Before analysing, before classifying, before thinking, before trying to do anything—we should listen. Categories and classifications play a large role in the institutions of mental health care for veterans, in the education of mental health care professionals, and as tentative guides to perception. All too often, however, our mode of listening deteriorates into intellectual sorting, with the professional grabbing the veterans’ words from the air and sticking them in mental bins … At its worst our educational system produces counselors, psychiatrists, psychologists, and therapists who resemble museum-goers whose whole experience consists of mentally saying “That’s cubist! … That’s El Greco!” and who never see anything they’ve looked at.
—Jonathan Shay, Achilles in Vietnam: Combat Trauma and the Undoing of Character
Happily, psychiatric “treatment” of gay people or unmarried mothers is almost entirely a thing of the past. But even now the frontiers of psychiatric disorder are as fluid and disputed as those of eighteenth-century Poland. Notable attempts to map the boundaries are the two overlapping major systems of classification: The Diagnostic and Statistical Manual of Mental Disorders (DSM), now in its fifth edition (DSM-5), and the relevant section of the International Classification of Diseases (ICD). Among the most controversial psychiatric diagnoses are the “personality disorders” and some deviant sexual tastes or orientations, known as the “paraphilias.”
What are the “personality disorders”? Lists vary, but both DSM-5 and ICD-10 include borderline personality disorder, obsessive-compulsive (or “anankastic”) personality disorder, schizotypal (or schizoid) personality disorder, and antisocial (or dissocial) personality disorder.
How is “personality disorder” defined? ICD-10 gives a number of criteria. “The individual’s characteristic and enduring patterns of behaviour deviate markedly as a whole from the culturally expected range,” as seen in their thinking, emotions, their control of impulses or their relations with other people. Their behaviour in different situations must be “inflexible, maladaptive, or otherwise dysfunctional.” There must be personal distress or “adverse impact on the social environment.”
This must be too broad. “Deviating markedly from the culturally expected range” at different times would have caught in its net dissidents in the Soviet Union or the Chinese Cultural Revolution, atheists in Saudi Arabia, and communists in 1950s America. Gays in the past (and in some of the more stifling societies now) would also be caught. In “the culturally expected range” we again glimpse William Blake’s “mind-forged manacles.”
“Inflexible, maladaptive, or otherwise dysfunctional” does not do much better. The word “maladaptive” sounds scientific, perhaps like an idea derived from Darwinian survival. But like “dysfunctional” it also has a worrying suggestion of not fitting well with prevailing social norms. “Maladaptive,” even in the more literal Darwinian sense of not being conducive to survival in a particular environment, may still include too much. Bravery in a firefighter may reduce the firefighter’s chances of survival. And Socrates held rather rigidly to the habit of asking questions that troubled people, a habit that eventually led to his death.
Definitions that include far too much may reflect on psychiatrists’ philosophical skills rather than their diagnostic ones. Some of them say, “The definition may be no good, but you recognize it when you see it.” There do seem to be people—not firefighters or Socrates—who seem messed up in ways that damage their relationships and their lives.
An anonymous person diagnosed with borderline personality disorder wrote: “Being a borderline feels like eternal hell. Nothing less. Pain, anger, confusion, hurt, never knowing how I’m gonna feel from one minute to the next. Hurting because I hurt those who I love. Feeling misunderstood. Analyzing everything. Nothing gives me pleasure. Once in a great while I will be ‘too happy’ and then anxious because of that. Then I self-medicate with alcohol. Then I physically hurt myself. Then I feel guilty because of that. Shame. Wanting to die but not being able to kill myself because I’d feel too much guilt for those I’d hurt, and then feeling angry about that so I cut myself or O.D. to make all the feelings go away. Stress!”1
Someone who feels like this does need help. The most urgent difficulties are practical. Are there effective ways to help? But behind the practical ones are theoretical issues, perhaps linked to helping people in future. If this a disorder, what makes it so? What kind of disorder is it, and how should we understand it?
Objections to the general definition of “personality disorder” are too easy. The substance is in the particular types. Is each of them a clear and unified condition? Leaving aside antisocial personality disorder, here are some of the key features given in the DSM-5 accounts of three major categories:
Borderline personality disorder includes:
Instability of self-image (often poor, with excessive self-criticism), of goals, values, or career plans, and of mood (with anxiety, depression, or feelings of emptiness);
hostility, limited empathy, with hypersensitivity to possible slights;
unstable personal relationships, marked by mistrust, neediness, alternating between extremes of idealization and devaluation, and between overinvolvement and withdrawal, anxiety about abandonment;
impulsiveness and taking risks.
Obsessive-compulsive personality disorder includes:
Sense of self derived mainly from work, constricted experience;
perfectionism, rigid and unreasonably high standards of behavior; obsession with detail, organization, and order;
thinking there is only one right way of doing things;
persistence at tasks when this is no longer effective.
Schizotypal personality disorder includes:
Confused boundaries between self and others, distorted self-concept;
Unrealistic or incoherent goals;
Difficulty in understanding the impact of own behavior on others, misinterpreting what others do;
Suspicious, mistrustful, and poor at developing close relationships;
Eccentric behavior, appearance, thought, or speech;
Unusual beliefs or experiences;
Withdrawal, coldness, limited emotional responses.
Lists of personality disorders invite an obvious party game, seeing which categories we and our friends fit. There is the risk of diagnosing personality disorders for what are simply unappealing personalities. Some of this looks very subjective. The person diagnosed with obsessive-compulsive personality disorder because of being perfectionist, rigid, obsessed with detail and order, with unreasonably high standards of behavior might reply that the psychiatrist who diagnosed her is slapdash, chaotic, and morally unprincipled. The person diagnosed with borderline personality partly on the basis of impulsiveness and risk-taking may see his psychiatrist as someone who has never been young or in love, and who probably started thinking about a pension at the age of 22.
Two different models lurk behind the diagnosis of personality disorder. One is based on the thought that some personalities dispose people to particular psychiatric illnesses: so “schizotypal personality disorder” is seen as incipient schizophrenia. The other model is based on dimensions of personality, with personality disorder being at an extreme of a continuum.
Each model has its difficulties. The incipient schizophrenia of one model has troubling echoes of the “latent” schizophrenia of Soviet psychiatry. The link between the personality disorder and the illness is unclear. On the other model, it is hard to see why a personality should count as disordered merely because it is at the extreme of some dimension. Why should extreme perfectionism or extreme solitariness count as symptoms of disorder while extreme honesty or extreme interest in mathematics do not? The choice of dimensions has a hint of “deviation from the culturally expected range.” And what are unusual beliefs doing in this list of pathology?
Trying to think in terms of the current conceptual framework of personality disorder and its varieties is like walking over a bridge made of chewing gum. And yet, “Being a borderline feels like eternal hell. Nothing less.” The anonymous writer does need help and so do many like her. Effective help may depend on looking through the “borderline” category, to see more clearly what is going on in the person behind it.
The “paraphilias” are minority sexual tastes. To merit this diagnosis, certain kinds of intense sexual fantasies, urges, or behavior have to recur for at least six months. According to DSM-5, diagnosis is appropriate only where the urges have been acted on, or where they cause significant distress or impairment in important areas of the individual’s functioning. Perhaps most people sometimes act on intense sexual fantasies and urges, and for quite a few people this causes problems in their lives. It is the kind of desire or act that leads to the diagnosis. Each “paraphilia” is specified by what triggers arousal:
Exhibitionistic disorder: the exposure of one’s genitals to an unsuspecting stranger
Fetishistic disorder: the sexual use of nonliving objects or nongenital bodily parts
Frotteuristic disorder: touching or rubbing against a nonconsenting person
Pedophilic disorder: sexual desire for prepubescent or early pubescent children
Sexual masochism disorder: a desire for being humiliated, beaten, bound, or otherwise made to suffer
Sexual sadism disorder: a desire to cause the physical or psychological suffering of another person
Transvestic disorder: cross-dressing
Voyeuristic disorder: seeking sexual gratification from clandestinely observing another person who is naked, in the process of disrobing or engaging in sexual activity
Unspecified paraphilic disorder: erotic interest in activities including telephone scatalogia (obscene phone calls), necrophilia (corpses), zoophilia (animals), coprophilia (feces), klismaphilia (enemas), and urophilia (urine)
This extraordinary ragbag needs sorting out. Two lists are needed. One is of the conditions that, when acted on, invade or harm other people. The other contains the harmless, noninvasive ones.
The first list obviously includes pedophilia. Protecting children at risk of harm justifies making it illegal to act on these inclinations. (It is essential that the inclinations are contained. If nothing better can be found, then, sadly, by coercive means. But this doesn’t mean stigmatizing, hating, or despising people for having the inclinations, which is probably outside their control.)
There are grounds for a legal ban where acting on some of the other conditions would be invasive of a person’s private space and might cause pain, shock, or distress. People should be protected from nonconsenting exposure to sexual sadism, exhibitionism, frotteurism, voyeurism, and obscene phone calls. Dying people need protection from the perhaps remote risk of nonconsenting necrophilia.
The key is consent or its lack. For some of these activities, such as pedophilia and zoophilia, competent consent is out of the question. And for some others it is ruled out by definition: frotteurism is defined as needing a nonconsenting person, and exhibitionism and voyeurism need the “unsuspecting” person. For yet others, competent consent must be a very remote possibility. Who would sign the consent form to receive obscene phone calls or the advance directive for necrophilia? But for other conditions, it is important to keep the consent loophole open, because they can be competently consented to, as when masochists consent to sadistic acts.
The second list, of the harmless, noninvasive conditions, should include fetishism, sexual masochism, and transvestism. Of course any of these can involve harm to others. The large transvestite may ruin his girlfriend’s clothes. But this is like the man whose obsession with stamp collecting leads to neglect of his family. The harm is contingent, not intrinsic to the activity. Perhaps, as once with homosexuality, the boundaries of psychiatry are being deformed by stigma and prejudice?
Whether or not people with conditions on either list should be candidates for psychiatric treatment (assuming, debatably, that effective psychiatric help is possible) depends on one of two reasons applying to their case.
One reason applies to conditions on the first list. The need to prevent harm to others might be argued to justify psychiatric treatment. If an effective treatment were available, there would be a case for requiring some people convicted of acts of pedophilia to accept it. I hope this case would be overridden by powerful opposing medical ethics and civil liberties arguments for the right of a competent person to refuse treatment. But prevention of harm to others could justify at least offering treatment.
The second reason could apply to conditions on either list. Some people, after serious consideration, might think their sexual preference constituted a disadvantage they would like to be rid of. Any legal or social penalties might be part of the disadvantage, although the wider social impact of further stigmatizing an otherwise harmless condition would be relevant here.
Where neither reason applies, there is no basis for psychiatric treatment. The idea that these conditions are in themselves disorders may come partly from a sloppy extrapolation from the fact that in some other cases the reasons do apply. Neither this blurred thinking, nor the kind of disgust once common as a response to homosexuality, has any standing as a reason for medicalizing these sexual tastes.
For sexual preferences not involving invasive or harmful acts with nonconsenting others, the approach should be very different from the stony-faced listing of “paraphilias.” Sharon Olds caught the guiding spirit with humanity and humor in her poem “The Solution,” which is about people saying what they want and then being paired up:
You would stand under a sign saying I Like To Be Touched And Held and when someone came and stood under the sign saying I Like To Touch And Hold they would send the two of you off together.
At first it went great. A steady stream of people under the sign I Like To Give Pain paired up with the steady stream of people from under I Like To Receive Pain. Foreplay only—No Orgasm found its adherents, and Orgasm only—No Foreplay matched up its believers. A loyal Berkeley, California policeman stood under the sign Married Adults, Lights Out, Face To Face, Under A Sheet because that’s the only way it was legal in Berkeley—but he stood there a long time in his lonely blue law coat. And the man under I Like To Be Sung to While Bread Is Kneaded on My Stomach had been there weeks without a reply.
From Sharon Olds, “The Solution.”2
(Part of the Berkeley policeman’s job was investigating obscene phone calls. Now he’s retrained as a psychiatrist and calls them “telephone scatalogia.” He enjoys his new work writing the DSM section on paraphilias.)