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)

The British National Institute for Health and Clinical Excellence has recently released new guidelines for the diagnosis, treatment and prevention of the psychiatric category antisocial personality disorder. Evident in these recommendations is a broader ambiguity regarding the ontology of ASPD. Although, perhaps, a mundane feature of much of medicine, in this case, ontological uncertainty has significant ethical implications as a product of the profound consequences for an individual categorised with this disorder. This paper argues that in (...) refraining from emphasising uncertainty, NICE risks reifying a controversial category. This is particularly problematical given that the guidelines recommend the identification of individuals “at risk” of raising antisocial children. Although this paper does not argue that NICE is “wrong” in any of its recommendations, more emphasis should have been placed on discussions of the ethical implications of diagnosis and treatment, especially given the multiple uncertainties associated with ASPD. It is proposed that these important issues be examined in more detail in revisions of existing NICE recommendations, and be included in upcoming guidance. This paper thus raises key questions regarding the place and role of ethics within the current and future remit of NICE. (shrink)

Individuals diagnosed with conduct disorder (CD) in childhood and adolescence are at risk for increasingly maladaptive and dangerous behaviors, which unchecked, can lead to antisocial personality disorder (ASPD) in adulthood. Children with CD, especially those with the callous unemotional subgroup qualifier (“limited prosocial emotions”/dsm‐5), present with a more severe pattern of delinquency, aggression, and antisocial behavior, all markings of prodrome ASPD. Given this recognized diagnostic trajectory, with a pathological course playing out tragically at the individual, (...) familial, and societal level, and lack of effective remediation via current standards of care, we posit an alternate treatment approach; case‐specific compulsory moral habilitation aimed at rectifying the undeveloped affective domain of adolescents and young adults suffering from these disorders. We begin with a brief historical overview of response to mental illness, review CD and ASPD diagnostic criteria and treatment limitations, and posit a unique neurohabilitative approach that focuses on the absent affective moral development of these populations. Next, we invoke a public health safety argument to justify case‐specific compulsory moral habilitation, discuss neurotechnologies to be considered in treatment, and conclude with ethical considerations and suggestions for further research. (shrink)

I present two philosophical arguments that Antisocial Personality Disorder (ASPD) and Psychopathy can be expected to be culturally variable. I argue that the ways in which people with ASPD and psychopaths can be expected to act will vary with societal values and culture. In the second part of the chapter, I will briefly review some of the empirical literature on cross-cultural variation in ASPD and psychopathy and argue that it is consistent with my philosophical claims. My conclusion (...) in this chapter is that methods of diagnosis will need to be culturally specific. A diagnostic instrument (such as the PCL-R or DSM) should not be uncritically employed in cultures that are very different from those in which it was initially developed. (shrink)

In the aftermath of the Port Arthur shootings, Dunblane or the schoolyard killings in America, communities try to come to terms with private and public trauma and there is a need to understand what kind of person can commit such terrible acts. The problem of how to understand dangerousness often centres on the role of the mental health and criminal justice systems and it is from the intersection of these two institutions that the categorisation of dangerous persons has emerged. This (...) 2001 book traces the history of the category of antisocial personality disorder and shows how it is linked to particular kinds of governing. It examines key legal and institutional developments in Australia, the UK and the US and also parallel developments within psychiatry and psychological medicine. Applying a social theoretical analysis to this material, McCallum challenges our assumptions about the formation and control concepts of dangerousness and personality. (shrink)

English Abstract: The Antisocial personality disorder and several other psychiatric constructs are questioned and deconstructed in this review, that uses psychoanalytic approach to explain the nature of psychopathy and to give recommendations in this respect. -/- German Abstract: In vorliegender Rezension werden psychiatrische Konstrukte psychoanalytischer Bewertung unterzogen und dekonstruiert. Während die Entität „Antisoziale Persönlichkeitsstörung“ aufgrund ihrer Unwissenschaftlichkeit verworfen wird, besteht mentales Konstrukt „Psychopathie“ der Realitätsprüfung. In weiterem Verlauf der Rezension wird Versuch unternommen, das Phänomen der Psychopathie aufzuklären, (...) um sie begrifflich sowie gesundheitlich einzugrenzen. (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)

The five factor trait of conscientiousness is a supertrait, denoting on one hand a pattern of excessive labor, rigidity, orderliness and compulsivity, and on the other hand a pattern of strict rectitude, scrupulosity, dutifulness and morality. In both respects the obsessive-compulsive personality is conscientious; indeed, it has been labeled a disorder of extreme conscientiousness. Antisocial personality disorder, in the present paper, is described as occupying the opposite end of the conscientiousness continuum. The antisocial is (...) impulsive rather than compulsive, illicit rather than licit, and furtive rather than forthright.After clinically comparing the obsessive and antisocial personalities, the present paper invokes evolutionary theory to explain their resultant behavioral, ideological, political and demographic differences. (shrink)

The five factor trait of conscientiousnessis a supertrait, denoting on one hand a pattern of excessive labor, rigidity, orderliness and compulsivity,and on the other hand a pattern of strict rectitude, scrupulosity, dutifulness and morality. In both respects the obsessive-compulsive personality is conscientious; indeed, it has been labeled a disorder of extreme conscientiousness. Antisocial personality disorder, in the present paper, is described as occupying the opposite end of the conscientiousness continuum. The antisocial is impulsive rather (...) than compulsive, illicit rather than licit, and furtive rather than forthright.After clinically comparing the obsessive and antisocial personalities, the present paper invokes evolutionary theory to explain their resultant behavioral, ideological, political and demographic differences. (shrink)

Individuals develop a narrative identity through constructing and internalizing an evolving life story composed of significant autobiographical memories. The ability to narrate these memories in a coherent manner has been related to well-being, identity functioning, and personality pathology. Previous studies have particularly focused on coherence of life story narratives, overlooking coherence of single event memories that make up the life story. The present study addressed this gap by examining associations between narrative coherence of single turning point memories and psychological (...) well-being, identity functioning, and personality disorder (PD) symptoms among 333 Belgian emerging adults (72.1% female;Mage= 22.56,SD= 3.13, age range = 18–30). In addition, the present study tested whether narrative coherence could predict unique variance in PD symptoms above and beyond identity and interpersonal functioning, both considered key components of personality pathology. The findings showed that narrative coherence was not significantly related to psychological well-being, but yielded significant negative associations with disturbed identity functioning and antisocial PD symptoms. Furthermore, narrative coherence predicted unique variance in antisocial PD symptoms above and beyond identity functioning, but did not predict unique variance in borderline and antisocial PD symptoms above and beyond both identity and interpersonal functioning. Collectively, these findings suggest that narrative incoherence within single event memories might be characteristic for disturbed identity functioning and antisocial personality pathology. (shrink)

Medical professionals, including mental health professionals, largely agree that moral judgment should be kept out of clinical settings. The rationale is simple: moral judgment has the capacity to impair clinical judgment in ways that could harm the patient. However, when the patient is suffering from a "Cluster B" personality disorder, keeping moral judgment out of the clinic might appear impossible, not only in practice but also in theory. For the diagnostic criteria associated with these particular disorders (Antisocial, (...) Borderline, Histrionic, Narcissistic) are expressed in overtly moral language. I consider three proposals for dealing with this problem. The first is to eliminate the Cluster B disorders from the DSM on the grounds that they are moral, rather than mental, disorders. The second is to replace the morally laden language of the diagnostic criteria with morally neutral language. The third is to disambiguate the notion of moral judgment so as to respect the distinction between having morally disvalued traits and having moral responsibility for those traits. Sensitivity to this distinction enables the clinician, at least in theory, to employ morally laden diagnostic criteria without adopting the sort of morally judgmental (and potentially harmful) attitude that results from the tacit presumption of moral responsibility. I argue against the first two proposals and in favor of the third. In doing so, I appeal to Grice's distinction between conventional and conversational implicature. I close with a few brief remarks on the irony of retaining overtly moral language in an ostensibly medical manual for the diagnosis of mental disorders. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.1 (2003) 25-27 [Access article in PDF] Gender, Body, Meaning:Anthropological Perspectives on Self-Injury and Borderline Personality Disorder Carolyn Sargent THE CENTRAL THEMES OF "Commodity Body/Sign: Borderline Personality Disorder and the Signification of Self-Injurious Behavior" reflect issues that cut across the disciplines represented by this journal and have received increasing attention from anthropologists. Medical anthropologists, as well as psychological anthropologists and others (...) interested in symbolic analysis of the body, have addressed such topics as the culture of biomedicine and the cultural shaping of psychiatric classification, the multiple meanings of body modifications, power relations in therapeutic interactions between doctor and patient, and cultural variation in understandings of normality and abnormality.Curiously, there is little anthropological literature that directly focuses on either borderline personality disorder (BPD) or self-injurious acts per se. Indeed anthropological research on psychiatric diagnosis, classification, and treatment, as well as ethnopsychiatry, include scant reference to personality disorders. One exception is Nuckolls' 1992 article, "Toward a Cultural History of the Personality Disorders," which raises pertinent questions for one of Potter's introductory statements—that the majority of those diagnosed with BPD are women. Nuckolls directly addresses gender ideology and gender roles in the United States in his comparison of antisocial personality and histrionic personality diagnoses. In his paper, he argues that these personality disorders have cultural histories and are strongly congruent with prevailing gender stereotypes, such that men are many times more likely to be diagnosed as antisocial than women and women much more likely to be diagnosed as histrionic (Nuckolls 1992, 37). He also historicizes the emergence of certain behavioral styles that have been seen as characteristic of women and men, and the evolution of psychiatric diagnoses that classify extreme manifestations of these behavioral styles.The issue of why women, rather than men, are more frequently diagnosed with BPD is not elaborated in Potter's article, although she notes the importance of considering the intersection of gender and "identifying behaviors" associated with BPD. Cultural analyses of gender ideology in the [End Page 25] United States might suggest that the connection involves gendered expectations concerning emotionality and relational context but these articulations remain intriguing and underexplored. One might speculate that BPD/self-injury occurs in the context of particular gender ideologies, perhaps in class-based, industrialized societies where the body is highly commodified. It appears that the history of this constellation of symptoms and behaviors remains to be written.Cultural analysis of self-injury, a theme that runs through Potter's article, tends to be embedded in the anthropological literature on body ornamentation, initiation rituals, and "culture-bound" syndromes. Mascia-Lees and Sharpe (1992, 1) describe the body as "a site of adornment, manipulation, and mutilation," practices with roots reaching back as far as 30,000 years, and include as examples head deformation, scarification, foot binding, tooth filing, lip plates, nose rings, tattoos, subincision, and genital cutting.However, the concept of self-injury, as Potter notes, is problematic in the discipline of anthropology given the significance historically accorded to cultural relativism. Correspondingly, body "modification" is not "self-injury" as long as it is socially normative, for example, a facet of an initiation ordeal or body ornamentation (e.g., circumcision, scarification, piercing). Among the rare examples of acts that seem readily identifiable as "self-injury" are New Guinea practices of cutting off a finger to demonstrate mourning and Baatombu (West African) male finger amputation to show grief and anger over a wife's infidelity. Both are, however, considered culturally legitimate and not indicative of pathology.Potter's argument draws heavily on the notion of "body as text," derived largely from literary theory and feminist philosophy (Butler 1990; Jaggar and Bordo 1989). The perspective of "body as text" has influenced anthropological theory over the past two decades, particularly in the interpretive and postmodernist schools of thought. The body as a text of femininity is aptly characterized by Bordo, who argues that the continuum between female disorder and normal femininity is revealed by means of an analysis of symbolic meaning of gender in... (shrink)

Effective and specifically targeted social and therapeutic responses for antisocial personality disorders and psychopathy are scarce. Some authors maintain that this scarcity should be overcome by revising current syndrome - based classifications of these conditions and devising better biocognitive classifications of antisocial individuals. The inspiration for the latter classifications has been embedded in the Research domain criteria approach (RDoC). RDoC - type approaches to psychiatric research aim at transforming diagnosis, provide valid measures of disorders, aid clinical practice, (...) and improve health outcomes by integrating the data on the genetic, neural, cognitive, and affective systems underlying psychiatric conditions. In the first part of the paper, we discuss the benefits of such approaches in comparison to the dominant syndrome-based ones and review recent attempts at building biocognitive classifications of antisocial individuals. Other researchers, how ever, have objected that biocognitive approaches in psychiatry are committed to an untenable form of explanatory. (shrink)

Should offenders with psychopathy or those exhibiting extreme forms of antisocial behav- iour be considered criminally responsible? The current debate seems to have reached a stalemate. Several scholars have argued that neuropsychologi- cal data on individuals with psychopathy might be relevant for determining their criminal responsibil- ity. However, relying on such data has not produced a consensus among legal scholars and philosophers on whether individuals with psychopathy should be excused from responsibility. We offer a diagnosis about why this debate (...) has reached a standoff. We argue that part of the problem is that psychopathy, being a syndrome-based category, is too heterogeneous and thus offers low prospects for being integrated with neuropsychological data that might support significant conclusions about the criminal responsibility of individuals with psychopathy. Moreover, the construct of psychopathy was not originally devised to discriminate criminally accountable from unac- countable antisocial individuals. To overcome these difficulties and advance the debate, we extend a currently less discussed theoretical framework for bridging biopsychology and the law that focuses on neuropsychological constructs, domains, and processes that directly measure capacities of offenders that are relevant for criminal responsibility, without necessarily relying on mediating syndrome-based constructs. The novelty of our contribution is that the biopsy- chological bases of exculpation can be further devel- oped and used for determining more fine-grained cat- egorisations of antisocial personality types. We show how this framework provides guidelines for inter- disciplinary research that can significantly advance our understanding of the preconditions for criminal responsibility and help the legal practice of ascribing or withholding it. (shrink)

We have made huge progress in understanding the biology of mental illnesses, but comparatively little in interpreting them at the psychological level. The eminent philosopher Jonathan Glover believes that there is real hope of progress in the human interpretation of disordered minds. -/- The challenge is that the inner worlds of people with psychiatric disorders can seem strange, like alien landscapes, and this strangeness can deter attempts at understanding. Do people with disorders share enough psychology with other people to make (...) interpretation possible? To explore this question, Glover tackles the hard cases—the inner worlds of hospitalized violent criminals, of people with delusions, and of those diagnosed with autism or schizophrenia. Their first-person accounts offer glimpses of inner worlds behind apparently bizarre psychiatric conditions and allow us to begin to learn the “language” used to express psychiatric disturbance. Art by psychiatric patients, or by such complex figures as van Gogh and William Blake, give insight when interpreted from Glover’s unique perspective. He also draws on dark chapters in psychiatry’s past to show the importance of not medicalizing behavior that merely transgresses social norms. And finally, Glover suggests values, especially those linked with agency and identity, to guide how the boundaries of psychiatry should be drawn. -/- Seamlessly blending philosophy, science, literature, and art, Alien Landscapes? is both a sustained defense of humanistic psychological interpretation and a compelling example of the rich and generous approach to mental life for which it argues. (shrink)

ArgumentResearch into the biological markers of pathology has long been a feature of British psychiatry. Such somatic indicators and associated features of mental disorder often intertwine with discourse on psychological and behavioral correlates and causes of mental ill-health. Disorders of sociality – particularly psychopathy and antisocial personality disorder – are important instances where the search for markers of pathology has a long history; research in this area has played an important role in shaping how mental health (...) professionals understand the conditions. Here, I characterize the multiplicity of psychiatric praxis that has sought to define the mark of antisociality as a form of “ontological anarchy.” I regard this as an essential feature of the search for biological and other markers of an unstable referent, positing that uncertainties endure – in part – precisely because of attempts to build consensus regarding the ontology of antisociality through biomedical means. Such an account is suggestive of the co-production of biomarkers, mental disorder, and psychiatric institutions. (shrink)

This review aimed at exploring the psychosocial disorders of Nigeria as a nation, its effect on the citizens and the remedy. Psychosocial disorder is a mental illness induced by life experiences, stress, as well as maladaptive cognitive and behavioural processes. The prevalence of these disorders include depression, schizophrenia, anxiety disorders, substance use disorder, personality disorder and autism spectrum disorders have rapidly increase over the past years in Nigeria with its negative impact on the socioeconomic status, psychological (...) well-being; peaceful coexistence and mental health of the entire society. These have precipitated some social anomalies such as bribery and corruption, antisocial behaviour, religious fanaticism, terrorism and so on. The study therefore recommends the need for government to implement effective mental health interventions program that would facilitate easy access to mental healthcare services in Nigeria. There is also an urgent need to improve the mental health awareness of Nigerians through education and public mental health campaign. (shrink)

New discoveries in neuroscience challenge our understanding of human responsibility and justice. Recent studies suggest that psychopaths not only exhibit specific behavioral patterns but may also have a distinct neuroanatomical blueprint. Scientists have shown that a significant number of individuals who have demonstrated psychopathic behaviors have reduced volume and other anatomical changes in various regions of the cerebral cortex as well as decreased functional connectivity between different brain areas (i.e., smaller dysfunctional amygdalae). These findings raise ethical questions about how our (...) criminal system deals with these individuals. Should dysfunctional anatomical or diseased features exonerate affected individuals from any responsibility for their criminal activity or the suffering they have caused to their victims? It is estimated that individuals with the signs and symptoms of antisocial personality disorder make up 25% of inmates. Should individuals classified with this disorder be incarcerated with other criminals? In this paper, we summarize the results of the latest brain imaging studies performed on individuals with antisocial personality traits, referred to as psychopaths or sociopaths, and we explore some of the ethical issues concerning psychopathy and the law. (shrink)

This book is the second volume of an interdisciplinary study, chiefly one of philosophy and psychology, which concerns personality, especially the abnormal in terms of states of aloneness, primarily that of the negative emotional isolation customarily known as loneliness. Other states of aloneness investigated include solitude, reclusiveness, seclusion, desolation, isolation, and what the author terms “aloneliness,” “alonism,” “lonism,” and “lonerism.” Insofar as this study most explicitly focuses on abnormal personalities, it employs the general and specific definitions of personality (...) aberrations as formulated by the American Psychiatric Association in its latest edition of the _Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)_. The author views personality as preeminently comprised of the individual's interpersonal relationships. Unlike the _DSM-IV_, he proposes that people with personality disorders not only possibly but necessarily manifest deviancy regarding interpersonal functioning via serious shortcomings in shared inwardness, paramountly reciprocated intimacy. This work also engages in an analysis of five social factors that are conducive to predisposing, precipitating, and maintaining negative kinds of personality and aloneness. The author has formed these factors into an acronym titled _SCRAM_ since when they are present, intimacy scurries away and in its absence, loneliness and other sorts of unwanted aloneness scamper in and fill the person with unhappiness via, for instance, sadness and self-worthlessness. The constituents of SCRAM are the following social illnesses: _S_uccessitis (for example, the fixation on fame and fortune), _C_apitalitis (greed-driven, unfettered capitalism), _R_ivalitis (competitivitis), _A_tomitis (hyper-individualism), and _M_aterialitis (for example, the anti-spirituality of consumeritis). In sum, this book provides a different perspective on personality via the lenses of various types of aloneness and their lack of public and private intimacy, especially love. (shrink)

Psychopaths are often regarded as a scourge of contemporary society and, as such, are the focus of much public vilification and outrage. But, arguably, psychopaths are both sinned against as well as sinners. If that is true, then their status as the victims of abusive subcultures partially mitigates their moral responsibility for the harms they cause. We argue, from the neuroethics of psychopathy and antisocial personality disorder (ASPD), that communities have a moral obligation to psychopaths as well (...) as a case against them. A reflection on the genesis and developmental epidemiology of psychopathy reveals an individualist, attribution-type error evident in much Western psychological and legal thinking—an error that obscures important moral truths about psychopaths. The resulting analysis makes us reconsider the distinction between disorders and moral failings and the ethical significance of the biological or neurocognitive mechanisms underpinning psychopathy. We claim that casting aside the deficit model (based on the presupposition that psychopaths are intrinsically unlike the rest of us) in favor of a relational and holistic view of personality potentiates a more informed and inclusive set of ethical, forensic, and therapeutic attitudes. (shrink)

The diagnosis of psychopathic personality disorder has salience for forensic clinical practice. It influences decisions regarding risk, treatability and sentencing, indeed, in certain jurisdictions it serves as an aggravating factor that increases the likelihood of a capital sentence. The concatenation of symptom that is associated with modern conceptions of the disorder can be discerned in early writings, including the book of Psalms. Despite its forensic clinical importance and historical pedigree the concept remains elusive and controverted. In this (...) paper I describe an attempt to map the concept of psychopathic personality disorder—the Comprehensive Assessment of Psychopathic Personality (CAPP). I outline the processes used to create the concept map; I summarise evidence in support of the content validity of the map and describe different operations designed to operationalise the construct. It is only when conceptual clarity is achieved that valid operations and measures can be created. I end with a plea for more carefully considered application of statistical methods; applications that better fit the theoretical questions being posed. (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...

This article critically examines Louis Charland’s claim that personality disorders are moral rather than medical kinds by exploring the relationship between personality disorders and virtue ethics. We propose that the conceptual resources of virtue theory can inform psychiatry’s thinking about personality disorders, but also that virtue theory as understood by Aristotle cannot be reduced to the narrow domain of ‘the moral’ in the modern sense of the term. Some overlap between the moral domain’s notion of character-based ethics (...) and the medical domain’s notion of character-based disorders is unavoidable. We also apply a modified version of John Sadler’s “moral wrongfulness test” to borderline and narcissistic personality disorders. With respect to both diagnoses, we argue that they involve negative moral evaluations, but may also have indispensable nonmoral features and, therefore, classify legitimate psychiatric disorders. (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)

I argue for two propositions. First, contrary to the common wisdom, we may justly punish individuals who are not morally responsible for their crimes. Psychopaths – individuals who lack the capacity to feel sympathy – help to prove this point. Scholars are increasingly arguing that psychopaths are not morally responsible for their behavior because they suffer from a neurological disorder that makes it impossible for them to understand, and therefore be motivated by, moral reasons. These same scholars then infer (...) from this conclusion that they must also lack criminal responsibility and therefore that our continuing to punish psychopaths for their crimes is unjust. My response is that this inference is entirely fallacious. -/- Criminal responsibility turns out to be quite distinct from moral responsibility. The two kinds of responsibility require very different conditions to be satisfied. In particular, criminal responsibility, unlike moral responsibility, does not require an agent be able to grasp and follow moral reasons; it requires only that the individual be able to grasp and follow criminal laws. Once this point is recognized, it becomes much easier to accept my thesis: while the subset of psychopaths who commit crimes are not morally responsible for their criminal behavior because they cannot understand moral reasons, they are still criminally responsible because they can understand what the consequences will be if they get caught. For this reason, even though I concede that psychopaths are not morally responsible for the crimes that they commit, our practice of punishing them for these crimes is still just. -/- Second, I argue that psychopathy is a mental illness and should be recognized as such. One reason that it should be recognized as a mental illness is simply because it is; it satisfies the main criteria for inclusion in the DSM-IV, the “bible” of mental disorders. The other reason is more practical than conceptual. It starts with two facts: the U.S. Supreme Court has decided that the preventive detention of any individual who is not a criminal suspect is not constitutional unless the individual is not only dangerous but also mentally ill; and psychopathy is not currently considered to be a mental illness. So, as things now stand, we cannot preventively commit dangerous psychopaths – that is, psychopaths who have clearly indicated that they will be committing serious crimes. Instead, we must wait for them to commit the crimes before we can lock them up. Unfortunately, this incarceration always comes too late for the victims. It would therefore be better if we could lock them up before they actually inflict any harm. Once again, then, I propose that the legal and psychological communities classify psychopathy as a mental illness. (shrink)

Borderline Personality disorder is a severe personality dysfunction characterized by behavioural features such as impulsivity, identity disturbance, suicidal behaviour, emptiness, and intense and unstable relationships. Approximately 2% of the population are thought to meet the criteria for BPD. The authors of this volume - Anthony Bateman and Peter Fonagy - have developed a psychoanalytically oriented treatment to BPD known as mentalization treatment. With randomised controlled trials having shown this method to be effective, this book presents the first (...) account of mentalization treatment for BPD. The first section gives an overview of BPD, including discussion of nosology, epidemiology, natural history, and psychosocial aetiology. It additionally summarises the present state of our research knowledge about effective psychotherapeutic treatments and use of medication. The second section outlines the authors' theoretical approach and contrasts it with other well known methods, including DBT, CAT, and CBT. In the extensive final section, the authors outline their clinical approach starting with how treatment is organised. A detailed account of the transferable features of the model is provided along with the main strategies and techniques of treatment. Numerous clinical examples are given to illustrate the core techniques and detailed information provided about how to apply aspects of the mentalization based treatment approach in everyday practice. Aimed at mental health professionals, along with counsellors, psychotherapists, and psychoanalysts, the book will be a valuable tool, providing an effective means of treating those suffering from Borderline Personality Disorder. (shrink)

The diagnostic category of borderline personality disorder (BPD) has come under increasing criticism in recent years. In this paper, we analyze the role and impact of epistemic injustice, specifically testimonial injustice, in relation to the diagnosis of BPD. We first offer a critical sociological and historical account, detailing and expanding a range of arguments that BPD is problematic nosologically. We then turn to explore the epistemic injustices that can result from a BPD diagnosis, showing how they can lead (...) to experiences of testimonial injustice which impede patient engagement in meaning-making activities, thereby undermining standard therapeutic goals. We conclude by showing how our arguments bolster ongoing efforts to replace the diagnostic category of BPD with alternatives such as complex post-traumatic stress disorder. (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)

The traditional view that having a personality disorder, unlike other mental disorders, is not usually reason enough to consider a person incompetent to make healthcare decisions is challenged. The example of a case in which a woman was treated for a physical disorder without her consent illustrates that personality disorder can render a person incompetent to refuse essential treatment, particularly because it can affect the doctor–patient relationship within which consent is given.

Several researchers point to disorganized attachment as a core feature of borderline personality disorder (BPD). However, recent studies suggest that specific internal working models (IWMs) of each parent combine to account for child outcomes and that a secure relationship with one parent can protect against the deleterious effects of an insecure relationship with the other parent. It was thus hypothesized that adolescents with BPD are more likely to be disorganized with both their parents, whereas non-clinical controls are more (...) secure with at least one of their caregivers. Thirty-six adolescents with BPD and 30 control participants (aged 13-19) were included. Psychiatrist diagnosis was verified with the SIDP-IV and comorbidity was assessed using the Kiddie-SADS. Reported trauma was assessed with the Childhood Trauma Questionnaire. Attachment IWMs of each parent were assessed with the Attachment Multiple Model Interview (AMMI), which enables separate coding for each attachment figure and in which disorganization is conceptualized as conflicting attachment strategies within a specific relationship. Results of a logistic regression analysis suggested that beyond insecure attachment, being disorganized not just with one but with both parents is particularly characteristic of adolescents with BPD. Conversely, belonging to the non-clinical group was predicted by higher security scores with the father and lower deactivation with the mother. Although higher levels of childhood abuse or neglect were reported by adolescents with BPD, the retained attachment dimensions predicted group membership over and above reported trauma. These findings have important implications for clinical intervention and highlight the protective role fathers may have. (shrink)

Once common, therapeutic privilege—the practice whereby a physician withholds diagnostic or prognostic information from a patient intending to protect the patient—is now generally seen as unethical. However, instances of therapeutic privilege are common in some areas of clinical psychiatry. We describe therapeutic privilege in the context of borderline personality disorder, discuss the implications of diagnostic non-disclosure on integrated care and offer recommendations to promote diagnostic disclosure for this patient population. There are no data in this work.

People with personality disorders should be treated fairly. Potential crime victims should be protected. That much is uncontroversial. The hard questions ask what is fair, when is protection adequate, and how should we achieve fairness and protection together. Peay outlines five main hurdles that the law must jump to reach these goals. All five raise serious challenges. To begin to address these challenges, we must first clarify what a personality disorder is. The notion of a personality (...) disorder is defined very broadly in DSM-IV-TR as any inflexible, pervasive, enduring, stable, and early-onset pattern of experience and behavior that deviates markedly from cultural expectations, leads to clinically .. (shrink)

Personality disorders: illegitimate subject positions The diagnosis of personality disorder is common in mental health nurse settings and is a term often used without critical consideration. In clinical practice, the term personality disorder has pejorative connotations, which arise out of the way in which these behaviours are constructed as behavioural rather than psychiatric. The discursive construction of categories of personality disorder are inculcated into clinical practice and become taken‐for‐granted by those in practice culture. (...) The construction of some personalities as disordered and, therefore, illegitimate becomes natural. This paper provides a critical analysis of the diagnosis and suggests an approach to mental health nursing care that is more legitimising for those people who receive psychiatric diagnoses. (shrink)

How psychopaths and their capacity for moral action are viewed is not only philosophically interesting but is also important and relevant for policy. The philosophical discussion of psychopathy has focussed upon the psychological faculties that are prerequisites for moral responsibility and empirical findings regarding psychopathy that are relevant to philosophical accounts of moral understanding and motivation. However, there are legitimate worries about whether psychopathy is a robust scientific construct, and there are risks attached to reifying psychopathy or other psychiatric constructs. (...) We defend the concept of psychopathy by pointing out the relevance of empirical studies about it for our ordinary practices of ascribing moral responsibility and folk psychological accounts of moral understanding and motivation. (shrink)

All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood. (Article 1, Universal Declaration of Human Rights 1948) This resounding statement encapsulates a number of problematic themes for lawyers with respect to personality disorder, and acutely so for the extremes of personality disorder embraced by designations such as psychopathy or dangerous and severe personality disorder (...) (DSPD). These designations are in themselves contentious; they do not have commonly agreed definitions either across disciplines or across jurisdictions. Morse (2008), for example, argues in a fascinating account that .. (shrink)

This chapter argues that the conditions under the umbrella “personality disorders” actually constitute two very different kinds of theoretical entities. In particular, several core personality disorders are actually moral, and not medical, conditions. Thus, the categories that are held to represent them are really moral, and not medical, theoretical kinds. The chapter works back from the possibility of treatment to the nature of the kinds that are allegedly treated, revisiting 18th-century ideas of moral treatment along the way. The (...) discussion closes with a reflection on how the ambiguous medical status of personality disorders and their treatment today is reminiscent of the ideological tug of war that pits alienist “mad doctors” like Pinel against their lay counterparts such as Tuke as they battled over who should be in charge of treating the mad. (shrink)

In “Personality Disorders: Moral or Medical Kinds—or Both?” Peter Zachar and Nancy Nyquist Potter (2010) reject any general dichotomy between morality and mental health, and specifically between character vices and personality disorders. In doing so, they provide a nuanced and illuminating discussion that connects Aristotelian virtue ethics to a multidimensional understanding of personality disorders. I share their conviction that dissolving morality–health dichotomies is the starting point for any plausible understanding of human beings (Martin 2006), but I register (...) some qualms about their discussion of responsibility. Zachar and Potter target the morality-health dichotomy as it appears in Louis C. .. (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)

A striking feature of post-modernism is its distrust of the subject. If the modern period, beginning with Descartes, sought in the subject a source of certainty, an Archimedian point from which all else could be derived, post- modernism has taken the opposite tack. Rather than taking the self as a foundation, it has seen it as founded, as dependent on the accidents which situate consciousness in the world. The same holds for the unity of the subject. Modernity, in its search (...) for a single foundation, held the subject to be an indissoluble unity. Post-modernism’s position, by contrast, is announced by Nietzsche: “The assumption of one single subject is perhaps unnecessary; perhaps it is just as permissible to assume a multiplicity of subjects, whose interaction and struggle is the basis of our thought and our consciousness in general? ...My hypotheses: The subject as multiplicity.” Given this, there is a natural correspondence between the success of post- modernism and the current interest in multiple personality disorder. In the latter, we actually have the experience of a “multiplicity of subjects” in their interaction and struggle. The subject stands there before us “as multiplicity.” It gives us a concrete case, one which raises some of the pressing questions associated with the post-modern denial of the subject. Confronting it, we ask: how real are the personalities composing the multiplicity of this disordered self? What, in fact, does this multiplicity tell us about the self? about its genesis and status? What does it reveal about “our thought and consciousness in general”? I plan, in the short compass of this paper, to sketch some answers to these questions. §1. A brief description of MPD. The American Psychiatric Association gives two criteria for (MPD) multiple personality disorder. First, and most obviously, there is “the existence within the person of two or more distinct personalities or personality states (each with its own relatively enduring pattern. (shrink)

Louis Charland has argued that the Cluster B personality disorders, including borderline personality disorder, are primarily moral rather than clinical conditions. Part of his argument stems from reflections on effective treatment of borderline personality disorder. In the argument from treatment, he claims that successful treatment of all Cluster B personality disorders requires a positive change in a patient’s moral character. Based on this claim, he concludes (1) that these disorders are, at root, deficits in (...) moral character, and (2) that effective treatment of these disorders requires a sort of moral education rather than clinical intervention. In this paper, I evaluate the argument from treatment through a critical analysis of two psychotherapeutic interventions that have shown recent effectiveness against borderline personality disorder. I suggest that both Dialectical Behaviour Therapy and Mentalization-Based Treatment indicate that borderline personality disorder is, at root, a deficit in non-moral cognitive and emotional capacities. I suggest that these non-moral deficits obscure the expression of an otherwise intact moral character. In light of this, I conclude that effective treatment of borderline personality disorder requires primarily clinical intervention rather than moral edification. (shrink)

The DSM-IV-TR (American Psychiatric Association 1994, 689) defines personality disorder (PD) as: An enduring pattern of experience and behavior that deviates markedly from the expectations of an individual’s culture. This pattern is manifested in two (or more) of the following areas: 1 Cognition (i.e., ways of perceiving and interpreting self, other people, and events); 2 Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response); 3 Interpersonal functioning; and 4 Impulse control. B The enduring ..

When i was in graduate school, I inadvertently walked in on a fellow student taking his comprehensive exams. He was extremely frustrated because two of the questions asked about conceptual issues in personality and personality disorders. This student was not expecting such questions and considered them to be unfair. I knew other students in that same program who would have considered it a gift to get such “interesting” questions. Those clinical and counseling psychologists with theoretical–philosophical interests are often (...) attracted to the topics of personality and personality disorders. It has, therefore, puzzled me why these same topics are largely ignored by those philosophers who study the conceptual issues of .. (shrink)

Interpersonal sensitivity, particularly threat of potential exclusion, is a critical condition in borderline personality disorder (BPD) which impairs patients’ social adjustment. Current evidence-based treatments include group components, such as mentalization-based group therapy (MBT-G), in order to improve interpersonal functioning. These treatments additionally focus on the therapeutic alliance since it was discovered to be a robust predictor of treatment outcome. However, alliance is a multidimensional factor of group therapy, which includes the fellow patients, and may thus be negatively affected (...) by the exclusion-proneness of BPD patients. The aim of this pilot study was to examine the predictive value of threat of social exclusion for the therapeutic alliance in MBT-G. In the first part of the study, social exclusion was experimentally induced in 23 BPD inpatients and 28 healthy subjects using the Cyberball paradigm, a virtual ball tossing game. The evoked level of threat was measured with the Need-Threat Scale (NTS) which captures four dimensions of fundamental human needs, i. e. the need for belongingness, for self-esteem, for control, and for a meaningful existence. In the second part of the study, therapeutic alliance was measured on three dimensions, the therapists, the fellow patients and the group as a whole, using the Group-Questionnaire (GQ-D). BPD patients scored higher in their level of threat according to the NTS in both, the inclusion and the exclusion condition. The level of threat after exclusion predicted impairments of the therapeutic alliance in MBT-G. It was associated with more negative relationships, lower positive bonding and a lower positive working alliance with the fellow patients and lower positive bonding to the group as a whole whilst no negative prediction of the alliance to the therapists was found. Consequently, our translational study design has shown that Cyberball is an appropriate tool to use as an approach for clinical questions. We further conclude that exclusion-proneness in BPD is a critical feature with respect to alliance in group treatments. In order to neutralize BPD patients’ exclusion bias, therapists may be advised to provide an “inclusive stance”, especially in initial sessions. It is also recommendable to strengthen patient to patient relations. (shrink)