Personality Disorders

The DSM-5 Alternative Model for Personality Disorders dimensionally defines personality pathology using severity of dysfunction and maladaptive style. As the empirical literature on the clinical utility of the AMPD grows, there is a need to examine changes in diagnostic profiles and personality expression in treatment over time. Assessing these changes in individuals diagnosed with borderline personality disorder is complicated by the tendency for patients to cycle through multiple therapists over the course of treatment leaving the potential for muddled diagnostic clarity (...) and disjointed case conceptualizations. Following patient trajectories across therapists offers a unique opportunity to examine the AMPD’s sensitivity to and utility for capturing personality stability and change over time for patients with BPD. This article demonstrates the utility of the AMPD for two clinical cases in three distinct ways: highlighting heterogeneity in BPD between patients, comparing improvements in personality severity and style over time, and elucidating profile change across therapist ratings. We present two patients diagnosed with DSM-5 Section II BPD, crossing between two therapists over the course of 3 years of psychodynamic psychotherapy. Treating clinicians rated patients for their respective treatment phases using the Level of Personality Functioning Scale, capturing severity, and the Personality Inventory for the DSM-5, capturing style. AMPD diagnostic profiles differentiated patients with BPD in both severity and style, and captured within-patient change beyond within-therapist response bias. Results indicated greater improvements in personality severity while personality style remained more stable. Implications for the patients’ treatment progress and associated challenges are discussed, as are considerations for the utility of the AMPD in therapy. (shrink)

Child trauma plays an important role in the etiology of Bordeline Personality Disorder. Of all traumas, sexual trauma is the most common, severe and most associated with receiving a BPD diagnosis when adult. Etiologic models posit sexual abuse as a prognostic factor in BPD. Here we apply machine learning using Multiple Kernel Regression to the Magnetic Resonance Structural Images of 20 BPD and 13 healthy control to see whether their brain predicts five sources of traumas: sex abuse, emotion neglect, emotional (...) abuse, physical neglect, physical abuse. We also applied the same analysis to predict symptom severity in five domains: affective, cognitive, impulsivity, interpersonal for BPD patients only. Results indicate that CTQ sexual trauma is predicted by a set of areas including the amygdala, the Heschl area, the Caudate, the Putamen, and portions of the Cerebellum in BPD patients only. Importantly, interpersonal problems only in BPD patients were predicted by a set of areas including temporal lobe and cerebellar regions. Notably, sexual trauma and interpersonal problems were not predicted by structural features in matched healthy controls. This finding may help elucidate the brain circuit affected by traumatic experiences and connected with interpersonal problems BPD suffer from. (shrink)

Autistic individuals without intellectual disabilities are sometimes not diagnosed until adolescence/adulthood. Due to increased risk of co-occurring mental health problems, these individuals may initially be referred to general, mental health services and not always be identified as autistic; some may be misdiagnosed with personality disorder prior to identification of autism. To explore possible mechanisms in misdiagnosis of autism, we report on the case of a young man with severe, non-suicidal self-injury and attention deficit disorder who had been diagnosed with and (...) treated for borderline PD prior to being diagnosed with autism. Following reassessment by mental health clinicians with experience of working with autistic individuals, the patient was diagnosed with autism, ADD, and depression—but not PD. Experiences from this case suggest that presence of co-occurring NSSI, depression, and ADD, as well as lack of comprehensive assessment and lack of autism knowledge in general mental health services, may contribute to risk that autism is misdiagnosed as PD. These findings highlight the need for autism expertise in general mental health services to facilitate appropriate diagnosis for autistic individuals who encounter these services, as well as the importance of undertaking comprehensive assessments. (shrink)

Borderline personality disorder is a complex psychopathological phenomenon. It is usually thought to consist in a vast instability of different aspects that are central to our experience of the world, and to manifest as “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity” [American Psychiatric Association, 2013, p. 663]. Typically, of the instability triad—instability in self, affect and emotion, and interpersonal relationships—only the first two are described, examined, and conceptualized from an experiential point of view. (...) In this context, disorders of self have often motivated analyses of self-experience and the sense of self, affective disorders have been frequently considered in the light of emotional experience and its phenomenological structure. Patterns in the phenomenology of social experience have found comparatively little traction when it comes to the conceptualization of the interpersonal disturbances in borderline. In this paper, I argue that interpersonal instability in borderline consists in much more than fragile and shifting relationships but, most importantly, also involves certain styles in experiencing others. These styles, I suggest, may play an explanatory role for the borderline-typical patterns of interpersonal turmoil and so deserve more attention. To better describe and understand these styles, I explore the phenomenological structure of borderline affective instability and discuss the implications it might have for how a person experiences and relates to other people. Considering core aspects of borderline affective instability, such as alexithymia, emotional contagion, emotion dysregulation, and chronic emptiness, I propose borderline can be interpreted as a disturbance of interaffective exchange, which gives rise to certain ways of experiencing others that imply a social impairment. (shrink)

This perspective paper aims at discussing theoretical principles that could explain how emotion regulation and physical diseases mutually influence each other in the context of borderline personality disorder (BPD). Furthermore, this paper discusses the clinical implications of the functional relationships between emotion regulation, BPD and medical conditions considering dialectical behavior therapy (DBT) as a well-validated therapeutic intervention, which encompasses these issues. The inflexible use of maladaptive emotion regulation strategies (e.g., suppression, experiential avoidance, and rumination) might directly increase the probability of (...) developing physical diseases through a physiological pathway, or indirectly through a behavioral pathway. Some metabolic and chronic medical conditions could significantly impact emotional functioning through biological alterations involved in emotion regulation. Several empirical studies have shown high co-occurrence rates between BPD and several chronic physical diseases, especially ones linked to emotion-based maladaptive behaviors. DBT addresses physical diseases reported by individuals with BPD reducing problematic behaviors functionally associated to emotion dysregulation and identifying physical health as a goal forBuilding a Life Worth Living. (shrink)

The ICD-11 personality disorder model is the first fully dimensional assessment of personality pathology. It consists of a personality disorder dysfunction-severity dimension, which encompasses both self- and interpersonal dysfunction, and six optional qualifiers for five prominent personality traits—Negative Affectivity, Detachment, Dissociality, Disinhibition, and Anankastia —plus a borderline pattern that is defined by the criteria of DSM-IV borderline PD. This article reports on the development of a new self-report measure to assess self- and interpersonal dysfunction and the five trait qualifiers. It (...) is the first comprehensive measure of the ICD-11 PD model in that it is the only one to include both PD dysfunction-severity as well as trait scales and because it is based on the Clinical Description and Diagnostic Guidelines, which are more detailed than the “statistical” model description that is currently on the ICD-11 website. The authors wrote 992 items and then reduced the pool to 300 items by eliminating redundancy and selecting the consensus best few items for each subconstruct. Data were collected using an online sample of 383 Prolific workers. Using exploratory factor analysis, seven domain scales were developed, each of which contained two to four scales assessing components of the domain. These preliminary scales’ psychometrics were excellent, as were the domains’ and their components’ convergent and discriminant validity, with a few generally minor exceptions. Structural analyses at the component level revealed a three-factor structure consisting of two moderately correlated Internalizing factors, one centered on Self Dysfunction with two NA components and a DSN component and the other on Interpersonal Dysfunction with DET and ANK components; as well as an Externalizing factor with DSL and a DSN component that was uncorrelated with the other two factors. Two aspects of the results in particular are striking: ANK was not the opposite end of a DSN dimension, but rather contributed to an Internalizing Interpersonal Dysfunction dimension and DSN had both an Internalizing and an Externalizing component. Implications of the findings and study limitations are discussed. (shrink)

The case of Félida X and her ‘doubled personality’ served in the last quarter of the 19th century as a proving ground for a distinctively French form of psychology that bore the stamp of physiology, including the comparative term normal state. Debates around Félida’s case provided the occasion for reflection about how that term and its opposites could take their places in the emerging discursive field of psychopathology. This article centres its analysis on Eugène Azam’s 1876–77 study of Félida, and (...) the ways his framing of the case was adopted or critiqued by subsequent researchers. Azam initially deployed the label normal state in a routine manner, in contrast to his use of condition seconde to designate Félida’s other state; this pairing served, I argue, to anchor the scientific legitimacy of Félida’s extraordinary psychological manifestations. Unpacking the conceptual associations of Azam’s use of normal state, we find it marked as qualitatively distinct, temporally fixed, and most of all individualized; this without becoming normative. It was only through responses to and criticism of Azam’s study that there emerged a more generalized sense of normality against which pathological (hysteric) subjects’ comportment could be contrasted. Félida’s case itself constitutes a highly individualized reconfiguration of the concept of a normal state, while the subsequent framing of doubled mental states provides a valuable vantage point from which to consider the articulations between the language of emerging French psychology and its evolving subjects of enquiry. (shrink)

Individuals with conditions like borderline personality disorder experience chronic, pervasive impairments that interfere with moral functioning. Even in recovery these individuals are plagued by residual symptoms, requiring diligence and management. First, I stipulate that some individuals who recover from BPD act morally. I argue that by acting morally while managing residual symptoms these individuals expand the boundaries of traditional Aristotelian virtue. Individuals who recover from BPD are simultaneously virtuous and outside the boundaries of traditional Aristotelian virtue if they meet the (...) following conditions: they experience marked, unchangeable morally-relevant difference in moral faculties; act morally at approximately the same rate or better than other moral agents; and act morally for the right reasons. These individuals challenge the boundaries of traditional Aristotelian virtue by demonstrating that many views of temperance and virtue are too restrictive. I evaluate multiple interpretations of McDowell’s [1] silencing view and call for a more inclusive virtue ethics that embraces continence in the vein of Foot’s [2] corrective view. (shrink)

Four couple therapy first consultations involving clients with diagnosed narcissistic problems were examined. A sociologically enriched and broadened concept of narcissistic disorder was worked out based on Goffman’s micro-sociology of the self. Conversation analytic methods were used to study in detail episodes in which clients resist to answer a therapist’s question, block or dominate the development of the conversation’s topic, or conspicuously display their interactional independence. These activities are interpreted as a pattern of controlling practices that were prompted by threats (...) that the first couple therapy consultation imposes upon the clients’ self-image. The results were discussed in the light of contemporary psychiatric discussions of narcissism; the authors suggest that beyond its conceptualization as a personality disorder, narcissism should be understood as a pattern of interactional practices. (shrink)

As schizotypal personality disorder increasingly prevails in the general population, a rapid and comprehensive measurement instrument is imperative to screen individuals at risk for SPD. To address this issue, we aimed to develop a computerized adaptive testing for SPD using a non-clinical Chinese sample, consisting of a calibration sample and a validation sample. The item pool of SPD was constructed from several widely used SPD scales and statistical analyses based on the item response theory via a calibration sample using a (...) graded response model. Finally, 90 items, which measured at least one symptom of diagnostic criteria of SPD in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and had local independence, good item fit, high slope, and no differential item functioning, composed the final item pool for the CAT-SPD. In addition, a simulated CAT was conducted in an independent validation sample to assess the performance of the CAT-SPD. Results showed that the CAT-SPD not only had acceptable reliability, validity, and predictive utility but also had shorter but efficient assessment of SPD which can save significant time and reduce the test burden of individuals with less information loss. (shrink)

Aberrations of self-experience are considered a core feature of borderline personality disorder (BPD). While prominent aetiological accounts of BPD, such as the mentalization-based approach, appeal to the developmental constitution of self in early infant–caregiver environments, they often rely on a conception of self that is not explicitly articulated. Moreover, self-experience in BPD is often theorized at the level of narrative identity, thus minimizing the role of embodied experience. In this article, we present the hypothesis that disordered self and interpersonal functioning (...) in BPD result, in part, from impairments in 'embodied mentalization' that manifest foundationally as alterations in minimal embodied selfhood, i.e. the first-person experience of being an individuated embodied subject. This account of BPD, which engages early intersubjective experiences, has symptomatic findings in BPD, and is consistent with contemporary theories of brain function. (shrink)

This paper explores the possibility of AI-based addendum therapy for borderline personality disorder, its potential advantages and limitations. Identity disturbance in this condition is strongly connected to self-narratives, which manifest excessive incoherence, causal gaps, dysfunctional beliefs, and diminished self-attributions of agency. Different types of therapy aim at boosting self-knowledge through self-narratives in BPD. The suggestion of this paper is that human-to-human therapy could be complemented by AI assistance holding out the promise of making patients' self-narratives more coherent through improving the (...) accuracy of their self-assessments, reflection on their emotions, and understanding their relationships with others. Theoretical and pragmatic arguments are presented in favour of this idea, and certain technical solutions are suggested to implement it. (shrink)

Borderline personality disorder (BPD) is characterized by severe disturbances in a subject’s sense of identity. Persons with BPD suffer from recurrent feelings of emptiness, a lack of self-feeling, and painful incoherence, especially regarding their own desires, how they see and feel about others, their life goals, or the roles to which they commit themselves. Over the past decade or so, clinical psychologists, psychotherapists, and psychiatrists have turned to philosophical conceptions of selfhood to better understand the borderline-specific ruptures in the sense (...) of identity, which are frequently associated with severe affective instability and turbulence in interpersonal relationships. Fuchs (2007) has suggested that these disturbances in self-experience can best be described and explained by using notions—widely discussed in philosophy and psychology—ofnarrativityandnarrative identity. On such a narrative view, key features of BPD present significant modifications of proto-narrative structures and inhibit the development of a narrative identity, resulting in a disturbed sense of identity. Although the role of narrativity in BPD has been acknowledged by many researchers, some have voiced dissatisfaction with what they take to be limitations of a narrativistic understanding of the disorders of identity characterizing BPD, and have proposed alternative, allegedly non-narrativistic, accounts. In this paper, we critically examine an example of the latter, viz. Gold and Kyratsous’ (2017) account ofthe person as an intrapersonal team reasoner. We defend a narrativistic understanding of BPD identity disorder against their objections. To this end, we propose a broader, and more finely-differentiated, concept of narrativity. On this account, four aspects of narrativity are distinguished, the disordering of which can affect those with BPD. As it turns out, our account implies that even Gold and Kyratsous—in order to ground their approach—must either make use of these aspects or propose an as-yet unarticulated alternative. This casts doubt upon whether their approach is non-narrativistic after all. (shrink)

Although not identical, this article suggests that complex posttraumatic stress disorder, depersonalization and schizophrenia share at least one feature: in all these cases, the body becomes a defective tool, an IT. In turn, those suffering from them can no longer be-in-the-world through the living body but rather experience their body as an object; they manage their lives on the level of body image.The next section outlines some cognitive and phenomenological concepts such as body schema, body image, body-as-subject and body-as-object. Thereafter, (...) the article explores the phenomenology of C-PTSD, depersonalization, and schizophrenia, finally suggesting that in each of these cases the body... (shrink)

Anne was sexually and physically abused as a child and adolescent. Since an adolescent, she has had episodes of engaging in self-injurious behavior, where she repetitively cuts her arms with a knife or scissors, sometimes so seriously that she has had to go to the emergency room. She is relatively high functioning as an individual, where her academic cleverness has enabled her to study for a philosophy degree at a top university. Owing to her history of deliberate self-injury, psychiatrists have (...) diagnosed her with borderline personality disorder. In moments of anger and emotional upset, like when her psychiatrist has seemed cold toward her or her session has stopped early, she reverts to cutting her arms.Borderline... (shrink)

People with Scrupulosity have rigorous, obsessive moral beliefs that lead to extreme and compulsive moral acts. These fascinating outliers raise profound questions about human nature, mental illness, moral belief, responsibility, and psychiatric treatment. Clean Hands? Uses a range of case studies to examine this condition and its philosophical implications.

Objective: To inquire into the subjective experience of treatment by persons diagnosed with avoidant personality disorder. Methods: Persons with avoidant personality disorder (N = 15) were interviewed twice, using semi-structured in-depth interviews, analyzed by and the responses subject to interpretative-phenomenological analysis. Persons with firsthand experience of avoidant personality disorder were included in the research process. Results: The superordinate theme emerging from the interviews, “searching for courage to be” encompassed three main themes: “seeking trust, strength, and freedom,” “being managed,” and “discovering (...) the possibility for change and development.” The main theme, “being managed,” included the subthemes: “getting a diagnosis,” “receiving medication,” and “attending therapy.” Conclusion: Although this may not be specific to avoidant personality disorder, Ttheese findings highlight the importance, importance of being met intersubjectively as a person with intentionality and agency, even when one does not feel like one.as an agentive intentional being, even when one does not feel like one, of being met intersubjectively by a therapist. The importance of establishing an emotional bond and emergent trust for open therapeutic communication, collaboration, learning, and becoming able to build courage to begin to approach that which one fears, is emphasized. (shrink)

'Cruel' simply ignores the supposed fact/value dichotomy and cheerfully allows itself to be used sometimes for a normative purpose and sometimes as a descriptive term.Personality disorders have always attracted considerable attention within the philosophy of psychiatry. It was not until two papers written by Louis Charland, however, that they simulated a wider and lively debate. The importance and, at least partly, the strength of Charland's analyses lie in the fact that they are relatively particular and focused in their...

Dominic Murphy in several influential publications has formulated and defended what he calls the strong medical model of mental illness. At the core of this project is the objectivist requirement of classifying mental illness in terms of their aetiologies, preferably characterised by multilevel mechanistic explanations of dysfunctions in neurocomputational processes. We are sympathetic to this project and we devise an argument to support it based on a conception of psychiatric kinds. Murphy has, moreover, maintained that there are some open issues (...) concerning the applicability of his program to antisocial personality disorders and psychopathy. We argue that, as a matter of fact, there are already plausible and well-motivated classificatory proposals for these types of disorders that accommodate well within Murphy's strong medical model. (shrink)

This article tells the story of an anthropologist and a research subject who encountered each other in the middle of the 20th century on an island in the southwestern Pacific. In the midst of an intensive spate of evidence gathering for his dissertation, anthropologist Melford Spiro noted that one of his would-be interlocutors, a man named Tarev – notable for failing all of his psychological tests – still managed to contribute a different form of evidence: if his views could not (...) be amalgamated in numbers via test scores, they could still be rendered as a case. Tarev’s personality study, ‘A Psychotic in the South Seas’, counted as one of many cases contributing to a broad, worldwide effort to explore the meaning of suffering – specifically psychological illnesses – in non-Western cultures. This article examines Tarev’s rejected test-response ‘data’ and the ways in which his answers did not fit the epistemological and geopolitical frameworks that provoked them. The encounter between anthropologist and interlocutor, today, allows an investigation into how mid-20th-century scholars amassed ambitious data sets meant to revolutionize the sciences that dealt with human beings as psycho-social entities. What sorts of data made it into their archives and what sorts did not? How was the data of happiness, sadness and other fleeting emotional states collected from whole islands newly under US naval occupation? (shrink)

It has recently been argued that persons diagnosed with a personality disorder ought to be held responsible for their actions because these actions are voluntary. Defending this claim, Hannah Pickard contends that exercising choice and control are definitive of voluntary action, and that the behaviors that are constitutive of PD are behaviors over which we have choice and control. Thus PD behaviors are voluntary, and on this basis, their agents can be held properly responsible for this type of behavior. In (...) what follows, I examine this claim with reference specifically to agents who display impulsive behavior, where this behavior is taken to be diagnostic of antisocial personality disorder... (shrink)

Narcissism continues to be an important topic of research, with a great deal of ongoing empirical work in social and personality psychology. But there are theoretical issues that have received less attention recently, including those that relate to the foundational theories of the psychoanalytic tradition. As the first step in a larger project of reevaluation, this article offers a critical review of Freud and Heinz Kohut’s theories of narcissism. Centered on a theoretical reconstruction, it clarifies several significant – and often (...) underspecified – features of each account. I also explore the continuities and discontinuities between these two closely related systems. Most notably, both Freud and Kohut lacked fully developed accounts of primary narcissism and the relevant instinctual drives. At the same time, Kohut’s theory expanded upon Freud’s in innovative ways, particularly with its emphasis on a secondary line of narcissistic development that has positive, transformative features. In the final section, however, I introduce a speculative reading that describes theoretical prefigurations of these features in elements of Freud’s structural theory. (shrink)

In this article, I examine the relation between philosophy and madness. It is often assumed that madness has to be suppressed, excluded, or conquered before a philosophically sensible text, logical argument, or world of meaning can appear. I argue, instead, that a certain concept of madness, when grafted on phenomenological psychiatry and philosophical mysticism, is intrinsically related to the project of philosophy. With the help of experiences of madness as presented in psychiatry and articulated in mad autobiographical reports, including my (...) own, I will show that philosophy and madness are in closer connection than is commonly assumed. In the introduction, I refer to some superficial... (shrink)

This groundbreaking volume of original essays presents fresh avenues of inquiry at the intersection of philosophy and psychiatry. Contributors draw from a variety of fields, including evolutionary psychiatry, phenomenology, biopsychosocial models, psychoanalysis, neuroscience, neuroethics, behavioral economics, and virtue theory. Philosophy and Psychiatry’s unique structure consists of two parts: in the first, philosophers write five lead essays with replies from psychiatrists. In the second part, this arrangement is reversed. The result is an interdisciplinary exchange that allows for direct discourse, and a (...) volume at the forefront of defining an emerging discipline. Philosophy and Psychiatry will be of interest to professionals in philosophy and psychiatry, as well as mental health researchers and clinicians. (shrink)

Many feminist researchers have been critical of the psychiatric category of borderline personality disorder 1 and have emphasized the gendered nature of the diagnosis. It is estimated that people diagnosed with BPD comprise 1 to 2 percent of the general population in the United States in a given year, and that women represent 75 percent of those diagnosed.2 Critics have argued that the diagnosis reinforces double-binds for women and pathologizes traits associated with both conventional femininity, such as emotionality, dependency, and (...) self-destructiveness, and unconventional femininity, such as rebelliousness and sexual promiscuity (Lester 2013; Potter 2009; Shaw.. (shrink)

This article introduces a novel theoretical framework for psychopathy that bridges dominant affective and cognitive models. According to the proposed impaired integration (II) framework of psychopathic dysfunction, topographical irregularities and abnormalities in neural connectivity in psychopathy hinder the complex process of information integration. Central to the II theory is the notion that psychopathic individuals are “‘wired up’ differently” (Hare, Williamson, & Harpur, 1988, p. 87). Specific theoretical assumptions include decreased functioning of the Salience and Default Mode Networks, normal functioning in (...) executive control networks, and less coordination and flexible switching between networks. Following a review of dominant models of psychopathy, we introduce our II theory as a parsimonious account of behavioral and brain irregularities in psychopathy. The II theory provides a unified theoretical framework for understanding psychopathic dysfunction and integrates principle tenets of affective and cognitive perspectives. Moreover, it accommodates evidence regarding connectivity abnormalities in psychopathy through its network theoretical perspective. (shrink)

Three pathologies of alienation have been claimed to refute the philosophical thesis that introspection-based self-ascriptions of mental states are immune to error through misidentification. In this paper, I show that this critique of the Immunity Thesis is misguided; the cases of alienation either are not self-ascriptions or do not involve misidentification. Rather, these cases undermine a widely assumed explanation of immunity, which is based on the idea that self-ascriptions of mental states are identification-free. I argue that, given a certain understanding (...) of the Immunity Thesis, identification-freedom does not explain immunity anyhow, and I offer an alternative explanation, one which posits a tight link between first-personal awareness and ownership of a mental state. (shrink)

In this chapter, our focus is the role played by notions of rationality in the diagnosis of mental disorders, and in the practice of overriding patient autonomy in psychiatry. We describe and evaluate different hypotheses concerning the relationship between rationality and diagnosis, raising questions about what features underpin psychiatric categories. These questions reinforce widely held concerns about the use of diagnosis as a justification for overriding autonomy, which have motivated a shift to mental incapacity as an alternative justification. However, this (...) approach too has recently been criticized from a mental disability rights perspective. Our analysis of the relationship between mental capacity and rationality is used to illuminate these concerns, and to investigate further the relationship between rationality and psychiatric diagnosis. (shrink)

Narrative theory provides an interesting contribution to the rich philosophical literature on the self and personal identity. This links with psychological and psychiatric themes concerning the self, because many cases of disorder involve some kind of loss or fragmentation of the self. What follows is a philosophical inquiry into these narrative theories, which should have some implications for how we should regard subjects with these disorders. My primary philosophical conclusion is that there is an interesting germ of truth in the (...) narrativist position, where it concerns narrative threads within a person, but that we should resist the generalization from this restricted claim to the implausible position that .. (shrink)

Long before i knew I had a personality disorder, I simply knew that my life felt unbearably difficult to live. For me, life has always been an uphill struggle, and at times I have just let myself tumble down the hill I have strived so hard to climb. Fortunately, I now understand how to keep going, and even to avoid falling down in the first place, but this learning process has taken the entire twenty-eight years of my life, and I (...) still feel I have a long way to go. It feels very difficult to describe the early years of my life. To me, it was like being stuck in a cage, gagged. I can remember feeling a great deal of fear, but being unable to express it. My dad would burst into anger very rapidly, and my .. (shrink)

The determinative issue in applying the insanity defense is whether the defendant experienced a legally relevant functional impairment at the time of the offense. Categorical exclusion of personality disorders from the definition of mental disease is clinically and morally arbitrary because it may lead to unfair conviction of a defendant with a personality disorder who actually experienced severe, legally relevant impairments at the time of the crime. There is no need to consider such a drastic approach in most states and (...) in the federal courts, where the sole test of insanity is whether the defendant was “unable to appreciate the wrongfulness of his conduct at the time of the offense.” This is because the only symptoms that are legally relevant in such jurisdictions are those that impair reality-testing and thereby affect the person's capacity to understand the nature and consequences of her actions. However, if the test of insanity includes a “volitional prong” (inability to control one's behavior), some way must be found to limit the scope of the defense to the core cases (involving psychotic conditions) to which it has traditionally been applied, and to prevent a shift toward a deterministic account of criminal conduct — i.e., “people can't help being who they are and doing what they do.” The best way of accomplishing this is to limit the definition of mental disease to severe disorders characterized by gross disturbances of the person's capacity to understand reality. (shrink)

This article argues in support of the proposition that “A Personality Disorder May Nullify Responsibility for a Criminal Act.” Building upon research in categorical and dimensional controversies in diagnosis, neurocognitive science and the behavioral genetics of mental disorders, and difficulties in differential diagnosis and co-morbidity with personality disorders, this article holds that a per se rule barring personality diagnosis as a basis for a defense of legal insanity is scientifically and conceptually indefensible. Rather, focus should be upon the severity and (...) impact in specific cases of any legally relevant functional deficits arising from a mental disorder (including personality disorders). Failure to do so risks potentially misleading “battles of the experts” about a defendant's diagnosis in criminal responsibility defenses and improper usurpation of the role of the legal finder of fact as mental health expert witnesses are inserted as gatekeepers indefensibly based upon diagnosis. Implications for practice and public policy are considered, including a “modest proposal” for post-trial management of defendants found not guilty by reason of insanity on the basis of functional deficits arising from personality disorder. (shrink)

The purpose of this inquiry is to explore the experience of Borderline Personality Disorder with the aim of developing a more liberating approach to its diagnosis and treatment. Eight participants diagnosed with Borderline Personality Disorder were recruited from a psychiatric hospital operated by the Surrey and Borders NHS Trust and an outpatient daycentre based in London, United Kingdom. A narrative approach to methodology was employed to collect and analyse the participants’ life-stories. Themes to emerge from the participant’s narratives were found (...) to coincide with R.D. Laing’s concept of ontological insecurity. Ontological insecurity describes a number of aspects of the participant’s distress. To conclude, some general implications of this research for psychotherapy are briefly explored. (shrink)

We are thankful for the opportunity to reflect more on the difficult problem of the relationship between moral evaluations and the construct of personality disorders in response to the commentaries by Mike Martin and Louis Charland. We begin by emphasizing to readers that this important problem is complicated by the different perspectives of the various disciplines involved, especially, philosophy, psychiatry, and psychology. Incredulity, anger, and dismay are among the reactions we encountered in discussions of these issues, especially with some mental (...) health professionals. Strong reactions on either side of a disciplinary divide occasionally present barriers to a dispassionate discussion of the topic. .. (shrink)

Whether treatment decision-making capacity can be meaningfully applied to patients with a diagnosis of “personality disorder” is examined. Patients presenting to a psychiatric emergency clinic with threats of self-harm are considered, two having been assessed and reviewed in detail. It was found that capacity can be meaningfully assessed in such patients, although the process is more complex than in patients with diagnoses of a more conventional kind. The process of assessing capacity in such patients is very time-consuming and may become, (...) in itself, a therapeutic intervention. (shrink)

Background Previous research on informed consent for research in psychiatric patients has centered on disorders that affect comprehension and appreciation of risks. Little has been written about consent to research in those subjects with Borderline Personality Disorder, a prevalent and disabling condition. Discussion Despite apparently intact cognition and comprehension of risks, a borderline subject may deliberately choose self-harm in order to fulfill abnormal psychological needs, or due to suicidality. Alternatively, such a subject may refuse enrollment due to transference or the (...) desire to harm him or herself. Such phenomena could be precipitated or prevented by the interpersonal dynamics of the informed consent encounter. Summary Caution should be exercised in obtaining informed consent for research from subjects with Borderline Personality Disorder. A literature review and recommendations for future research are discussed. (shrink)

Classifying Madness (Springer, 2005) concerns philosophical problems with the Diagnostic and Statistical Manual of Mental Disorders, more commonly known as the D.S.M. The D.S.M. is published by the American Psychiatric Association and aims to list and describe all mental disorders. The first half of Classifying Madness asks whether the project of constructing a classification of mental disorders that reflects natural distinctions makes sense. Chapters examine the nature of mental illness, and also consider whether mental disorders fall into natural kinds. The (...) second half of the book addresses epistemic worries. Even supposing a natural classification system to be possible in principle, there may be reasons to be suspicious of the categories included in the D.S.M. I examine the extent to which the D.S.M. depends on psychiatric theory, and look at how it has been shaped by social and financial factors. I aim to be critical of the D.S.M. without being antagonistic towards it. Ultimately, however, I am forced to conclude that although the D.S.M. is of immense practical importance, it is unlikely to come to reflect the natural structure of mental disorders. (shrink)

An exploration of the roots of terrorism suggests one primal source arises from so-called “self-made” males who find difficulty forming community attachments. Those who fail to see that they live within the boundaries of humanity fail to recognize where dark ambitions of their souls fester and where inter-subjective reality begins. They suffer from what psychiatrists call borderline disorders. Cut off from a lived community, they become monsters of humanity.