Are all disorders interpersonal?

cheli personality disorders

Today I spoke at the Workshop “Personality and Its Disturbances in Philosophy, Psychology, and Artificial Intelligence,” organized by the University of Montgomery. The presentation is part of the activities of the Evolution and Personality Lab.

The objective of the talk was to analyze three different hypotheses on the role of the interpersonal domain in psychopathology: specifically, whether none, some, or all disorders should be considered interpersonal. In evaluating these three theoretical positions, I present a general thesis and an antithesis for each, aiming to bolster an interpersonal perspective in psychotherapy. This perspective draws on principles formulated almost a century ago by Harry Stack Sullivan. The null hypothesis (“none” disorders) offers a critical analysis of modern psychopathology beginning with Freud; the quasi-interpersonal hypothesis (“some” disorders) focuses on Wright, Hopwood, and Pincus’s proposal to redefine personality disorders as interpersonal disorders; and the fully-interpersonal hypothesis (“all” disorders) reviews possible integrations between psychopathology and personality from an interpersonal perspective.

Finally, I discuss an evolutionarily-informed synthesis of all the proposed theses and antitheses. Drawing from models in evolutionary psychology and behavioral ecology—specifically the Social Brain Hypothesis, Life History Theory, and Tinbergen’s four questions—I attempt to motivate a radical interpretation of Sullivan’s thought.

My tentative conclusion is that the history of our species, human personality, and thus mental health and psychopathology, have always and distinctly evolved socially. Implications for conceptualizing and treating psychopathology are discussed.

An alternative view at needs and motivations

Yesterday I attended a symposium on needs, goals, and motivations. The introductory lecture was by Carol Dweck, followed by various perspectives based on Schema Therapy (e.g., Eskhol Rafaeli), CBT (e.g., Francesco Mancini), and Compassion Focused Therapy (e.g., Niki Petrocchi). I presented an alternative view of needs and motivations. My perspective was informed by evolutionary theory and aimed to offer a critical reading of these constructs. A special thanks to Maurizio Brasini who chaired the symposium and invited me.

In particular, I sought to emphasize two points. First, psychological constructs such as needs and motivations are created ex post to explain probabilistic processes such as natural and sexual selection. Defining general human functioning (e.g., personality) based on these low-order aspects risks making us forget a principle known since Gestaltpsychologie: the whole is not the sum of its parts.

Second, the phylogenetic trajectory of Homo sapiens is now primarily defined by cultural systems (which represent an analogue of genotypes), and many of the motivational models are almost exclusively consistent with Western cultural contexts—contexts where the individualistic, purposeful, and additive perspective on processes undoubtedly dominates.

This was an alternative view at needs and motivations of mine. A view rooted in an evolutionarily informed look at human personality.

The French philosopher François Julien, in discussing the effectiveness in East and West, cites two examples. On the one hand, Ulysses, who single-handedly resolved a decade-long war in one night. On the other, Sun Tzu, who saw the ideal of war as not taking the field. Perhaps what we think is certain is uncertain or undetermined.

For those interested, below is my presentation at the symposium:

Personality disorders and evolutionary psychopathology

Personality disorders and evolutionary psychopathology offers an intriguing perspective. Martin Brüne and I wrote a chapter on a new book published by Cambridge University Press.

“Personality” is considered as a set of individual characteristics and behavioral dispositions based on both temperamental (partially genetic-driven) and developmental (partially culture-driven) components that are relatively stable across time and context. We suggest that these two intertwined components progressively shape autopoietic processes operating at an individual and a social level in accordance with the theory of evolution and its application to human behavior. We discuss existing evidence linking personality traits to the manifestations of personality disorders and diverse forms of psychopathology. Particular attention is dedicated to the evolutionary concept referred to as Life History Theory, considering its utility in predicting the development of personality traits. We also emphasize the need to explore sources of critique and further research, suggesting that a multifaceted approach to the understanding of personality dimensions is crucial.

We hope this chapter may foster research on personality disorders and evolutionary psychopathology. For those interested in the topic here’s our Lab on personality and evolution!

Cheli, S., & Brüne, M. (2025). When Do Personality Traits Become Pathological?: An Epistemological and Evolutionary View. In K. Banicki & P. Zachar (Eds.), Conceptualizing Personality Disorder: Perspectives from Philosophy, Psychological Science, and Psychiatry (pp. 160–178). chapter, Cambridge: Cambridge University Press.

Personality and physical health

Personality and Health

Sara Bui and I wrote a chapter on personality and physical health for the new Palgrave Encyclopedia of Disability. In this chapter we explore the evidence about the relation between personality and physical health.

The existing approach in health highlights the importance of combining biological, psychological, and social factors to understand the mechanisms associated with the onset, adaptation, and outcomes of diseases. The area of research that has become increasingly important is the relationship between personality and physical health. Although the complexity of the interactions between the varied factors involved does not allow for conclusive answers, robust evidence confirms that personality plays a fundamental role along the entire continuum of health. In this entry we review the existing evidence, suggesting the importance of further research within a lifespan, dimensional, and evolutionary perspective on personality.

In the chapter we present an evolutionarily informed model of personality development to understand the responses and adjustment to illness and disability. This model is a revised version of the one developed by Martin Brüne and I on personality pathology.

This chapter is the second (I guess last) contribution Sara and I wrote for this interesting project.

Bui, S., Cheli, S. (2025). Personality in Physical Disability and Diseases. In: Bennett, G., Goodall, E. (eds) The Palgrave Encyclopedia of Disability. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-031-40858-8_482-1

Evolution and Personality

Evolution and Personality in Pula

On Friday I presented the research of our Evolution and Personality Lab in Pula. The Mind & Brain Congress is a congress of psychiatry and neurology that takes place every year in the Croatian city. This year one of the invited symposiums was on “Personality development and pathology in an evolutionary perspective”. Martin Brüne (Ruhr-University Bochum), Darko Marčinko (Zaghreb University) and I discussed the research of our teams in this area. In short, it was like having our own Evolution and Personality Lab in Pula!

In my presentation I presented the evolutionarily informed conceptualization model that we have been using for a few years and the evidence collected so far. You can see the slides in the video.

First, I motivated the clinical utility of an evolutionarily informed model to personality pathology. Second, I presented data on the inter-reter reliabily, perceived utility and cross-cultural validity of the model. Third, I summarized data on treatment based on this model, namely Evolutionary Systems Therapy.

A meta-analysis of treatments for Cluster A

Cluster A Personality Disorders

Our Evolution and Personality Lab just published a meta-analysis of treatments for Cluster A of personality disorders. The paper has been published by the APA journal Personality Disorders: Theory, Research and Treatment. Here, we disprove the hypothesis that patients with Cluster A personality disorders are poorly adherent to treatments and that these are not effective. Our data suggest that with respect to these outcomes, Cluster A is not dissimilar from other clusters.

Despite an overall prevalence of about 4% and a possible association with well-studied conditions such as schizotypy, little is known about effective treatments for Cluster A personality disorders (PDs), that is, para- noid, schizoid, and schizotypal PD. The aim of this systematic review and meta-analysis was to conduct a narrative synthesis of existing randomized controlled trials and explore the effectiveness of psychosocial and pharmacological treatments for these disorders. Nineteen studies including 468 participants diagnosed with any one of the three Cluster A PDs were included in the systematic review. Data from 291 (k = 5) and 213 (k = 5) participants were included in two different meta-analyses evaluating the reduction of distinctive clin- ical features and the increase of general functioning following treatment, respectively. All the treatments in meta-analyses reported a low overall attrition rate (0.23). The two meta-analyses showed medium-to-large effect sizes (g = .60–.91), but were limited by small sample sizes and large heterogeneity. Collected findings suggest that treatments for paranoid, schizoid, and schizotypal PD may be feasible and effective. We discuss implications for further research.

This systematic review and meta-analysis aimed to explore the feasibility and effectiveness of existing psychosocial and pharmaco- logical treatments for all the Cluster A PDs, that is, PPD, SZPD, and SPD. Despite the heterogeneity of the studies and the limited sample sizes, important findings emerge. Both the narrative synthesis and the two meta-analyses invalidated the hypothesis that patients with these disorders are unlikely to complete treatments and that treat- ments are not safe. Our results suggest that the level of feasibility and safety of treatments for Cluster A PDs are similar to those for all other PDs. Existing treatments also appear to be sufficiently effective in reducing distinctive clinical features and increasing general functioning. Numerous constraints of generality urge the development of new research to identify robust mechanisms of change and effective treatments.

Cheli, S., Wisepape, C. N., Witten, C. D. Y., Floridi, M., Cavalletti, V., Hasson-Ohayon, I., Brüne, M., & Ottaviani, C. (2025). Psychosocial and pharmacological interventions for cluster a personality disorders: A systematic review and two exploratory meta-analyses. Personality Disorders: Theory, Research, and Treatment. Advance online publication. https://doi.org/10.1037/per0000732

New therapy for obsessive-compulsive personality disorder

Evolutionary Systems Therapy, Evolution and Personality Lab

Journal of Personality Disorders published our paper on a new therapy for obsessive-compulsive personality disorder. In this study we extend what we knew about the clinical utility of our treatment model, namely Evolutionary Systems Therapy.

Obsessive-compulsive personality disorder is the most common personality disorder, with a prevalence of approximately 6.5% in the general population. However, little is known about the effective psychotherapy for this disorder. In this case series, we employed evolutionary systems therapy to support five adults diagnosed with obsessive-compulsive personality disorder. Evolutionary systems therapy is a novel form of psychotherapy that integrates evolutionary psychopathology, compassion-focused therapy, and metacognitively oriented treatments. Primary outcome (personality pathology) was assessed monthly from baseline to follow-up. Secondary outcomes (anxiety, depression, perfectionism, self-criticism, overcontrol) were assessed at initial and final sessions. Moreover, we evaluated the feasibility of intervention (completion, attendance, adverse events). At the end of 6 months of treatment, all the participants reported reliable changes and remitted from diagnosis. These outcomes were maintained at 1-month and 3-month follow-ups. Further research is needed to provide evidence about the acceptability of evolutionary systems therapy in the treatment of obsessive-compulsive personality disorder.

In this five cases series we preliminarily explored the acceptability and feasibility of EST for OCPD. Despite the limitations of a cases series design – which is an important constraint on the generality of the collected outcomes – we reported promising findings. All the patients remitted from diagnosis and showed a significant downward trend in personality pathology. These changes were maintained at the 3-month follow-up. Moreover, we found reliable changes in symptoms such as anxiety and depression and in possible therapeutic targets such as perfectionism, self-criticism and overcontrol. Our study seemingly supports the importance of evolutionarily informed approaches to conceptualization and treatment, which allow distinguishing maladaptive strategies from distinctive personality features. In conclusion, we hope that there will be an increase in studies aimed at developing empirically validated treatments for a highly prevalent disorder with elevated suicidal risk such as OCPD.

This new therapy for obsessive-compulsive personality disorder confirms that Evolutionary Systems Therapy may be effective across the whole spectrum of personality disorders.

Cheli, S. Goldzweig, G. Hewitt, P., Bui, S., & Cavalletti, V. (2025). Evolutionary Systems Therapy for Obsessive-Compulsive Personality Disorder: A Five Case Series. Journal of Personality Disorders39(1), 61–76. https://doi.org/10.1521/pedi.2025.39.1.61

The Savant Syndrome

Savant Syndrome, Autism

The Savant Syndrome is a very rare condition that has been extensively debated in fiction and non-fiction. Sara Bui and I wrote a chapter for the new Palgrave Encyclopedia of Disability on this very topic.

Savant Syndrome is a rare condition in which individuals display exceptional skills in one or more areas of functioning. Historically, the presence of these skills is reputed to be associ- ated with some disability, the most frequent (50%) of which is autism spectrum disorder. The prevalence in the general population is estimated at about 1%, with the majority of studies suggesting that nine out of ten cases are congenital and eight out of ten cases are males.

The exceptional skills that are distinctive of this syndrome typically range from music, art, calendar calculating, mathematics, or mechanical/visual-spatial skills. Little is known about the mechanisms involved in Savant Syndrome, and there are no guidelines for the assessment and treatment of associated impairment or distress. Recent advances suggest considering the exceptional skills and possible disabilities along a continuum. This new perspective may lead to a greater understanding about the relationship between this syndrome and wider and better studied conditions such as autism, neurodiversity, and giftedness.

In the final section about treatments we also refer to one of the few existing examples of psychosocial treatment for this condition, that is our evolutionarily informed protocol.

Cheli, S., Bui, S. (2025). Savant Syndrome. In: Bennett, G., Goodall, E. (eds) The Palgrave Encyclopedia of Disability. Palgrave Macmillan, Springer. https://doi.org/10.1007/978-3-031-40858-8_216-1

Complex cases and comorbidities between personality and eating disorders

Complex cases and comorbidities between personality and eating disorders are tricky challanges for the clinician. Indeed, patients live their experience and (rightly!) have little interest in psychiatry, psychopathology and psychotherapy manuals. The condition of a single disorder is rare. And even in the case of complex symptoms such as eating disorders it is important to consider the functioning of the personality as a whole.

Journal of Clinical Psychology has recently accepted a paper I worked on together with an amazing international team: Veronica Cavalletti (Tages Charity, Florence), Francesco Gazzillo (University of La Sapienza, Rome), Martin Brüne (Bochum University, Bochum), and Paul Hewitt (University of British Columbia, Vancouver). Here we present a clear-cut example of complex cases and comorbidities between personality and eating disorders.

In this case study we present the course of the psychotherapy of Myriam, a 19-year old female with a severe personality disorder and comorbid eating disorder. During the initial assessment she reported high levels of neuroticism that parallel the diagnosis of obsessive-compulsive personality disorder, borderline personality disorder, and anorexia nervosa. Myriam showed a severely impaired personality functioning defined by perfectionism, self-criticism, interpersonal guilt and overcontrol. Her daily experience was shaped by a self-recriminative inner dialogue associated with maladaptive patterns in the form of food, water and sleep restrictions, self-harm behaviors, and suicidal ideation. She accessed an integrative treatment based on individual (Evolutionary Systems Therapy) and group psychotherapy (Mindful Compassion for Perfectionism). At the end of 14-month intervention she remitted from all the categorical diagnoses and showed reliable changes in several measures. These outcomes were maintained at 3-month follow-up. We describe the integrative conceptualization based on Myriam’s perfectionistic self-recrimination patterns, and the consequent treatment that targeted these patterns rather than focusing on symptom reduction exclusively.

The picture presents the conceptualization of the client based on the Evolutionary Systems Therapy.

For those interested in, the preprint of the paper is freely available and and the published version will have only minimal differences due to production process:

Cheli, S., Cavalletti, V., Gazzillo, F., Brüne, M., & Hewitt P.L. (2024). I don’t deserve anything good: Perfectionistic self-recrimination in a case of comorbid personality and eating disorder. Journal of Clinical Psychology. Preprint available on Authorea, July 16, 2024. https://doi.org/10.22541/au.172114929.99232229/v1 (DOI: 10.1002/jclp.23753).