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We are all terminally ill. It is a matter of time before we all die. Aging and death remain almost as mysterious as ever. We feel awed and uncomfortable when we contemplate these twin afflictions. Indeed, the very word denoting illness contains its own best definition: dis-ease. A mental component of lack of well being must exist SUBJECTIVELY. The person must FEEL bad, must experience discomfiture for his condition to qualify as a disease. To this extent, we are justified in classifying all diseases as "spiritual" or "mental".

Is there any other way of distinguishing health from sickness - a way that does NOT depend on the report that the patient provides regarding his subjective experience?

Some diseases are manifest and others are latent or immanent. Genetic diseases can exist - unmanifested - for generations. This raises the philosophical problem or whether a potential disease IS a disease? Are AIDS and Haemophilia carriers - sick? Should they be treated, ethically speaking? They experience no dis-ease, they report no symptoms, no signs are evident. On what moral grounds can we commit them to treatment? On the grounds of the "greater benefit" is the common response. Carriers threaten others and must be isolated or otherwise neutered. The threat inherent in them must be eradicated. This is a dangerous moral precedent. All kinds of people threaten our well-being: unsettling ideologists, the mentally handicapped, many politicians. Why should we single out our physical well-being as worthy of a privileged moral status? Why is our mental well being, for instance, of less import?

Moreover, the distinction between the psychic and the physical is hotly disputed, philosophically. The psychophysical problem is as intractable today as it ever was (if not more so). It is beyond doubt that the physical affects the mental and the other way around. This is what disciplines like psychiatry are all about. The ability to control "autonomous" bodily functions (such as heartbeat) and mental reactions to pathogens of the brain are proof of the artificialness of this distinction.

It is a result of the reductionist view of nature as divisible and summable. The sum of the parts, alas, is not always the whole and there is no such thing as an infinite set of the rules of nature, only an asymptotic approximation of it. The distinction between the patient and the outside world is superfluous and wrong. The patient AND his environment are ONE and the same. Disease is a perturbation in the operation and management of the complex ecosystem known as patient-world. Humans absorb their environment and feed it in equal measures. This on-going interaction IS the patient. We cannot exist without the intake of water, air, visual stimuli and food. Our environment is defined by our actions and output, physical and mental.

Thus, one must question the classical differentiation between "internal" and "external". Some illnesses are considered "endogenic" (=generated from the inside). Natural, "internal", causes - a heart defect, a biochemical imbalance, a genetic mutation, a metabolic process gone awry - cause disease. Aging and deformities also belong in this category.

In contrast, problems of nurturance and environment - early childhood abuse, for instance, or malnutrition - are "external" and so are the "classical" pathogens (germs and viruses) and accidents.

But this, again, is a counter-productive approach. Exogenic and Endogenic pathogenesis is inseparable. Mental states increase or decrease the susceptibility to externally induced disease. Talk therapy or abuse (external events) alter the biochemical balance of the brain. The inside constantly interacts with the outside and is so intertwined with it that all distinctions between them are artificial and misleading. The best example is, of course, medication: it is an external agent, it influences internal processes and it has a very strong mental correlate (=its efficacy is influenced by mental factors as in the placebo effect).

The very nature of dysfunction and sickness is highly culture-dependent. Societal parameters dictate right and wrong in health (especially mental health). It is all a matter of statistics. Certain diseases are accepted in certain parts of the world as a fact of life or even a sign of distinction (e.g., the paranoid schizophrenic as chosen by the gods). If there is no dis-ease there is no disease. That the physical or mental state of a person CAN be different - does not imply that it MUST be different or even that it is desirable that it should be different. In an over-populated world, sterility might be the desirable thing - or even the occasional epidemic. There is no such thing as ABSOLUTE dysfunction. The body and the mind ALWAYS function. They adapt themselves to their environment and if the latter changes - they change. Personality disorders are the best possible responses to abuse. Cancer may be the best possible response to carcinogens. Aging and death are definitely the best possible response to over-population. Perhaps the point of view of the single patient is incommensurate with the point of view of his species - but this should not serve to obscure the issues and derail rational debate.

As a result, it is logical to introduce the notion of "positive aberration". Certain hyper- or hypo- functioning can yield positive results and prove to be adaptive. The difference between positive and negative aberrations can never be "objective". Nature is morally-neutral and embodies no "values" or "preferences". It simply exists. WE, humans, introduce our value systems, prejudices and priorities into our activities, science included. It is better to be healthy, we say, because we feel better when we are healthy. Circularity aside - this is the only criterion that we can reasonably employ. If the patient feels good - it is not a disease, even if we all think it is. If the patient feels bad, ego-dystonic, unable to function - it is a disease, even when we all think it isn't. Needless to say that I am referring to that mythical creature, the fully informed patient. If someone is sick and knows no better (has never been healthy) - then his decision should be respected only after he is given the chance to experience health.

All the attempts to introduce "objective" yardsticks of health are plagued and philosophically contaminated by the insertion of values, preferences and priorities into the formula - or by subjecting the formula to them altogether. One such attempt is to define health as "an increase in order or efficiency of processes" as contrasted with illness which is "a decrease in order (=increase of entropy) and in the efficiency of processes". While being factually disputable, this dyad also suffers from a series of implicit value-judgements. For instance, why should we prefer life over death? Order to entropy? Efficiency to inefficiency?

Health and sickness are different states of affairs. Whether one is preferable to the other is a matter of the specific culture and society in which the question is posed. Health (and its lack) is determined by employing three "filters" as it were:

Is the body affected?
Is the person affected? (dis-ease, the bridge between "physical" and "mental illnesses)
Is society affected?

In the case of mental health the third question is often formulated as "is it normal" (=is it statistically the norm of this particular society in this particular time)?

We must re-humanize disease. By imposing upon issues of health the pretensions of the accurate sciences, we objectified the patient and the healer alike and utterly neglected that which cannot be quantified or measured - the human mind, the human spirit.

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The Normal Personality

First published here: "Personality Disorders (Suite101)"

By: Dr. Sam Vaknin

In their opus magnum "Personality Disorders in Modern Life", Theodore Millon and Roger Davis define personality as:

"(A) complex pattern of deeply embedded psychological characteristics that are expressed automatically in almost every area of psychological functioning." (p. 2)

The Diagnostic and Statistical Manual (DSM)) IV-TR (2000), published by the American Psychiatric Association, defines personality traits as:

"(E)nduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts." (p. 686)

Laymen often confuse and confute "personality" with "character" and "temperament".

Our temperament is the biological-genetic template that interacts with our environment.

Our temperament is a set of in-built dispositions we are born with. It is mostly unalterable (though recent studies demonstrate that the brain is far more plastic and elastic than we thought).

In other words, our temperament is our nature.

Our character is largely the outcome of the process of socialization, the acts and imprints of our environment and nurture on our psyche during the formative years (0-6 years and in adolescence).

Our character is the set of all acquired characteristics we posses, often judged in a cultural-social context.

Sometimes the interplay of all these factors results in an abnormal personality.

Personality disorders are dysfunctions of our whole identity, tears in the fabric of who we are. They are all-pervasive because our personality is ubiquitous and permeates each and every one of our mental cells. I just published the first article in this topic titled "What is Personality?". Read it to understand the subtle differences between "personality", "character", and "temperament".

In the background lurks the question: what constitutes normal behavior? Who is normal?

There is the statistical response: the average and the common are normal. But it is unsatisfactory and incomplete. Conforming to social edicts and mores does not guarantee normalcy. Think about anomic societies and periods of history such as Hitler's Germany or Stalin's Russia. Model citizens in these hellish environments were the criminal and the sadist.

Rather than look to the outside for a clear definition, many mental health professionals ask: is the patient functioning and happy (ego-syntonic)? If he or she is both then all is well and normal. Abnormal traits, behaviors, and personalities are, therefore defined as those traits, behaviors, and personalities that are dysfunctional and cause subjective distress.

But, of course, this falls flat on its face at the slightest scrutiny. Many evidently mentally ill people are rather happy and reasonably functional.

Some scholars reject the concept of "normalcy" altogether. The anti-psychiatry movement object to the medicalization and pathologization of whole swathes of human conduct. Others prefer to study the disorders themselves rather to "go metaphysical" by trying to distinguish them from an imaginary and ideal state of being "mentally healthy".

I subscribe to the later approach. I much prefer to delve into the phenomenology of mental health disorders: their traits, characteristics, and impact on others.

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The Myth of Mental Illness

By: Dr. Sam Vaknin

"You can know the name of a bird in all the languages of the world, but when you're finished, you'll know absolutely nothing whatever about the bird… So let's look at the bird and see what it's doing – that's what counts. I learned very early the difference between knowing the name of something and knowing something."

Richard Feynman, Physicist and 1965 Nobel Prize laureate (1918-1988)

"You have all I dare say heard of the animal spirits and how they are transfused from father to son etcetera etcetera – well you may take my word that nine parts in ten of a man's sense or his nonsense, his successes and miscarriages in this world depend on their motions and activities, and the different tracks and trains you put them into, so that when they are once set a-going, whether right or wrong, away they go cluttering like hey-go-mad."

Lawrence Sterne (1713-1758), "The Life and Opinions of Tristram Shandy, Gentleman" (1759)

I. Overview

Someone is considered mentally "ill" if:

His conduct rigidly and consistently deviates from the typical, average behaviour of all other people in his culture and society that fit his profile (whether this conventional behaviour is moral or rational is immaterial), or
His judgment and grasp of objective, physical reality is impaired, and
His conduct is not a matter of choice but is innate and irresistible, and
His behavior causes him or others discomfort, and is
Dysfunctional, self-defeating, and self-destructive even by his own yardsticks.

Descriptive criteria aside, what is the essence of mental disorders? Are they merely physiological disorders of the brain, or, more precisely of its chemistry? If so, can they be cured by restoring the balance of substances and secretions in that mysterious organ? And, once equilibrium is reinstated – is the illness "gone" or is it still lurking there, "under wraps", waiting to erupt? Are psychiatric problems inherited, rooted in faulty genes (though amplified by environmental factors) – or brought on by abusive or wrong nurturance?

These questions are the domain of the "medical" school of mental health.

Others cling to the spiritual view of the human psyche. They believe that mental ailments amount to the metaphysical discomposure of an unknown medium – the soul. Theirs is a holistic approach, taking in the patient in his or her entirety, as well as his milieu.

The members of the functional school regard mental health disorders as perturbations in the proper, statistically "normal", behaviours and manifestations of "healthy" individuals, or as dysfunctions. The "sick" individual – ill at ease with himself (ego-dystonic) or making others unhappy (deviant) – is "mended" when rendered functional again by the prevailing standards of his social and cultural frame of reference.

In a way, the three schools are akin to the trio of blind men who render disparate descriptions of the very same elephant. Still, they share not only their subject matter – but, to a counter intuitively large degree, a faulty methodology.

As the renowned anti-psychiatrist, Thomas Szasz, of the State University of New York, notes in his article "The Lying Truths of Psychiatry", mental health scholars, regardless of academic predilection, infer the etiology of mental disorders from the success or failure of treatment modalities.

This form of "reverse engineering" of scientific models is not unknown in other fields of science, nor is it unacceptable if the experiments meet the criteria of the scientific method. The theory must be all-inclusive (anamnetic), consistent, falsifiable, logically compatible, monovalent, and parsimonious. Psychological "theories" – even the "medical" ones (the role of serotonin and dopamine in mood disorders, for instance) – are usually none of these things.

The outcome is a bewildering array of ever-shifting mental health "diagnoses" expressly centred around Western civilisation and its standards (example: the ethical objection to suicide). Neurosis, a historically fundamental "condition" vanished after 1980. Homosexuality, according to the American Psychiatric Association, was a pathology prior to 1973. Seven years later, narcissism was declared a "personality disorder", almost seven decades after it was first described by Freud.

II. Personality Disorders

Indeed, personality disorders are an excellent example of the kaleidoscopic landscape of "objective" psychiatry.

The classification of Axis II personality disorders – deeply ingrained, maladaptive, lifelong behavior patterns – in the Diagnostic and Statistical Manual, fourth edition, text revision [American Psychiatric Association. DSM-IV-TR, Washington, 2000] – or the DSM-IV-TR for short – has come under sustained and serious criticism from its inception in 1952, in the first edition of the DSM.

The DSM IV-TR adopts a categorical approach, postulating that personality disorders are "qualitatively distinct clinical syndromes" (p. 689). This is widely doubted. Even the distinction made between "normal" and "disordered" personalities is increasingly being rejected. The "diagnostic thresholds" between normal and abnormal are either absent or weakly supported.

The polythetic form of the DSM's Diagnostic Criteria – only a subset of the criteria is adequate grounds for a diagnosis – generates unacceptable diagnostic heterogeneity. In other words, people diagnosed with the same personality disorder may share only one criterion or none.

The DSM fails to clarify the exact relationship between Axis II and Axis I disorders and the way chronic childhood and developmental problems interact with personality disorders.

The differential diagnoses are vague and the personality disorders are insufficiently demarcated. The result is excessive co-morbidity (multiple Axis II diagnoses).

The DSM contains little discussion of what distinguishes normal character (personality), personality traits, or personality style (Millon) – from personality disorders.

A dearth of documented clinical experience regarding both the disorders themselves and the utility of various treatment modalities.

Numerous personality disorders are "not otherwise specified" – a catchall, basket "category".

Cultural bias is evident in certain disorders (such as the Antisocial and the Schizotypal).

The emergence of dimensional alternatives to the categorical approach is acknowledged in the DSM-IV-TR itself:

“An alternative to the categorical approach is the dimensional perspective that Personality Disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another” (p.689)

The following issues – long neglected in the DSM – are likely to be tackled in future editions as well as in current research. But their omission from official discourse hitherto is both startling and telling:

The longitudinal course of the disorder(s) and their temporal stability from early childhood onwards;
The genetic and biological underpinnings of personality disorder(s);
The development of personality psychopathology during childhood and its emergence in adolescence;
The interactions between physical health and disease and personality disorders;
The effectiveness of various treatments – talk therapies as well as psychopharmacology.

III. The Biochemistry and Genetics of Mental Health

Certain mental health afflictions are either correlated with a statistically abnormal biochemical activity in the brain – or are ameliorated with medication. Yet the two facts are not ineludibly facets of the same underlying phenomenon. In other words, that a given medicine reduces or abolishes certain symptoms does not necessarily mean they were caused by the processes or substances affected by the drug administered. Causation is only one of many possible connections and chains of events.

To designate a pattern of behaviour as a mental health disorder is a value judgment, or at best a statistical observation. Such designation is effected regardless of the facts of brain science. Moreover, correlation is not causation. Deviant brain or body biochemistry (once called "polluted animal spirits") do exist – but are they truly the roots of mental perversion? Nor is it clear which triggers what: do the aberrant neurochemistry or biochemistry cause mental illness – or the other way around?

That psychoactive medication alters behaviour and mood is indisputable. So do illicit and legal drugs, certain foods, and all interpersonal interactions. That the changes brought about by prescription are desirable – is debatable and involves tautological thinking. If a certain pattern of behaviour is described as (socially) "dysfunctional" or (psychologically) "sick" – clearly, every change would be welcomed as "healing" and every agent of transformation would be called a "cure".

The same applies to the alleged heredity of mental illness. Single genes or gene complexes are frequently "associated" with mental health diagnoses, personality traits, or behaviour patterns. But too little is known to establish irrefutable sequences of causes-and-effects. Even less is proven about the interaction of nature and nurture, genotype and phenotype, the plasticity of the brain and the psychological impact of trauma, abuse, upbringing, role models, peers, and other environmental elements.

Nor is the distinction between psychotropic substances and talk therapy that clear-cut. Words and the interaction with the therapist also affect the brain, its processes and chemistry - albeit more slowly and, perhaps, more profoundly and irreversibly. Medicines – as David Kaiser reminds us in "Against Biologic Psychiatry" (Psychiatric Times, Volume XIII, Issue 12, December 1996) – treat symptoms, not the underlying processes that yield them.

IV. The Variance of Mental Disease

If mental illnesses are bodily and empirical, they should be invariant both temporally and spatially, across cultures and societies. This, to some degree, is, indeed, the case. Psychological diseases are not context dependent – but the pathologizing of certain behaviours is. Suicide, substance abuse, narcissism, eating disorders, antisocial ways, schizotypal symptoms, depression, even psychosis are considered sick by some cultures – and utterly normative or advantageous in others.

This was to be expected. The human mind and its dysfunctions are alike around the world. But values differ from time to time and from one place to another. Hence, disagreements about the propriety and desirability of human actions and inaction are bound to arise in a symptom-based diagnostic system.

As long as the pseudo-medical definitions of mental health disorders continue to rely exclusively on signs and symptoms – i.e., mostly on observed or reported behaviours – they remain vulnerable to such discord and devoid of much-sought universality and rigor.

V. Mental Disorders and the Social Order

The mentally sick receive the same treatment as carriers of AIDS or SARS or the Ebola virus or smallpox. They are sometimes quarantined against their will and coerced into involuntary treatment by medication, psychosurgery, or electroconvulsive therapy. This is done in the name of the greater good, largely as a preventive policy.

Conspiracy theories notwithstanding, it is impossible to ignore the enormous interests vested in psychiatry and psychopharmacology. The multibillion dollar industries involving drug companies, hospitals, managed healthcare, private clinics, academic departments, and law enforcement agencies rely, for their continued and exponential growth, on the propagation of the concept of "mental illness" and its corollaries: treatment and research.

VI. Mental Ailment as a Useful Metaphor

Abstract concepts form the core of all branches of human knowledge. No one has ever seen a quark, or untangled a chemical bond, or surfed an electromagnetic wave, or visited the unconscious. These are useful metaphors, theoretical entities with explanatory or descriptive power.

"Mental health disorders" are no different. They are shorthand for capturing the unsettling quiddity of "the Other". Useful as taxonomies, they are also tools of social coercion and conformity, as Michel Foucault and Louis Althusser observed. Relegating both the dangerous and the idiosyncratic to the collective fringes is a vital technique of social engineering.

The aim is progress through social cohesion and the regulation of innovation and creative destruction. Psychiatry, therefore, is reifies society's preference of evolution to revolution, or, worse still, to mayhem. As is often the case with human endeavour, it is a noble cause, unscrupulously and dogmatically pursued.

VII. The Insanity Defense

"It is an ill thing to knock against a deaf-mute, an imbecile, or a minor. He that wounds them is culpable, but if they wound him they are not culpable." (Mishna, Babylonian Talmud)

If mental illness is culture-dependent and mostly serves as an organizing social principle - what should we make of the insanity defense (NGRI- Not Guilty by Reason of Insanity)?

A person is held not responsible for his criminal actions if s/he cannot tell right from wrong ("lacks substantial capacity either to appreciate the criminality (wrongfulness) of his conduct" - diminished capacity), did not intend to act the way he did (absent "mens rea") and/or could not control his behavior ("irresistible impulse"). These handicaps are often associated with "mental disease or defect" or "mental retardation".

Mental health professionals prefer to talk about an impairment of a "person's perception or understanding of reality". They hold a "guilty but mentally ill" verdict to be contradiction in terms. All "mentally-ill" people operate within a (usually coherent) worldview, with consistent internal logic, and rules of right and wrong (ethics). Yet, these rarely conform to the way most people perceive the world. The mentally-ill, therefore, cannot be guilty because s/he has a tenuous grasp on reality.

Yet, experience teaches us that a criminal maybe mentally ill even as s/he maintains a perfect reality test and thus is held criminally responsible (Jeffrey Dahmer comes to mind). The "perception and understanding of reality", in other words, can and does co-exist even with the severest forms of mental illness.

This makes it even more difficult to comprehend what is meant by "mental disease". If some mentally ill maintain a grasp on reality, know right from wrong, can anticipate the outcomes of their actions, are not subject to irresistible impulses (the official position of the American Psychiatric Association) - in what way do they differ from us, "normal" folks?

This is why the insanity defense often sits ill with mental health pathologies deemed socially "acceptable" and "normal" - such as religion or love.

Consider the following case:

A mother bashes the skulls of her three sons. Two of them die. She claims to have acted on instructions she had received from God. She is found not guilty by reason of insanity. The jury determined that she "did not know right from wrong during the killings."

But why exactly was she judged insane?

Her belief in the existence of God - a being with inordinate and inhuman attributes - may be irrational.

But it does not constitute insanity in the strictest sense because it conforms to social and cultural creeds and codes of conduct in her milieu. Billions of people faithfully subscribe to the same ideas, adhere to the same transcendental rules, observe the same mystical rituals, and claim to go through the same experiences. This shared psychosis is so widespread that it can no longer be deemed pathological, statistically speaking.

She claimed that God has spoken to her.

As do numerous other people. Behavior that is considered psychotic (paranoid-schizophrenic) in other contexts is lauded and admired in religious circles. Hearing voices and seeing visions - auditory and visual delusions - are considered rank manifestations of righteousness and sanctity.

Perhaps it was the content of her hallucinations that proved her insane?

She claimed that God had instructed her to kill her boys. Surely, God would not ordain such evil?

Alas, the Old and New Testaments both contain examples of God's appetite for human sacrifice. Abraham was ordered by God to sacrifice Isaac, his beloved son (though this savage command was rescinded at the last moment). Jesus, the son of God himself, was crucified to atone for the sins of humanity.

A divine injunction to slay one's offspring would sit well with the Holy Scriptures and the Apocrypha as well as with millennia-old Judeo-Christian traditions of martyrdom and sacrifice.

Her actions were wrong and incommensurate with both human and divine (or natural) laws.

Yes, but they were perfectly in accord with a literal interpretation of certain divinely-inspired texts, millennial scriptures, apocalyptic thought systems, and fundamentalist religious ideologies (such as the ones espousing the imminence of "rupture"). Unless one declares these doctrines and writings insane, her actions are not.

we are forced to the conclusion that the murderous mother is perfectly sane. Her frame of reference is different to ours. Hence, her definitions of right and wrong are idiosyncratic. To her, killing her babies was the right thing to do and in conformity with valued teachings and her own epiphany. Her grasp of reality - the immediate and later consequences of her actions - was never impaired.

It would seem that sanity and insanity are relative terms, dependent on frames of cultural and social reference, and statistically defined. There isn't - and, in principle, can never emerge - an "objective", medical, scientific test to determine mental health or disease unequivocally.

VIII. Adaptation and Insanity - (correspondence with Paul Shirley, MSW)

"Normal" people adapt to their environment - both human and natural.

"Abnormal" ones try to adapt their environment - both human and natural - to their idiosyncratic needs/profile.

If they succeed, their environment, both human (society) and natural is pathologized.

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The Diagnostic and Statistical Manual (DSM) - Pros and Cons

First published here: "Personality Disorders (Suite101)"

By: Dr. Sam Vaknin

The Diagnostic and Statistical Manual, fourth edition, text revision [American Psychiatric Association. DSM-IV-TR, Washington, 2000] - or the DSM-IV-TR for short - describes Axis II personality disorders as "deeply ingrained, maladaptive, lifelong behavior patterns". But the classificatory model the DSM has been using since 1952 is harshly criticized as woefully inadequate by many scholars and practitioners.

The DSM is categorical. It states that personality disorders are "qualitatively distinct clinical syndromes" (p. 689). But this is by no means widely accepted. As we saw in my previous article and blog entry, the professionals cannot even agree on what constitutes "normal" and how to distinguish it from the "disordered" and the "abnormal". The DSM does not provide a clear "threshold" or "critical mass" beyond which the subject should be considered mentally ill.

Moreover, the DSM's diagnostic criteria are ploythetic. In other words, suffice it to satisfy only a subset of the criteria to diagnose a personality disorder. Thus, people diagnosed with the same personality disorder may share only one criterion or none. This diagnostic heterogeneity (great variance) is unacceptable and non-scientific.

In another article we deal with the five diagnostic axes employed by the DSM to capture the way clinical syndromes (such as anxiety, mood, and eating disorders), general medical conditions, psychosocial and environmental problems, chronic childhood and developmental problems, and functional issues interact with personality disorders.

Yet, the DSM's "laundry lists" obscure rather than clarify the interactions between the various axes. As a result, the differential diagnoses that are supposed to help us distinguish one personality disorder from all others, are vague. In psych-parlance: the personality disorders are insufficiently demarcated. This unfortunate state of affairs leads to excessive co-morbidity: multiple personality disorders diagnosed in the same subject. Thus, psychopaths (Antisocial Personality Disorder) are often also diagnosed as narcissists (Narcissistic Personality Disorder) or borderlines (Borderline Personality Disorder).

The DSM also fails to distinguish between personality, personality traits, character, temperament, personality styles (Theodore Millon's contribution) and full-fledged personality disorders. It does not accommodate personality disorders induced by circumstances (reactive personality disorders, such as Milman's proposed "Acquired Situational Narcissism"). Nor does it efficaciously cope with personality disorders that are the result of medical conditions (such as brain injuries, metabolic conditions, or protracted poisoning). The DSM had to resort to classifying some personality disorders as NOS "not otherwise specified", a catchall, meaningless, unhelpful, and dangerously vague diagnostic "category".

One of the reasons for this dismal taxonomy is the dearth of research and rigorously documented clinical experience regarding both the disorders and various treatment modalities. Read this week's article to learn about the DSM's other great failing: many of the personality disorders are "culture-bound". They reflect social and contemporary biases, values, and prejudices rather than authentic and invariable psychological constructs and entities.

The DSM-IV-TR distances itself from the categorical model and hints at the emergence of an alternative: the dimensional approach:

According to the deliberations of the DSM V Committee, the next edition of this work of reference (due to be published in 2010) will tackle these long neglected issues:

The longitudinal course of the disorder(s) and their temporal stability from early childhood onwards;

The genetic and biological underpinnings of personality disorder(s);

The development of personality psychopathology during childhood and its emergence in adolescence;

The interactions between physical health and disease and personality disorders;

The effectiveness of various treatments - talk therapies as well as psychopharmacology.

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The History of Personality Disorders

First published here: "Personality Disorders (Suite101)"

By: Dr. Sam Vaknin

Well into the eighteenth century, the only types of mental illness - then collectively known as "delirium" or "mania" - were depression (melancholy), psychoses, and delusions. At the beginning of the nineteenth century, the French psychiatrist Pinel coined the phrase "manie sans delire" (insanity without delusions). He described patients who lacked impulse control, often raged when frustrated, and were prone to outbursts of violence. He noted that such patients were not subject to delusions. He was referring, of course, to psychopaths (subjects with the Antisocial Personality Disorder). Across the ocean, in the United States, Benjamin Rush made similar observations.

In 1835, the British J. C. Pritchard, working as senior Physician at the Bristol Infirmary (hospital), published a seminal work titled "Treatise on Insanity and Other Disorders of the Mind". He, in turn, suggested the neologism "moral insanity".

To quote him, moral insanity consisted of "a morbid perversion of the natural feelings, affections, inclinations, temper, habits, moral dispositions, and natural impulses without any remarkable disorder or defect of the intellect or knowing or reasoning faculties and in particular without any insane delusion or hallucination" (p. 6).

He then proceeded to elucidate the psychopathic (antisocial) personality in great detail:

"(A) propensity to theft is sometimes a feature of moral insanity and sometimes it is its leading if not sole characteristic." (p. 27). "(E)ccentricity of conduct, singular and absurd habits, a propensity to perform the common actions of life in a different way from that usually practised, is a feature of many cases of moral insanity but can hardly be said to contribute sufficient evidence of its existence." (p. 23).

"When however such phenomena are observed in connection with a wayward and intractable temper with a decay of social affections, an aversion to the nearest relatives and friends formerly beloved - in short, with a change in the moral character of the individual, the case becomes tolerably well marked." (p. 23)

But the distinctions between personality, affective, and mood disorders were still murky.

Pritchard muddied it further:

"(A) considerable proportion among the most striking instances of moral insanity are those in which a tendency to gloom or sorrow is the predominant feature ... (A) state of gloom or melancholy depression occasionally gives way ... to the opposite condition of preternatural excitement." (pp. 18-19)

Another half century were to pass before a system of classification emerged that offered differential diagnoses of mental illness without delusions (later known as personality disorders), affective disorders, schizophrenia, and depressive illnesses. Still, the term "moral insanity" was being widely used.

Henry Maudsley applied it in 1885 to a patient whom he described as:

"(Having) no capacity for true moral feeling - all his impulses and desires, to which he yields without check, are egoistic, his conduct appears to be governed by immoral motives, which are cherished and obeyed without any evident desire to resist them." ("Responsibility in Mental Illness", p. 171).

But Maudsley already belonged to a generation of physicians who felt increasingly uncomfortable with the vague and judgmental coinage "moral insanity" and sought to replace it with something a bit more scientific.

Maudsley bitterly criticized the ambiguous term "moral insanity":

"(It is) a form of mental alienation which has so much the look of vice or crime that many people regard it as an unfounded medical invention (p. 170).

In his book "Die Psychopatischen Minderwertigkeiter", published in 1891, the German doctor J. L. A. Koch tried to improve on the situation by suggesting the phrase "psychopathic inferiority". He limited his diagnosis to people who are not retarded or mentally ill but still display a rigid pattern of misconduct and dysfunction throughout their increasingly disordered lives. In later editions, he replaced "inferiority" with "personality" to avoid sounding judgmental. Hence the "psychopathic personality".

Twenty years of controversy later, the diagnosis found its way into the 8th edition of E. Kraepelin's seminal "Lehrbuch der Psychiatrie" ("Clinical Psychiatry: a textbook for students and physicians"). By that time, it merited a whole lengthy chapter in which Kraepelin suggested six additional types of disturbed personalities: excitable, unstable, eccentric, liar, swindler, and quarrelsome.

Still, the focus was on antisocial behavior. If one's conduct caused inconvenience or suffering or even merely annoyed someone or flaunted the norms of society, one was liable to be diagnosed as "psychopathic".

In his influential books, "The Psychopathic Personality" (9th edition, 1950) and "Clinical Psychopathology" (1959), another German psychiatrist, K. Schneider sought to expand the diagnosis to include people who harm and inconvenience themselves as well as others. Patients who are depressed, socially anxious, excessively shy and insecure were all deemed by him to be "psychopaths" (in another word, abnormal).

This broadening of the definition of psychopathy directly challenged the earlier work of Scottish psychiatrist, Sir David Henderson. In 1939, Henderson published "Psychopathic States", a book that was to become an instant classic. In it, he postulated that, though not mentally subnormal, psychopaths are people who:

"(T)hroughout their lives or from a comparatively early age, have exhibited disorders of conduct of an antisocial or asocial nature, usually of a recurrent episodic type which in many instances have proved difficult to influence by methods of social, penal and medical care or for whom we have no adequate provision of a preventative or curative nature."

But Henderson went a lot further than that and transcended the narrow view of psychopathy (the German school) then prevailing throughout Europe.

In his work (1939), Henderson described three types of psychopaths. Aggressive psychopaths were violent, suicidal, and prone to substance abuse. Passive and inadequate psychopaths were over-sensitive, unstable and hypochondriacal. They were also introverts (schizoid) and pathological liars. Creative psychopaths were all dysfunctional people who managed to become famous or infamous.

Twenty years later, in the 1959 Mental Health Act for England and Wales, "psychopathic disorder" was defined thus, in section 4(4):

"(A) persistent disorder or disability of mind (whether or not including subnormality of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the patient, and requires or is susceptible to medical treatment."

This definition reverted to the minimalist and cyclical (tautological) approach: abnormal behavior is that which causes harm, suffering, or discomfort to others. Such behavior is, ipso facto, aggressive or irresponsible. Additionally it failed to tackle and even excluded manifestly abnormal behavior that does not require or is not susceptible to medical treatment.

Thus, "psychopathic personality" came to mean both "abnormal" and "antisocial". This confusion persists to this very day. Scholarly debate still rages between those, such as the Canadian Robert, Hare, who distinguish the psychopath from the patient with mere antisocial personality disorder and those (the orthodoxy) who wish to avoid ambiguity by using only the latter term.

Moreover, these nebulous constructs resulted in co-morbidity. Patients were frequently diagnosed with multiple and largely overlapping personality disorders, traits, and styles. As early as 1950, Schneider wrote:

"Any clinician would be greatly embarrassed if asked to classify into appropriate types the psychopaths (that is abnormal personalities) encountered in any one year."

Today, most practitioners rely on either the Diagnostic and Statistical Manual (DSM), now in its fourth, revised text, edition or on the International Classification of Diseases (ICD), now in its tenth edition.

The two tomes disagree on some issues but, by and large, conform to each other.

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The Brain

Metaphors of the Mind (Part I)

By: Dr. Sam Vaknin

The brain (and, by implication, the mind) have been compared to the latest technological innovation in every generation. The computer metaphor is now in vogue. Computer hardware metaphors were replaced by software metaphors and, lately, by (neuronal) network metaphors.

Metaphors are not confined to the philosophy of neurology. Architects and mathematicians, for instance, have lately come up with the structural concept of "tensegrity" to explain the phenomenon of life. The tendency of humans to see patterns and structures everywhere (even where there are none) is well documented and probably has its survival value.

Another trend is to discount these metaphors as erroneous, irrelevant, deceptive, and misleading. Understanding the mind is a recursive business, rife with self-reference. The entities or processes to which the brain is compared are also "brain-children", the results of "brain-storming", conceived by "minds". What is a computer, a software application, a communications network if not a (material) representation of cerebral events?

A necessary and sufficient connection surely exists between man-made things, tangible and intangible, and human minds. Even a gas pump has a "mind-correlate". It is also conceivable that representations of the "non-human" parts of the Universe exist in our minds, whether a-priori (not deriving from experience) or a-posteriori (dependent upon experience). This "correlation", "emulation", "simulation", "representation" (in short : close connection) between the "excretions", "output", "spin-offs", "products" of the human mind and the human mind itself - is a key to understanding it.

This claim is an instance of a much broader category of claims: that we can learn about the artist by his art, about a creator by his creation, and generally: about the origin by any of the derivatives, inheritors, successors, products and similes thereof.

This general contention is especially strong when the origin and the product share the same nature. If the origin is human (father) and the product is human (child) - there is an enormous amount of data that can be derived from the product and safely applied to the origin. The closer the origin to the product - the more we can learn about the origin from the product.

We have said that knowing the product - we can usually know the origin. The reason is that knowledge about product "collapses" the set of probabilities and increases our knowledge about the origin. Yet, the converse is not always true. The same origin can give rise to many types of entirely unrelated products. There are too many free variables here. The origin exists as a "wave function": a series of potentialities with attached probabilities, the potentials being the logically and physically possible products.

What can we learn about the origin by a crude perusal to the product? Mostly observable structural and functional traits and attributes. We cannot learn a thing about the "true nature" of the origin. We can not know the "true nature" of anything. This is the realm of metaphysics, not of physics.

Take Quantum Mechanics. It provides an astonishingly accurate description of micro-processes and of the Universe without saying much about their "essence". Modern physics strives to provide correct predictions - rather than to expound upon this or that worldview. It describes - it does not explain. Where interpretations are offered (e.g., the Copenhagen interpretation of Quantum Mechanics) they invariably run into philosophical snags. Modern science uses metaphors (e.g., particles and waves). Metaphors have proven to be useful scientific tools in the "thinking scientist's" kit. As these metaphors develop, they trace the developmental phases of the origin.

Consider the software-mind metaphor.

The computer is a "thinking machine" (however limited, simulated, recursive and mechanical). Similarly, the brain is a "thinking machine" (admittedly much more agile, versatile, non-linear, maybe even qualitatively different). Whatever the disparity between the two, they must be related to one another.

This relation is by virtue of two facts: (1) Both the brain and the computer are "thinking machines" and (2) the latter is the product of the former. Thus, the computer metaphor is an unusually tenable and potent one. It is likely to be further enhanced should organic or quantum computers transpire.

At the dawn of computing, software applications were authored serially, in machine language and with strict separation of data (called: "structures") and instruction code (called: "functions" or "procedures"). The machine language reflected the physical wiring of the hardware.

This is akin to the development of the embryonic brain (mind). In the early life of the human embryo, instructions (DNA) are also insulated from data (i.e., from amino acids and other life substances).

In early computing, databases were handled on a "listing" basis ("flat file"), were serial, and had no intrinsic relationship to one another. Early databases constituted a sort of substrate, ready to be acted upon. Only when "intermixed" in the computer (as a software application was run) were functions able to operate on structures.

This phase was followed by the "relational" organization of data (a primitive example of which is the spreadsheet). Data items were related to each other through mathematical formulas. This is the equivalent of the increasing complexity of the wiring of the brain as pregnancy progresses.

The latest evolutionary phase in programming is OOPS (Object Oriented Programming Systems). Objects are modules which encompass both data and instructions in self contained units. The user communicates with the functions performed by these objects - but not with their structure and internal processes.

Programming objects, in other words, are "black boxes" (an engineering term). The programmer is unable to tell how the object does what it does, or how does an external, useful function arise from internal, hidden functions or structures. Objects are epiphenomenal, emergent, phase transient. In short: much closer to reality as described by modern physics.

Though these black boxes communicate - it is not the communication, its speed, or efficacy which determine the overall efficiency of the system. It is the hierarchical and at the same time fuzzy organization of the objects which does the trick. Objects are organized in classes which define their (actualized and potential) properties. The object's behaviour (what it does and what it reacts to) is defined by its membership of a class of objects.

Moreover, objects can be organized in new (sub) classes while inheriting all the definitions and characteristics of the original class in addition to new properties. In a way, these newly emergent classes are the products while the classes they are derived from are the origin. This process so closely resembles natural - and especially biological - phenomena that it lends additional force to the software metaphor.

Thus, classes can be used as building blocks. Their permutations define the set of all soluble problems. It can be proven that Turing Machines are a private instance of a general, much stronger, class theory (a-la Principia Mathematica). The integration of hardware (computer, brain) and software (computer applications, mind) is done through "framework applications" which match the two elements structurally and functionally. The equivalent in the brain is sometimes called by philosophers and psychologists "a-priori categories", or "the collective unconscious".

Computers and their programming evolve. Relational databases cannot be integrated with object oriented ones, for instance. To run Java applets, a "virtual machine" needs to be embedded in the operating system. These phases closely resemble the development of the brain-mind couplet.

When is a metaphor a good metaphor? When it teaches us something new about the origin. It must possess some structural and functional resemblance. But this quantitative and observational facet is not enough. There is also a qualitative one: the metaphor must be instructive, revealing, insightful, aesthetic, and parsimonious - in short, it must constitute a theory and produce falsifiable predictions. A metaphor is also subject to logical and aesthetic rules and to the rigors of the scientific method.

If the software metaphor is correct, the brain must contain the following features:

Parity checks through back propagation of signals. The brain's electrochemical signals must move back (to the origin) and forward, simultaneously, in order to establish a feedback parity loop.

The neuron cannot be a binary (two state) machine (a quantum computer is multi-state). It must have many levels of excitation (i.e., many modes of representation of information). The threshold ("all or nothing" firing) hypothesis must be wrong.

Redundancy must be built into all the aspects and dimensions of the brain and its activities. Redundant hardware -different centers to perform similar tasks. Redundant communications channels with the same information simultaneously transferred across them. Redundant retrieval of data and redundant usage of obtained data (through working, "upper" memory).

The basic concept of the workings of the brain must be the comparison of "representational elements" to "models of the world". Thus, a coherent picture is obtained which yields predictions and allows to manipulate the environment effectively.

Many of the functions tackled by the brain must be recursive. We can expect to find that we can reduce all the activities of the brain to computational, mechanically solvable, recursive functions. The brain can be regarded as a Turing Machine and the dreams of Artificial Intelligence are likely come true.

The brain must be a learning, self organizing, entity. The brain's very hardware must disassemble, reassemble, reorganize, restructure, reroute, reconnect, disconnect, and, in general, alter itself in response to data. In most man-made machines, the data is external to the processing unit. It enters and exits the machine through designated ports but does not affect the machine's structure or functioning. Not so the brain. It reconfigures itself with every bit of data. One can say that a new brain is created every time a single bit of information is processed.

Only if these six cumulative requirements are met - can we say that the software metaphor is useful.

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Metaphors of the Mind (Part II)

Psychology and Psychotherapy

By: Dr. Sam Vaknin

Storytelling has been with us since the days of campfire and besieging wild animals. It served a number of important functions: amelioration of fears, communication of vital information (regarding survival tactics and the characteristics of animals, for instance), the satisfaction of a sense of order (justice), the development of the ability to hypothesize, predict and introduce theories and so on.

We are all endowed with a sense of wonder. The world around us in inexplicable, baffling in its diversity and myriad forms. We experience an urge to organize it, to "explain the wonder away", to order it in order to know what to expect next (predict). These are the essentials of survival. But while we have been successful at imposing our mind's structures on the outside world – we have been much less successful when we tried to cope with our internal universe.

The relationship between the structure and functioning of our (ephemeral) mind, the structure and modes of operation of our (physical) brain and the structure and conduct of the outside world have been the matter of heated debate for millennia. Broadly speaking, there were (and still are) two ways of treating it:

There were those who, for all practical purposes, identified the origin (brain) with its product (mind). Some of them postulated the existence of a lattice of preconceived, born categorical knowledge about the universe – the vessels into which we pour our experience and which mould it. Others have regarded the mind as a black box. While it was possible in principle to know its input and output, it was impossible, again in principle, to understand its internal functioning and management of information. Pavlov coined the word "conditioning", Watson adopted it and invented "behaviourism", Skinner came up with "reinforcement". The school of epiphenomenologists (emergent phenomena) regarded the mind as the by product of the brain's "hardware" and "wiring" complexity. But all ignored the psychophysical question: what IS the mind and HOW is it linked to the brain?

The other camp was more "scientific" and "positivist". It speculated that the mind (whether a physical entity, an epiphenomenon, a non-physical principle of organization, or the result of introspection) – had a structure and a limited set of functions. They argued that a "user's manual" could be composed, replete with engineering and maintenance instructions. The most prominent of these "psychodynamists" was, of course, Freud. Though his disciples (Adler, Horney, the object-relations lot) diverged wildly from his initial theories – they all shared his belief in the need to "scientify" and objectify psychology. Freud – a medical doctor by profession (Neurologist) and Bleuler before him – came with a theory regarding the structure of the mind and its mechanics: (suppressed) energies and (reactive) forces. Flow charts were provided together with a method of analysis, a mathematical physics of the mind.

But this was a mirage. An essential part was missing: the ability to test the hypotheses, which derived from these "theories". They were all very convincing, though, and, surprisingly, had great explanatory power. But - non-verifiable and non-falsifiable as they were – they could not be deemed to possess the redeeming features of a scientific theory.

Deciding between the two camps was and is a crucial matter. Consider the clash - however repressed - between psychiatry and psychology. The former regards "mental disorders" as euphemisms - it acknowledges only the reality of brain dysfunctions (such as biochemical or electric imbalances) and of hereditary factors. The latter (psychology) implicitly assumes that something exists (the "mind", the "psyche") which cannot be reduced to hardware or to wiring diagrams. Talk therapy is aimed at that something and supposedly interacts with it.

But perhaps the distinction is artificial. Perhaps the mind is simply the way we experience our brains. Endowed with the gift (or curse) of introspection, we experience a duality, a split, constantly being both observer and observed. Moreover, talk therapy involves TALKING - which is the transfer of energy from one brain to another through the air. This is directed, specifically formed energy, intended to trigger certain circuits in the recipient brain. It should come as no surprise if it were to be discovered that talk therapy has clear physiological effects upon the brain of the patient (blood volume, electrical activity, discharge and absorption of hormones, etc.).

All this would be doubly true if the mind was, indeed, only an emergent phenomenon of the complex brain - two sides of the same coin.

Psychological theories of the mind are metaphors of the mind. They are fables and myths, narratives, stories, hypotheses, conjunctures. They play (exceedingly) important roles in the psychotherapeutic setting – but not in the laboratory. Their form is artistic, not rigorous, not testable, less structured than theories in the natural sciences. The language used is polyvalent, rich, effusive, and fuzzy – in short, metaphorical. They are suffused with value judgements, preferences, fears, post facto and ad hoc constructions. None of this has methodological, systematic, analytic and predictive merits.

Still, the theories in psychology are powerful instruments, admirable constructs of the mind. As such, they are bound to satisfy some needs. Their very existence proves it.

The attainment of peace of mind is a need, which was neglected by Maslow in his famous rendition. People will sacrifice material wealth and welfare, will forgo temptations, will ignore opportunities, and will put their lives in danger – just to reach this bliss of wholeness and completeness. There is, in other words, a preference of inner equilibrium over homeostasis. It is the fulfilment of this overriding need that psychological theories set out to cater to. In this, they are no different than other collective narratives (myths, for instance).

In some respects, though, there are striking differences:

Psychology is desperately trying to link up to reality and to scientific discipline by employing observation and measurement and by organizing the results and presenting them using the language of mathematics. This does not atone for its primordial sin: that its subject matter is ethereal and inaccessible. Still, it lends an air of credibility and rigorousness to it.

The second difference is that while historical narratives are "blanket" narratives – psychology is "tailored", "customized". A unique narrative is invented for every listener (patient, client) and he is incorporated in it as the main hero (or anti-hero). This flexible "production line" seems to be the result of an age of increasing individualism. True, the "language units" (large chunks of denotates and connotates) are one and the same for every "user". In psychoanalysis, the therapist is likely to always employ the tripartite structure (Id, Ego, Superego). But these are language elements and need not be confused with the plots. Each client, each person, and his own, unique, irreplicable, plot.

To qualify as a "psychological" plot, it must be:

All-inclusive (anamnetic) – It must encompass, integrate and incorporate all the facts known about the protagonist.

Coherent – It must be chronological, structured and causal.

Consistent – Self-consistent (its subplots cannot contradict one another or go against the grain of the main plot) and consistent with the observed phenomena (both those related to the protagonist and those pertaining to the rest of the universe).

Logically compatible – It must not violate the laws of logic both internally (the plot must abide by some internally imposed logic) and externally (the Aristotelian logic which is applicable to the observable world).

Insightful (diagnostic) – It must inspire in the client a sense of awe and astonishment which is the result of seeing something familiar in a new light or the result of seeing a pattern emerging out of a big body of data. The insights must be the logical conclusion of the logic, the language and of the development of the plot.

Aesthetic – The plot must be both plausible and "right", beautiful, not cumbersome, not awkward, not discontinuous, smooth and so on.

Parsimonious – The plot must employ the minimum numbers of assumptions and entities in order to satisfy all the above conditions.

Explanatory – The plot must explain the behaviour of other characters in the plot, the hero's decisions and behaviour, why events developed the way that they did.

Predictive (prognostic) – The plot must possess the ability to predict future events, the future behaviour of the hero and of other meaningful figures and the inner emotional and cognitive dynamics.

Therapeutic – With the power to induce change (whether it is for the better, is a matter of contemporary value judgements and fashions).

Imposing – The plot must be regarded by the client as the preferable organizing principle of his life's events and the torch to guide him in the darkness to come.

Elastic – The plot must possess the intrinsic abilities to self organize, reorganize, give room to emerging order, accommodate new data comfortably, avoid rigidity in its modes of reaction to attacks from within and from without.

In all these respects, a psychological plot is a theory in disguise. Scientific theories should satisfy most of the same conditions. But the equation is flawed. The important elements of testability, verifiability, refutability, falsifiability, and repeatability – are all missing. No experiment could be designed to test the statements within the plot, to establish their truth-value and, thus, to convert them to theorems.

There are four reasons to account for this shortcoming:

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