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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.

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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

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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.

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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

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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 Disorders, 39(1), 61–76. https://doi.org/10.1521/pedi.2025.39.1.61

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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

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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).

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Two new studies registered

Evolutionary Systems Therapy, Evolution and Personality Lab

Two new studies registered at our lab! The main goal of Evolution & Personality Lab is to investigare personality and its pathology through the lens of evolutionary psychology and psychopathology. Consistently with this goal and ongoing studies, we registered two research protocols.

The first study is aimed to validate cross-culturally the evolutionarily informed conceptualization model we have worked on in the last few years. The protocol has been registered on ClinicalTrials.gov and comprises three studies involving teams from USA, Italy, Spain, Poland, China: (i) to explore the inter-rater reliability of the model in therapists; (ii) to explore the acceptability by therapists and patients; (iii) to explore the cross-cultural and cross-theoretical validity of training and application of the model. We hope this project will confirm that our model can be used within different cultural contexts and by clinicians with different therapeutic backgrounds.

The second study is aimed to explore the clinical utility of the three interpersonal styles and dynamics we have tested in a previous trial. In a recently concluded study we found that patients with personality pathology may show three prominent interpersonal styles that would correspond to the three main spectra of psychopathology: perfectionistic style and internalizing spectrum; antagonistic style and externalizing spectrum; schizotypal style and reality impairing/psychosis spectrum. The methodology used was potentially biased (patients were forced to chose only one style through a dummy variable). In this new study (registered on OSF) we used de-sitgmatizing labels for the three styles and offer a continuous Likert-type scale.

These two new studies registered on ClinicalTrials and OSF will better describe the clinical utility of our protocol for conceptualizing and treating personality pathology: namely, Evolutionary Systems Therapy. This protocol may be hopefully useful not only as and independent treatment. We are not that interested in proving what we do is good! It would be more important to show how an evolutionarily informed conceptualization may support different kinds of treatments (we are involving colleagues from a variety of background: psychodynamic, integrative, humanistic, cognitive, etc.) and may be reliable in spite of the different cultural background and interpersonal style of the patient.

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Interpersonal dynamics and styles in personality pathology

We have finally presented our work on interpersonal dynamics and styles in personality pathology. During a symposium a was chairing on this topic at the 7° Congress of the European Society of Personality Disorders I summarized our pre-registered trial on the feasibility of our Evolutionary Systems Therapy for personality pathology at large.

This study is part of the activities of our Evolution and Personality Lab and showed promising results. The paper about interpersonal dynamics and styles in personality pathology is under submission….so figers crossed!

The objective of this study was to evaluate the feasibility and rationale of a six-month Evolutionary Systems Therapy for personality pathology. In doing so, we employed a conceptualization that is supposed to be consistent with dimensional models of personality disorders and evolutionary psychopathology. Twenty-one patients were recruited and stratified into three homogeneous subgroups in accordance with spectra of psychopathology (internalizing, externalizing, schizotypy). An evolutionarily informed conceptualization was shared with patients based on three interpersonal styles that we consider to be prominent in the three spectra. Feasibility indicators were evaluated monthly, while changes in clinical measures were assessed by three procedures: ecological momentary assessment, monthly self-report measures, pre-post self-reports and interviews.

Eighteen out of 21 patients remitted from diagnosis, all indicators suggested a high feasibility. Individually, all patients showed reliable changes in measures of symptomatology and personality pathology. A repeated-measures ANOVA reported large effect sizes (η2 ranging between .892 to .979) for the whole sample. Ecological momentary assessment suggests that the three interpersonal styles are prominent in the corresponding spectra both before and after the treatment. This study supports the need for a confirmatory randomized controlled trial on the clinical utility of Evolutionary Systems Therapy. Despite the limited sample size, the findings are consistent with the importance of a dimensional approach to psychopathology and of an evolutionarily informed conceptualization of personality disorders.

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