Personality Disorders Are Not Illnesses

by Phil on May 5, 2010

The central theme of this blog is that there are no mental illnesses. The concept of mental illness is a spurious invention of psychiatrists and other mental health professionals for the purpose of medicalizing normal human problems and selling drugs.

The central tenet of the mental health system is that unusual, bizarre, and disturbing behaviors are caused by mental disorders (or illnesses). But their definition of a mental disorder is: a serious behavioral problem. So problem behavior is caused by problem behavior. This is the facile logic behind the widespread peddling of drugs in which psychiatry and the mental health system engage.

Within the mental health system a personality disorder is conceptualized as a specific kind of mental illness and is defined as follows:

“an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” (DSM-IV-TR, p. 685)

DSM lists eleven different kinds of personality disorder. These are: paranoid; schizoid; schizotypal; antisocial; borderline; histrionic; narcissistic; avoidant; dependent; obsessive-compulsive; and of course, personality disorder not otherwise specified.

Let us examine schizoid personality disorder. The APA lists the following criteria:

A. A pervasive pattern of detachment from social relationships and a restricted range of
expression of emotions in interpersonal settings, beginning by early adulthood and
present in a variety of contexts, as indicated by four (or more) of the following:

(1) neither desires nor enjoys close relationships, including being part of a family
(2) almost always chooses solitary activities
(3) has little if any, interest in having sexual experiences with another person
(4) takes pleasure in few, if any, activities
(5) lacks close friends or confidants other than first-degree relatives
(6) appears indifferent to the praise or criticism of others
(7) shows emotional coldness, detachment, or flattened affectivity

B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder
With Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental
Disorder and is not due to the direct physiological effects of a general medical
condition. (DSM-IV-TR, p 697)

It is clear from even a cursory examination of these criteria that what’s involved here are the qualities of solitariness, introspection, and stoicism. Note in particular that the criteria do not require that the individual be troubled by these qualities. Even if a person is perfectly contented with his habitual state of quiet isolation, he nevertheless has a mental illness and swells the ranks of the “untreated sufferers.” The so-called schizoid personality disorder is one of the more blatant examples of the APA’s pathologizing of normal human differences. Even their selection of the word “schizoid” serves to impart connotations of danger and hidden pathology.

The fact is that each of the criterion qualities listed above is present in the human population to a varied degree. And it is indeed the case that some individuals are introspective and isolative to an extreme degree. Assuming, however, that this necessarily constitutes a problem is unwarranted and dangerous. Most of the introspective individuals I have known are contented productive people who would be truly appalled to learn that in reality they are suffering from a mental illness and that they need treatment (i.e. drugs). The drugs, of course, will be prescribed by a psychiatrist and manufactured by a pharmaceutical company. It is little wonder that a former surgeon general could state that one fifth of the US population is suffering from a mental disorder in any given year. As has been stressed many times in this blog, the primary purpose of DSM is not to advance our knowledge of ourselves as a species, or help us become more resilient and adaptive, but rather to generate income for psychiatrists and pharmaceutical companies.

The reader who is not particularly isolative or introspective might be thinking “Oh, well – but it doesn’t apply to me.” Read on.

Here are the DSM criteria for dependent personality disorder:

A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
(1) has difficulty making everyday decisions without an excessive amount of advice and reassurance from others
(2) needs others to assume responsibility for most major areas of his or her life
(3) has difficulty expressing disagreement with others because of fear of loss of support or approval. Note: Do not include realistic fears of retribution.
(4) has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy)
(5) goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant
(6) feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself
(7) urgently seeks another relationship as a source of care and support when a close relationship ends
(8) is unrealistically preoccupied with fears of being left to take care of himself or herself

Two generations ago probably half the women in our culture would have met these criteria. (Note that only five of the items have to be met.) Even today a substantial percentage of the women in our society are raised to think of themselves as essentially dependent and as having little or no personal identity until they have become “hitched” to a man. By calling this a mental disorder, the APA is pathologizing what for many individuals is a normal state. It is also critical to note that the only reason that this particular lifestyle is a mental disorder is that the APA say so. The APA attempts to promote the idea that their so-called diagnoses are based on science. This is simply not the case, and is certainly not true of the so-called personality disorders. The APA and its various committees have simply decided that certain lifestyles and mindsets are to be considered pathological. They pretend that this reflects some kind of reality, i.e. that in fact these individuals are truly damaged in some way. But in fact the determination that certain mindsets constitute disorders while others do not is entirely arbitrary.

Why, for instance, is there not an independent personality disorder? After all, if people who are extremely dependent are to be considered pathologized, why not the individuals at the other end of the continuum? Individuals who never ask for help; who conceptualize asking for help as shameful; who are driven to succeed by their own efforts; who never see themselves as part of a team, etc., etc.. One could easily draft eight or ten criteria, arbitrarily require that 3 or 4 or 5 of these be met, and voila! A new diagnosis. Frighteningly, there are probably individuals within the APA who would take this suggestion seriously. The APA’s objective is to pathologize as much normal behavior as possible, and this has been demonstrated clearly by each successive revision of the DSM.

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  • Andras Gregorik

    Hi Philip,
    this post is a true eye opener!
    You speak the heart of many of us. The DSM is long considered such an authority that few dare to question its criteria. Yet in reality, it’s an arrogant, narrow-minded and judgmental excuse for a manual. To put it bluntly, it’s some of the DSM authors that should be probably pathologized.
    Cheers!

  • http://behaviorismandmentalhealth.com Phil

    Andras,

    Thanks for the comment and for the kind words. The DSM treatment of personality is indeed facile nonsense.

    Best wishes.

  • Alfy

    There are no recommended drugs to treat personality disorders. If a clients come to treatment they have “pathologized” themselves. I prefer to say that they feel they have a problem; then that is specified. But I agree that these diagnoses should not be used to categorize people just to standardize the

  • Alfy

    There are no recommended drugs to treat personality disorders. If a clients come to treatment they have “pathologized” themselves. I prefer to say that they feel they have a problem; then that is specified. But I agree that these diagnoses should not be used to categorize people just to standardize the psychological presentation of clients, especially among mental health professionals in case of referral or consultation. That’s what is taught to trainee therapists and that’s how these conceptualizations should be used. That is also the problem with misunderstanding the work of trained professionals. Psychology is funny because people think they know people better than experts. No ever says that they can build a bridge better than an engineer.

  • Andras Gregorik

    “I prefer to say that they feel they have a problem”

    Even if they do, it’s clear that it’s basically a cultural problem that they are having: they do not feel up to current sociocultural expectations, which can actually be a good thing; psychiatrists will never agree on this, but most theologians, philosophers and sociologists would agree that Western culture is “ill”, corrupted, shallow, whatever. A “personality disorder” within the framework of this culture may well indicate a valid (if primitive) criticism of this culture, along with a subconscious wish to get out of it. At this point, psychiatry adds insult to injury by pathologizing this valid criticism by the “patient”.

  • http://behaviorismandmentalhealth.com Phil

    Alfy,

    Thanks for coming in. You make some interesting points. Of course you are correct in that some clients do indeed “pathologize themselves.” However, I think that the direction of therapy should be encouraging people not to do this, rather than crystallizing the process with a so-called diagnosis.

    Best wishes.

  • http://behaviorismandmentalhealth.com Phil

    Andras,

    Thanks for coming in.

    This is a very good point about incongruence with cultural expectations, and in a more general sense is a problem with all the DSM “diagnoses,” not just the personality disorders.

    Take oppositional defiance disorder, for example. This problem is almost always more a matter of parenting behavior than anything intrinsic to the child. But the APA insists on labeling the child as mentally ill and in need of “treatment” (i.e. drugs). The real problem is never addressed.

    Best wishes.

  • Andras Gregorik

    Phil,
    thanks. ODD is a good example, and so is schizoid PD, which is simply not a “disorder” but a peculiar way of experiencing life that used to be well accepted for centuries: take mystics, monks, nuns, hermits, poets, novelists and so forth. Many of these so-called “schizoids” were among the greatest minds of their generation (Beethoven, Michelangelo, Emily Dickinson etc.).

    Enter the APA and suddenly these gifted artists are “in need of medication”. The APA tolerates nothing else but herd mentality and colorless cultural conformism.

  • http://behaviorismandmentalhealth.com Phil

    Andras,

    Thanks for coming back. Karl Marx once wrote: “The ideas of the ruling class are in every epoch the ruling ideas.” Pharmaceutical companies with their enormous wealth are a part of the ruling class. The APA are willing pawns whose self-interest happens to coincide with that of the pharmaceutical companies. Individual psychiatrists follow like sheep in the wake of easy money.

    The problem, of course, is that people like to take drugs, and even more tragically, like to feed drugs to their children. It makes for an easy life.

    I agree that schizoid personality disorder is a particularly noxious piece of medical stigmatizing. It is noteworthy that the criteria do not require that the individual is experiencing any distress. He is simply a loner – someone who prefers to be alone, do things alone, etc..

    There is literally no behavior or collection of behaviors that the APA is not willing to target for the sake of business.

    Best wishes

  • Andras Gregorik

    Phil,
    again, very insightful. We can add to this the fact that the ruling ideas (of the ruling class) constitute a “a social setting with a given set of expectations” (to quote Erving Goffman), with built-in stigmatization of those unwilling or incapable of fulfilling these expectations.

    In the APA’s case this is further aggravated by the apparent financial aspect, i.e. that they wish to profit from their stigmatizating process.

    I don’t know what else conscientious psychologists/psychiatrists can do other than completely ignore the APA’s directives and help their patients realize that they are dealing with a cultural stigma that requires a “holistic” approach; meaning that once the “patient” gains a certain degree of psychological, sociological and philosophical knowledge, their perspective grows to a point where they no longer view themselves through the skewed lens of their given society, resulting in their stopping of being “sufferers of personality disorders” and becoming sovereign, uncontrolled human beings.

  • http://behaviorismandmentalhealth.com Phil

    Andras,

    Thanks for coming back.

    I agree that social expectation is an important concept. All of the behaviors listed as “symptoms” in DSM are behaviors that are unusual or disturbing to others, i.e. outside expectations.

    Ignoring APA’s system is, of course, the right thing to do. However, here in the U.S. at least, this is very difficult, as third party payers won’t reimburse without a billable “diagnosis.” And economics makes cowards of us all. I have heard of psychologists who simply say to the client: “I will help you work on whatever it is you want to work on. You will have to pay me directly, as I don’t get involved with third party billing, and I don’t use the DSM system.” The problem is that people who see psychologists aren’t usually awash with cash, so it’s hard for psychologists who work outside the system to make a living.

    With regards to psychiatrists – I have never met one who had even the slightest qualms about the DSM. I believe that medical training stresses acceptance of status quo doctrine from the “great men.” Psychology training, in contrast, traditionally stresses questioning and challenging, but in recent decades courses in DSM have become standard fare in psychology degrees. In fact, many (30 or 40%) of the questions on the psychology licensing exam are based on DSM! It’s a bit like learning how to identify a witch.

    You mention the acquisition of knowledge on the client’s part, and to this I would add what would commonly be called skills. I realize that the two terms overlap considerably, but both need to be emphasized. For instance, over-eating and consequent obesity are problems that beset large numbers of people. Now, one can know that over-eating is a counterproductive behavior, but until one has acquired the skill of eating appropriately-sized portions, and the habit of moving around more, the problem will persist. And it is these kinds of problems that, in my view, cumulatively undermine the personal sovereignty which you mention. I don’t think the mental health system, at least here in the U.S., does much to promote personal autonomy. The emphasis is on: do what you’re told, eat your pills, and come back in three months.

    Anyway, thanks for coming back. These are deep issues. Best wishes.

  • http://twitter.com/Bamftiger Bamftiger

    A psychologist is an Arts graduate, ie an Arts student who successfully graduates. To suggest people with the level of intellect required to enter into an Arts degree are capable of rising to the level of true expertise is beyond bizarre.

    Psychiatry at least has the rigour of medical training behind it, and that in itself bears other problems not the least of which is the catastrophic lack of affect so many “practitioners” of the medical profession manifest.

    In short, there is a reason why so many people are turning to magical thinking and outright shamanism- it does no more harm and enjoys no less success than psychology (Arts degree) or psychiatry (professional but of questionable origin).

  • Anonymous

    Bamftiger,

    Thanks for your interesting comment to Alfy. I’m sure you are correct. We psychologists are probably not as bright as we should be.

  • George

    It is not just a peculiar way of experiencing reality, it  is a real disorder because their distorted view of reality is not consistent with reality itself. I can attest it is a real disorder from personal experience because i had it. DSM criteria does not describe “qualities”, of stoicism, solitude, and introspection but an individulals who is dysfuctional, imature, and completely isolated from reality and external world. Also, cognitive disorganization is not a prerequisite for diagnosis of SPD in DSM criteria, so one can be highly intelligent and schizoid at same time. Also did you consider the possibility that some that mystics, monks, hermits, poets, novelists actually were Schizoid because not many people can  tolerate complete isolation, but many of them became isolated they are capable of doing just that. There are several ways for people to cope with isolation; sensory distortion, cognitive distortion, and obsession with fantasy. Isolated individuals who have high capacity for imagination do not develop formal thought disorder because their rich fantasy prevents from distorting their cognition.  Schizoid as described may be creative and intelligent but they have no social life and are detached from reality and as such they are dysfuctional. I also had Dependent personality disorder, analogy with women is just a Straw man fallacy because despite cultural expectations most women are capable of taking care of themselves. And in familial setting women are only partially dependent on man, while women who have DPD are incapable of performing traditional gender roles such as cooking, cleaning sewing, etc. And for anyone who believes that mental disorders do not exist, I would strongly suggest you to take visit to psychiatric hospital.

  • George

     Since schizoid spend a lot of time fantasizing they have highly developed imagination, this would explain why some historical schizoids were creative geniuses. But developed imagination is all they have, in other areas of life they are dysfunctional.

  • Anonymous

    George,

    Thanks for an interesting comment.  I’m not sure if Andras will be responding to you, but here are my thoughts on the matter.

    Nobody is disputing that the behaviors listed in the DSM categories exist.  Of course they exist, in that people do, in fact, sometimes behave in these fashions.  The issue is whether these behaviors (or clusters of behaviors) can legitimately be considered illnesses.  That’s the fundamental issue in this blog.  My contention is that the so-called diagnoses listed in DSM are not illnesses, but are simply ordinary problems of living.  Furthermore, it is my contention that shoe-horning these behavioral problems into an illness model is counterproductive, and much of the so-called treatment provided by the mental health system does more harm than good.

    With specific regard to the so-called personality disorders, there is an additional issue, in that many of the behaviors listed are not actually problems for the individuals concerned.  Now I’m not saying that none of these behaviors are problems – some are, some are not.  The example mentioned was schizoid personality disorder, which is a complicated pseudo-medical way of saying “loner.”  Now I have come across loners who were perfectly content to be loners.  Pathologizing these people by called them schizoid personality disorders is, in my view, destructive and unhelpful.

    The fact is that each individual is different to begin with, and then each of us grows and develops in a unique environment.  As we mature, some behaviors are routinely reinforced more than others, and these behaviors tend to become habitual.   In general loners are people for whom social contact was not strongly reinforced during their formative years.  That’s basically it!  It’s not an illness or a disease – it’s just a question of what learning experiences people have been exposed to.

    As I’m sure you realize, the only ‘treatment” offered by psychiatrists today is drugs.  A learning theory approach, by contrast, provides a great deal of real help for people who – for whatever reason – want to change a deep-rooted habit.  A loner, for instance, who wants to become more outgoing, needs to take steps to ensure that his social encounters are reinforced (artificially if necessary) until they become self-reinforcing.

    The other criticism I make of the illness theory is that although it purports to be an explanation of the behavior in question, in fact is has no explanatory value.  To say that a person has schizoid personality disorder is no more informative than saying he is a loner.  It is simply another example of psychiatric turf expansion, the primary result of which is the pushing of drugs towards another segment of the population.

    You suggest a visit to a psychiatric hospital.  Well, of course I have visited many psychiatric hospitals, and what I have seen there is not inspiring.  Indeed, it is because of my conviction that psychiatry is doing so much damage to people in and out of hospitals that I started writing this blog in the first place.George, it is clear from your comment that you have a great deal to say in this area.  I hope you will come back.  Also, if you would like to tell your story in more detail, you can do so at the tab above labeled “Tell Your Story.”Best wishes.

  • Anonymous

    George,

    Thanks for coming back.  I can’t agree that “developed imagination is all they have.”  Human existence is always more complicated than that.

    Dysfunctional is a value-laden word.  A person may seem “dysfunctional” to others yet be perfectly happy in himself.  We tend to use the word “dysfunctional” to stigmatize things that we don’t like in others.  I guess I would limit the word to behaviors that are truly injurious to self or others.  In the mental health system, of course, the word is used much more freely.

  • Anonymous

    George,

    Thanks for an interesting comment.  I’m not sure if Andras will be responding to you, but here are my thoughts on the matter.

    Nobody is disputing that the behaviors listed in the DSM categories exist.  Of course they exist, in that people do, in fact, sometimes behave in these fashions.  The issue is whether these behaviors (or clusters of behaviors) can legitimately be considered illnesses.  That’s the fundamental issue in this blog.  My contention is that the so-called diagnoses listed in DSM are not illnesses, but are simply ordinary problems of living.  Furthermore, it is my contention that shoe-horning these behavioral problems into an illness model is counterproductive, and much of the so-called treatment provided by the mental health system does more harm than good.

    With specific regard to the so-called personality disorders, there is an additional issue, in that many of the behaviors listed are not actually problems for the individuals concerned.  Now I’m not saying that none of these behaviors are problems – some are, some are not.  The example mentioned was schizoid personality disorder, which is a complicated pseudo-medical way of saying “loner.”  Now I have come across loners who were perfectly content to be loners.  Pathologizing these people by called them schizoid personality disorders is, in my view, destructive and unhelpful.

    The fact is that each individual is different to begin with, and then each of us grows and develops in a unique environment.  As we mature, some behaviors are routinely reinforced more than others, and these behaviors tend to become habitual.   In general loners are people for whom social contact was not strongly reinforced during their formative years.  That’s basically it!  It’s not an illness or a disease – it’s just a question of what learning experiences people have been exposed to.

    As I’m sure you realize, the only ‘treatment” offered by psychiatrists today is drugs.  A learning theory approach, by contrast, provides a great deal of real help for people who – for whatever reason – want to change a deep-rooted habit.  A loner, for instance, who wants to become more outgoing, needs to take steps to ensure that his social encounters are reinforced (artificially if necessary) until they become self-reinforcing.

    The other criticism I make of the illness theory is that although it purports to be an explanation of the behavior in question, in fact is has no explanatory value.  To say that a person has schizoid personality disorder is no more informative than saying he is a loner.  It is simply another example of psychiatric turf expansion, the primary result of which is the pushing of drugs towards another segment of the population.

    You suggest a visit to a psychiatric hospital.  Well, of course I have visited many psychiatric hospitals, and what I have seen there is not inspiring.  Indeed, it is because of my conviction that psychiatry is doing so much damage to people in and out of hospitals that I started writing this blog in the first place.George, it is clear from your comment that you have a great deal to say in this area.  I hope you will come back.  Also, if you would like to tell your story in more detail, you can do so at the tab above labeled “Tell Your Story.”

    Best wishes.

  • mike

    Maybe we should go back to the old Greek Tragedy: human behaviors that cause the character to have an unhappy ending (not to be confused with the English Tragedy which just indicates that the main character dies).

    Where the behavior is tied into the character’s unhappy ending as opposed to simply being difficult behavior for the parents.

  • Phil_Hickey

    Mike,

     

    Interesting thought.  There
    is also a Greek flavor to the perennial struggle between parent and child:
    child fighting to retain his self-centered, hedonistic qualities; parent trying
    to instill qualities like altruism, gratification delay, etc..  What’s particularly interesting is that if
    the child wins the battle, he loses the war.

     

    Thanks for coming in..

     

     

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