteria were: a denite diagnosis of one of four subtypes of a major affective disorder (unipolar melancholia, bipolar II disorder, typical bipolar I disorder, and bipolar I disorder with a marked preponderance of manic (M) over depressive (D) episodes in the order of M:D $ 4:1), furthermore, an almost equal size per subgroup and almost equal distributions of gender and age, etc. The sequence of the four subgroups was supposed to represent the assumed spectrum adequately. The diagnostically blind rater had to assign the patients according to the biographical data to either the melancholic or the manic type using different strategies for his assign-

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ments. Irrespective of such methodological differences (e.g. subsequent assignment or mutual comparisons of all case notes), the proportion of the manic type to the melancholic type increased from the unipolar end of the spectrum to the other, predominantly manic end.

6. Development of a comprehensive typology of PP in psychiatric disorders based on a biographical approach A new attempt was started to check the (relative) specicity of the relationships between PP types and subtypes of a major affective disorder (Possl and von Zerssen, 1990b). For this purpose, the case history analyses were extended to other psychiatric disorders, above all schizophrenia and so-called neurotic disorders (mainly anxiety disorders and dysthymia, the latter, in our clinical population, usually superimposed by a non-melancholic major depression; von Zerssen et al., 1984). The abnormality of a patients premorbid development was also taken into account by means of a global rating: inconspicuous, questionably conspicuous, conspicuous within normal limits, denitely abnormal. The concordance of different raters using this scale was satisfactory (von Zerssen, 1993). The scale discriminated very clearly patients with from those without a PD (Possl and von Zerssen, 1990b; von Zerssen, 1993). In the two subgroups of patients, schizophrenics and neurotics, the trait patterns of the manic and the melancholic types were rarely found. Instead, two other constellations of traits predominated, the more frequent one described by us as the anxious, insecure type, the other one as the nervous, tense type. A rare variant of the anxious, insecure type, characterized by active seclusion from social relations and a rich fantasy life, was named the unrealistic, dreamy type. Later, these three types were summarized under the heading of neurotoid types because (with the exception of the unrealistic, dreamy type) they resembled classical descriptions of neurotic personalities and the concept of neuroticism more than the picture of schizoid or schizotypal personality. They are, however, concordant with behavioural antecedents of schizophrenia as well as

neurotic disorders as documented in an extensive prospective eld study (Crow et al., 1995). In our typological concept, the neurotoid types were contrasted to the manic and melancholic types as affective types, named according to their predominance in major affective disorders. To the latter two types, a third type was added as a rare variant of the manic type, namely a happy-go-lucky or relaxed, easy-going type which was discovered in some of the case histories of bipolar patients (Possl and von Zerssen, 1990b) examined in addition to those of the preceding study by Possl and von Zerssen (1990a). This type resembles the concept of syntonia sensu Bleuler (Section 2) in several respects (see Table 1 in von Zerssen, 2000). The extended typology of PP features of psychiatric patients was applied to a new sample of biographical case notes concerning 103 patients whose clinical diagnoses had been conrmed at a 58-year follow-up (Possl and von Zerssen, 1990b). The main diagnoses were: unipolar endogenous depression (melancholia) (n 5 13), bipolar disorder (n 5 9), schizoaffective disorder (n 5 26), schizophrenia (n 5 34), and personality disorder (n 5 21). The last group had been included in this study (without the raters knowledge) for testing the validity of the global rating of abnormality of personality development from biographical case notes. The diagnostically blind rating revealed the highest prevalence of abnormality among personality disorders, followed by the schizophrenic group, and then by schizoaffective disorders, the group of major affective disorders reaching the lowest rank. This sequence was expected and conrmed the validity of the rating. With respect to the personality types, the affective types clearly prevailed in the affective group and the neurotoid types in the groups of schizophrenics and patients with personality disorders. This was predictable on the basis of our type concepts. However, the schizoaffective group, expected to hold an intermediate position between the schizophrenic and the affective groups, resembled the latter group very closely in this respect. On the whole, however, the results seemed rather promising and stimulated us to further improve the biographical case history approach. For this purpose, an attempt was undertaken (von Zerssen et al., 1994a) to operationalize the rating

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procedure as far as possible by developing an extensive item list, an appropriate scoring of items and algorithms for forming additive scores for each of the six types of PP so far discovered by us. These type-scores could be used for a dimensional description of each rated biography. The respective subject might then be assigned to the type which had achieved the intra-individually highest score. This procedure was applied by two independent, diagnostically blind raters to a total of 261 case notes (von Zerssen et al., 1994a,b). These included the 103 cases just referred to and the 42 cases for assessing the manic and melancholic types in major affective disorders (see last subsection). The others were 75 additional cases from the 58-year follow-up from which the 103 cases had also been recruited (mainly cases diagnosed as neurotic depression or anxiety disorder) and, furthermore, 41 additional cases of a major affective disorder. All cases belonging to this last diagnostic category were subdivided into those with and those without mania, i.e. bipolar I disorder on the one hand and unipolar melancholia and bipolar II disorder on the other. For a statistical analysis of associations between the PP types and the disorders, the latter were grouped into major affective disorders (with and without mania), other affective or partially affective disorders (neurotic depression and schizoaffective disorder according to the ICD-9 denition: World Health Organisation, 1978) and non-affective disorders (schizophrenia, anxiety disorders and personality disorders). The two ratings of PP types concorded well with each other (r 5 0.770.80 per type concept). Moreover, the assignments to the intra-individually dominating type agreed with the global assignment by J.P. in the subgroup of n 5 103 ( 1 3 additional cases) in the same order as they agreed with each other (k 5 0.55). According to both ratings the affective types markedly prevailed in the group of major affective disorders, the manic type in the subgroup with mania, and the melancholic type in the subgroup without mania. In the group of other affective disorders, the distribution of types hardly deviated from the statistically expected values. In the group of non-affective disorders, however, there was a clear predominance of neurotoid types. These results were strong arguments for the validity of the type concepts and their operational diagnosis by

means of the biographical case note analysis. Beyond the agreement of type ratings, also associations among different types were disclosed which, however, were largely concordant with the respective concepts. Nonetheless, it seemed remarkable that the most pronounced contrast was not between the manic and melancholic types but between the manic and the anxious, insecure types as well as between the melancholic and the nervous, tense types. The latter type turned out to be somewhat similar to the manic type and the anxious, insecure type to the melancholic type. There is, however, no contradiction between these ndings and the original typology because the two groups of types, the affective and the neurotoid, had been discovered independently of each other in diagnostically different samples (major affective disorders on the one hand, neurotic disorders and schizophrenia on the other). The ndings referred to here will be in the centre of attention when modelling the interrelationships among the types of PP (Section 8); but before achieving that stage, the associations of these types with subtypes of a major affective disorder according to the blind assignment of biographical case reports to our clinical grouping and the construction of new personality inventories as supplements to our biographical approach (this paragraph) and further developments of this approach (Section 7) have to be considered. The four main types of PP, two of them put together with their rare variants (see above), turned out to be associated with the four subtypes of a major affective disorder in the following way (von Zerssen et al., 1994b): not only did the manic type prevail in both subgroups with mania (M:D , 4:1 and $ 4:1, respectively) and the melancholic type in the subgroups without mania (unipolar melancholia and bipolar II disorder), but the differences within the groups with and without mania were also in the expected directions, with one exception: the combined manic and happy-go lucky types were slightly less frequent in the bipolar II subgroup than in unipolar melancholics and the score for the manic type discriminated particularly well between the subgroups of bipolar II disorder and the predominantly manic group. The other differences were concordant with our theoretical assumptions although not signicant with respect to the extreme and the

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adjacent intermediate subgroups. Yet an application of our operationalized rating procedure to a larger number of case notes (n 5 396) from Zurich, Switzerland (Ernst et al., 1996) provided differences that were consistently in the predicted direction and signicant for all comparisons between the subgroups. This nding corroborates our spectrum concept and, at the same time, excludes a local bias in the case records from Munich. Nonetheless, the case note analysis has several methodological disadvantages (von Zerssen, 1996a) which we tried to overcome by developing an alternative approach, the Biographical Personality Interview (BPI) to be described in the next Section (7). Parallel to our biographical analyses, we designed two new short but comprehensive personality inventories (each of them composed of | 50 items) on the basis of a series of factor analyses of a large item pool in various samples of psychiatric patients, former patients and healthy subjects. One, the Munich Personality Test (MPT: von Zerssen et al., 1988; see also von Zerssen, 1994) contains almost exclusively items that possess the highest discriminative power in comparisons between various diagnostic subgroups of patients and between these and healthy controls (with the same distributions of gender and age as in the respective group of patients). The scales measure reliably the dimensions: extraversion, neuroticism, frustration tolerance, rigidity, isolation tendency, esoteric tendencies, and an orientation towards social norms. This test has been extensively used in case control and high risk studies on affective disorders. Elevated sores of rigidity, a core feature of the melancholic type, was consistently elicited in subjects remitted from or at high risk of unipolar major depression (von Zerssen, 1996b, 2000). The other inventory, named Six Factor Test (SFT: von Zerssen, 1994; see also Steinmeyer et al., 1996), consists of items that either correlate specically with one of the scales of the NEO-FFI (Costa and McCrae, 1989) (ve scales) or with none of them (one scale). Thus, by denition, ve scales reect the Big Five of factor analytic personality research (neuroticism, extraversion, openness to experience, agreeableness versus aggressiveness, and conscientiousness, a concept quite similar to that of rigidity); the sixth scale represents a conventional religious attitude. The overlap in the content of

scales from both tests makes it possible to control the reliability of results if the two instruments are applied simultaneously (see next subsection).

7. Development of the Biographical Interview (BPI) for the assessment of PP in psychiatric patients The BPI is an interview technique to be applied, diagnostically blindly, by trained investigators to patients in remission or control subjects. An interview protocol structured in an order similar to that of our case records at the former Psychiatric Department of the Max Planck Institute of Psychiatry in Munich is rated globally by another trained investigator. This is done with respect to the degree of abnormality of the interviewees personality development and along the items of a list derived from the one used in our case note analyses (von Zerssen et al., 1994a; see last subsection). Type-scores as sumscores of items and the intra-individually dominating type are then calculated by means of a computer program. More information about the method is provided by von Zerssen et al. (1998a,b). In brief, in a study of 120 subjects (100 patients remitted from an axis I disorder and 20 healthy control subjects equal with respect to the sex ratio and similar in the distributions of age and verbal IQ), the inter-rater agreement for the global rating of abnormality was only 0.44. However, that per operationalized type-score reached values between r 5 0.81 and 0.89 and that for the assignments to the intra-individually dominating type achieved a kappavalue of 0.60. In a comparison of two diagnostic subgroups of patients with major affective disorders and healthy controls of equal sex and similar age distributions, 15 cases in each group, patients with primary unipolar major depression achieved lower scores for the manic type than the controls and, in addition, higher scores for the melancholic type and lower scores for the unrealistic, dreamy type than the bipolar patients. Both patient groups exceeded the controls with respect to the anxious, insecure type. All 36 patients with a major affective disorder (among them 21 with a primary unipolar major depression) differed from all other patients (n 5 64) by a higher score for the melancholic type

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and a lower one for the nervous, tense type, however, not with respect to the nosologically relatively unspecic anxious, insecure type (which, in a way, is a pendant to questionnaire neuroticism; see below). The lack of difference between the melancholic type-scores of 15 unipolar depressives and 15 controls is apparently due to the low sample sizes. After all, ten of the depressives but only ve of the controls were assigned to this type which discriminated well in accordance with our concept in the other group comparisons. As there were only a few predominantly manic cases in the subgroup of 15 bipolar patients, the hypothesis of an association of the manic type with the manic component of a bipolar disorder could not be tested. Such an association was, however, found in an independent BPI study at Freiburg, Germany, for which a higher number of former inpatients in remission from a major affective disorder and healthy controls had been recruited. In that study, the increase of the score for the melancholic type of unipolar depressives (plus bipolar II patients) reached statistical signicance not only in comparison with bipolar I patients but also with healthy controls (Hecht et al., 1997). Within the bipolar I group, the ratio of the manic type-score to the melancholic type-score increased gradually from the unipolar depressives over the bipolar II group, bipolar I patients with a predominance of depressive over manic episodes, and those with an equal proportion of both kinds of episodes to those with a preponderance of manic over depressive episodes (Hecht et al., 1998). This is perfectly in line with predictions from our spectrum concept of affective disorders. In the total sample from Munich (n 5 120), the BPI type-scores correlated signicantly with the abnormality score and quite consistently with questionnaire scores of the MPT and the SFT (Section 6) of which only those concerning the Big Five will be referred to here (von Zerssen, 1996a, 2000; von Zerssen et al., 1998b). As expected, abnormality of (premorbid) personality development correlated positively with scores of all three neurotoid types, most strongly with that of the unrealistic, dreamy type, and not at all (in the case of the manic type) or negatively with those of the affective types, opposing the relaxed, easy-going type as a kind of

supernormal variant of personality directly with the unrealistic, dreamy type. It suits these ndings that questionnaire neuroticism correlates negatively with the score of the former and positively with that of the latter, although even more strongly with that of the anxious, insecure type. The six types can be characterized by the Big Five in the following manner: manic type: extraverted relaxed, easy-going type: extraverted, unneurotic and conscientious melancholic type: conscientious and agreeable (non-aggressive) anxious, insecure type: introverted and neurotic unrealistic, dreamy type: introverted, neurotic and unconscientious nervous, tense type: unconscientious and disagreeable or aggressive (corresponding with high psychoticism; Eysenck, 1992). The similarities and dissimilarities of the types become even more apparent by the intercorrelations of type-scores. These associations were used by us for constructing a circular model (circumplex) of variations in PP from which the position of PDs could be derived on rational grounds (von Zerssen, 2000).

8. A two-dimensional taxonomic model of PP and PDs The similarity relationships among the types of PP can be represented visually in a circular order by placing similar constructs near to each other and dissimilar ones far away, i.e. in more or less opposite positions to each other. An equivalent two-dimensional structure should result from a two factor solution of intercorrelations of the BPI item-scores. Indeed, when correlating the type-scores with factor scores obtained that way (i.e. independently of our preconceived type concepts), the location of typescores in the factor space follows the same sequence as the one derived from the intercorrelations of type-scores (von Zerssen, 2000). Fig. 2 presents the structure achieved by an analysis of intercorrelations of type-scores that had been obtained in the group of

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Fig. 2. Two-dimensional model of premorbid personality (PP) and personality disorders (PDs) from von Zerssen (2000). Abbreviations: A, cluster A PDs; B, cluster B PDs; C, cluster C PDs; man. t., manic type of PP; r.,e.-g. t., relaxed, easy-going type of PP; mel. t., melancholic type of PP; a.,i. t., anxious, insecure type of PP; u.,d. t., unrealistic, dreamy type of PP; n.,t. t., nervous, tense type of PP. * Placed here because of its high aggressiveness.

remitted psychiatric patients from the Munich BPI study (n 5 100; von Zerssen et al., 1998b). The circumplex contrasts the three affective types on the right side to the neurotoid types on the left side and the easily changeable manic and nervous, tense types in the upper part of the circle to the less changeable melancholic and anxious, insecure types in the lower part. The melancholic and the nervous, tense types form the negative and positive poles, respectively, of an axis that can be interpreted as psychoticism in the sense of Eysenck (see last subsection); the manic and the anxious, insecure types, however, are opposed to each other on an axis that seems to represent the complex dimension

of mental vitality (combining extraversion and emotional stability) referred to under Subsection 3.1. The same contrast of the two pairs of types was already detected in the analysis of case records (Subsection 3.4). The centre of the circumplex would represent the average type of PP; outside the circle, extreme variants of personality would be located. PDs as maladapted extreme variant would thus be placed outside the left part of the circle, i.e. at the side of the neurotoid types which represent a comparatively high degree of an abnormal personality development. Exceptions are the hyperthymic PD (Sa et al., 1993) that can be regarded as a dysfunctional extreme variant of the manic type, or one with a melange of adaptive and maladaptive traits (Akiskal, 1992); and the obsessive-compulsive PD that may be professionally rather successful as long as no obsessive-compulsive disorder becomes manifest. The hypothetical location of DSM-III-R PDs (American Psychiatric Association, 1987), and two of the subaffective PDs (Sa et al., 1993), as derived from the similarity relationships of these disorders with our types of PP (von Zerssen, 2000), is reproduced in Fig. 2. This structure has meanwhile been largely conrmed by independent research (Pukrop et al., 2000) based on self-ratings of PP by psychiatric patients using the SFT (Subsections 3.4 and 3.5) and clinical ratings of criteria of PDs according to the DSM-III-R and writings on subaffective PDs (Sa et al., 1993). The results are more in accord with our model than with alternative ones (Kiesler, 1986; Becker, 1998). The unidimensional model based on Kretschmers concept of relationships between personality and PDs (Section 2) is apparently too simple to describe the relationships adequately. However, the fact that one of the other models (Becker, 1998) has been derived from data obtained (by Schroeder et al., 1992) in healthy subjects and, nonetheless, is rather similar to ours, indicates that variations in personality within the general population and in the PP of psychiatric patients differ only with respect to frequency distributions and not to basic structures (von Zerssen et al., 1988, 1998b). Probably, the main difference lies in the comparatively higher frequency of neurotoid types in the population of patients corresponding to a higher degree of mental abnormality (as dened

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in Subsections 3.3 and 3.4) and thus a lower degree of mental vitality (Section 3) and higher scores on questionnaire scales of neuroticism and / or psychoticism.

9. Extension of the model to axis I disorders, with special reference to major affective disorders In Kretschmers concept, the main forms of socalled endogenous psychoses according to Kraepelin are viewed as extreme variants of temperament that even exceed the degree of a PD. This is not convincing because usually transitional states are conceived as mere accentuations of habitual traits. They can, however, hardly be represented within the same dimensions. Furthermore, the many exceptions to the rule of concordance between personality and type of disorder are difcult to comprehend within such a conceptual framework. The same applies to the fact that the prevalence of PDs in so-called endogenous psychoses, in particular the major affective disorders (Doyle et al., 1999; Zarate and Tohen, 1999), is not high enough to justify a general transition from PD to such a disorder. Therefore, an additional dimension is required for a spatial representation of the relationships in question. Our circumplex would thus describe the two main dimensions of habitual thoughts, feelings and behaviours whereas a third dimension has to be employed for describing actual deviations from this basic level, i.e. mental state disorders. Transitional accentuations of habitual mentation would be placed directly above the respective position of an individual at the ground oor, so to speak. Thus, if a person habitually exhibiting pronounced traits of the manic type develops a hypomanic episode, the position in the upper right part of our circumplex would move straight upwards, not markedly changing the orthogonal projection on the ground oor. If, however, the same subject becomes severely depressed, the position would not only move upwards from that level but also in a southern direction. This means that it should be possible to describe the main psychopathological states in the frame of our extended model as points within the space above the level of the original circumplex. Here the question arises whether there is any empirical proof of a two-

dimensional distribution of such states that corresponds with the two main dimensions determining the circumplex of PP and PDs. The answer to this question is clearly positive as can be inferred from Fig. 3 which shows the distribution of psychopathological syndromes according to the Inpatient Multidimensional Psychiatric Scales (IMPS: Lorr and Klett, 1967) in a sample of well over 1000 patients with psychotic (mainly schizophrenic) and severe mood disorders, investigated at admission to the former Psychiatric Department of the Max Planck Institute of Psychiatry in Munich (von Zerssen, 1985). The data were factor analysed; the result of the two factor solution is presented here. It is well in accord with similar analyses of psychopathological symptoms and syndromes performed by the group of Angst in Zurich, Switzerland (Woggon, 1979) that the rst, unidimensional factor represents syndromes of schizophrenic disorders. The second factor is a bipolar one, contrasting subsyndromes of mania (Excitement, Grandiose expensiveness and Hostile belligerence) with subsyndromes of depression (Anxious depression, Impaired functioning and Retardation

Fig. 3. Two factor solution of intercorrelations among the 12 Inpatient Multidimensional Psychiatric Scales (IMPSs) of 1080 psychotic inpatients (including those with major affective disorders) (data from Table 3 in von Zerssen, 1985).

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155

and apathy), i.e. it puts the typical features of the two main forms of major affective disorders opposite to each other. This distribution corresponds to a remarkable extent with the distribution of the main affective types of PP and that of the two subaffective PDs in Fig. 2. With respect to the second (bipolar) factor of psychopathology, the most typical syndromes of a schizophrenic disorder are located between the subsyndromes of major affective disorders in an area corresponding with the location of the most abnormal variant of PP, the unrealistic, dreamy type, and of cluster A PDs in the circumplex depicted in Fig. 2. The spatial concordance of types of psychopathological states and types of PP, the latter primarily derived from case notes on patients with the respective disorders makes sense. It suggests common dimensions of variations in normal as well as abnormal habitual behaviour (behaviour in a broad sense, including subjective experience) and transitional deviations of behaviour during axis I disorders. We have interpreted these dimensions within a structural-dynamic concept of normal as well as abnormal behaviour (modied after Janzarik, 1959) as a (structural) dimension of integration versus disintegration (the latter possibly leading to schizophrenic break-down of vulnerable individuals under stress), and a dimension of dynamic expansion (at the manic pole) versus dynamic reduction / restriction (at the depressive pole, respectively). This concept was rst presented during a discussion at an international conference on Personality . . . in Major Psychiatric Disorders, Ringberg Castle, Bavaria, Germany, April 1997. It cannot be discussed here in detail; but it should be pointed out that it may explain the associations of PP and PDs with axis I disorders as revealed by our research and that of many others (von Zerssen, 2000, 2001a; concerning PDs and unipolar depression: Doyle et al., 1999, and especially Oldham et al., 1995; and concerning bipolar disorder, in particular mania: Zarate and Tohen, 1999).

10. Concluding remarks The peculiarities of our integrated model of PP, PDs and axis I disorders have to be taken into account when using it for the description of in-

dividual cases within the three-dimensional space provided by it. First, the position of a case on the basic level of habitual mental traits, by denition, does not change markedly within short periods of time, at least not under normal conditions. Yet during an axis I disorder, the position may change rather quickly, even within hours or minutes (e.g. during 48-h cycles of affective disorders; von Zerssen et al., 1983). It may be appropriate to symbolize the course of an individual disorder by an arrow, starting at the subjects original position on the ground oor and moving from there into the space above that level, the direction to south (toward the depressive pole of the dynamic axis), north (toward the manic pole of that axis), etc., depending on the just dominating psychopathological (sub)syndrome. In the case of complete recovery, the individual would again reach the starting position (Fig. 4). If, however, a postmorbid scar remains, the position on the ground oor would change in relation to the original position, usually in direction to the left (more abnormal) side of the circumplex. Another point has to be considered in this context. On the basic level, a median position indicates the average of variations in personality, i.e. normality in a statistical sense. Above this level, however, a median position signies the average of psychopathology, the degree of which is indicated by the distance from the ground. Thus, at the level of severe psychopathology, a median position regarding the structural and the dynamic axes would correspond with a schizoaffective symptomatology. Finally, one may wonder why there is no pendant to the right part of the structural axis (indicating a higher than average degree of integration) in the space above the basic level. The reason is apparently that psychopathology is not induced by an increase of integration of mental processes and their connections with the environment. Rather, a disintegration has occurred either with an increase in dynamics (as in the case of a manic disorder) or a decrease, due to a reduction (as in schizophrenic deciency) or restriction (as usually in severe major depression). Probably, the relaxed, easy-going type which overlaps with Bleulers concept of syntonia (Sections 2 and 6) is so infrequently found in mental disorders because of its high degree of integration of mental functioning. Its (rare) presence may improve the prognosis of a disorder as suggested by a study on

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Fig. 4. Three-dimensional model of PP (PDs omitted; for their location in this model see Fig. 2) and actual psychopathology, with the example of a hypothetical case. Curved arrow: episode of a bipolar II disorder in a subject of the melancholic type of PP. Dotted lines: projections of maxima and minimum of the curve on the ground level. For abbreviations see legend to Fig. 2.

predictors of relapse of a bipolar affective disorder (Krober et al., 1998). The author would like to propose for future research on psychopathology in affective and other disorders to concentrate more on descriptions of clinical phenomena within the frame of an integrated model of the kind presented here than to rely merely on nosological concepts.

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