The International Journal of Psychosocial Rehabilitation
A Critical Look At Current Concepts of Personality Disorders: Moral vs. Medical Aspects
Marcelo Caixeta, M.D.
Psychiatry Service ASMGO Medical Center Goiania, Brazil

 

Reprint: International Journal of Psychopathy, Psychopharmacology and Psychotherapy 1996, 1 (1).


A Critical Look At Current Concepts of Personality Disorders: Moral vs. Medical Aspects
1. DSM IV (APA,1995) states that personality disorders lead to distress or impairment. However, all mental disorders lead to that, as do many "normal" behaviors. For example, a "normal" criminal does things that lead to distress . . . do all criminals have a personality disorder? Someone who goes through a divorce will often have some kind of impairment in his or her psychological equilibrium . . . does such a person have a psychiatric disorder? People who think only about themselves, and do things that totally disregard the interests of others . . . such people are narcissists . . . but if they are considered ill, we are defining illness as something other than a medical concept.

2. The medical concept of disease should defined as involving some self disadvantageous biological process. (Scadding, 1967)

3. Psychiatry is psychological medicine. We could say that for a person to be classified as a "psychiatric patient," they must display the effects of a biological self disadvantageos process upon their thinking, feeling or behavior.

Thus, according to the paragraph above, criminals, people reacting to the stress of divorce, or narcissists should not be seen as "sick" since they are searching for behaviors that could improve their lives.

4. According to this point of view, anti-social people would be considered to have psychiatric problems only when committing self disadvantageous crimes . . . such as attempting a robbery in the presence of the police. Anti-social people who refrain from such self-defeating behaviors should be considered “normal criminals. They should be of concern to the criminal justice system not to physicians and the medical community.

5. While, according to our conceptualization, narcissistic, passive-aggressive and paranoid persons do not have, psychiatric disorders, their personality traits often predispose them to develop true medical diseases. We see in daily clinical practice that narcissists become depressed or aggressive when they do not fulfill their objectives; obsessives become anxious when they lose control over some aspect of their life, and so on. But in these cases the medical problem is not their personality . . . their personality has simply predisposed them to develop the medical entity. This process is paralleled by the predisposition to myocardial infarction that accompanies anxiety. The medical entity is the infarct, and not the individual's anxious personality. The later is not a central concern of Medicine. We obviously can try to modify some such factors, but such factors are not "medical entities". If they were, cardiologists might consider "anxiety" as a cardiological entity.

6. We are not denying that some psychiatric diseases can lead to personality disorders. It is well known that people in a manic episode may shown many kinds of disturbed behavior (similar to behaviors seen in people with personality disorders) such as anti-social behavior and hypersexuality. But, once the biological disorder is gotten under control, their behavioral symptoms disappear. This is quite different from what happens with some of the DSM-IV "personality disorders."

7. Some people with borderline, antisocial, schizoid and obsessive compulsive personality disorders may have a "true" psychiatric disorder. Such people display self disadvantageous behaviors, and they often show a lessening of such behaviors following psychopharmacologic treatment. The anatomical, electrical, and neurochemical markers of their underlying biological disturbances are in the process of being discovered.

8. If mental health professionals do not pay attention to such considerations, we risk confusing medical and moral problems. Such confusion can only have deleterious consequences for both the medical and criminal justice systems.

References

1. American Psychiatric Association. DSM IV. Artes Médicas. Porto Alegre-BR. 1995.

2. Scadding,JG:(1967) Medical Diagnosis. Lancet 2: 877-882.



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