MAD, SAD OR BAD?
Professor Glenn Wilson, Gresham College, London
NAMED AND SHAMED
Last week a celebrity chef
was caught shop-lifting from
Tesco's.
He cited overwork, stress and
child abuse but still baffled
by his motives and
announced that he would
enter therapy immediately.
Was he slightly sad, slightly
mad, or slightly bad? Perhaps
a bit of each?
JUST A NAUGHTY BOY?
Drug companies encourage
diagnostic labels so that drugs
can be sold to address the
illness. ADHD is diagnosed in
around 20% of US schoolboys
and prescriptions for Ritalin
are skyrocketing.
Parents in the UK may receive
disability allowance
contingent on the diagnosis.
Diet, lack of exercise, late
nights, fast-moving images on
TV and computer games may
be real causes of
distractibility.
WOMEN AND DEPRESSION
Twice as many women
as men are diagnosed as
depressed and rates are
increasing. In previous
decades large amounts of
Valium were prescribed
for “anxiety”. Prozac
seems to have taken over
as “mother’s little
helper”. Are women
really under greater
stress or is drug
marketing contributing?
SEXUAL DYSFUNCTION
Many “sexual disorders” would
in the past have been regarded
as normal variations. The
“medical” take opens the door
to marketing of drugs (e.g.,
testosterone therapy) and
surgical procedures (e.g., radio
frequency nerve ablation of
pleasure signals).
SOME NEW DISORDERS
Suggested new disorders for the DSM-5:
Absexuality – exaggerated concern with
stamping out obscenity.
Hypersexuality – excessive libido.
Hebephilia – attraction to adolescents
Coercive paraphilic disorder – forcing
people into sexual acts they find
distasteful.
Cognitive tempo disorder – laziness.
Negativistic personality disorder –
whinging.
Nicotine use disorder – smoking.
Intermittent explosive disorder –
tantrums.
HOMOSEXUALITY IN THE DSM
Classification of homosexuality in the DSM
has followed changing social views:
1953 DSM-1 Sociopathic personality
disturbance (SPD)
1973 DSM-2 Sexual orientation disturbance
(SOD)
1980 DSM-3 Egodystonic homosexuality
(EDH)
1987 DSM-3R Sexual disorder not
otherwise specified (“persistent marked
distress about one’s sexual
orientation”).
2013 DSM-5 Homophobia?
PERSONALITY DISORDERS
DSM-4
ICD-10
Paranoid
}Odd-eccentric
Paranoid
Schizoid
}
Schizoid
Schizotypal
}
Antisocial
}Dramatic-erratic
Dyssocial
Borderline
}
Impulsive/Borderline
Histrionic
}
Histrionic
Narcissistic
)
Avoidant
)Anxious-fearful
Anxious
Dependent
}
Dependent
Obsessive-compulsive}
Anankastic
PROBLEMS WITH PD CATEGORIES





Determined by consensus/committee rather
than psychometric logic.
Reliability of diagnosis is poor and there is
much “co-morbidity” (overlap) among
them.
Continuity between normal and abnormal
personality is not recognised.
Diagnosis incorporates theories of aetiology
(exclusions for stress, brain damage,
drugs, neurosis & psychosis).
Labels may be insulting and stigmatising.
BORDERLINE PERSONALITY
An especially vague
category, referring to a grabbag of symptoms including
black & white thinking,
unstable mood and
relationships, self-image and
identity problems and
tendency to selfharm/suicide.
Unclear that that these traits
cohere meaningfully or what
border is between (neurosis
and psychosis?)
MULTIPLE PERSONALTY?
Multiple personality acquired great
popularity with with publication of
The Three Faces of Eve (1957) and
Sybil (1973), who sported 16
personalities.
Now called Dissociative Identity
Disorder - classed as a “neurosis”
rather than PD.
A rare condition (mostly female,
mostly American). Sometimes
coerced by therapists (c.f., false
memory syndrome)?
Kenneth Bianchi (The Hillside
Strangler) tried to fake it to prove his
insanity.
THE CASE OF DAVID ICKE
Difficulties of psychiatric
diagnosis are illustrated by the
case of David Icke. Claiming
that the world is ruled by alien,
shape-shifting lizards, Icke is
handsome, intelligent, articulate,
rich and attractive to women. Is
he delusional (mad) or a conman
(bad)? Certainly, he is not sad –
he is a functional and highly
successful writer and public
speaker.
PSYCHOPATHY
A term often used to describe
people in the erratic-dramatic
groups of PD (especially antisocial and narcissistic).
Indexed by the Psychopathy
Checklist of Robert Hare.
Psychopaths have a disregard
for the law and the rights of
others, are grandiose and
lacking in empathy or
remorse. They may also be
glib, charming and intelligent
(like Ted Bundy, The Campus
Killer).
THE PSYCHOPATHIC BOSS
According to Babiak & Hare
(2006) around 4% of bosses are
clinical psychopaths (compared
with 1% of the general population).
They are attracted to the high-risk/
high-gain culture of the corporate
world and rise up the ladder with
charm and cunning. Their
arrogance and grandiosity seem
like leadership but they are poor
team players and might have
become serial killers were they not
protected by positive experiences
or high IQ.
MAD OR BAD? DOES IT MATTER?
When psychopaths commit crimes
who should take responsibility,
medical or penal authorities?
It should make little difference
since dangerous people need
containment anyway.
We are confused about what
prison is for – punishment,
retribution, deterrence,
rehabilitation or protection of the
public? Only the latter is a good
reason for incarcerating people.
BRAIN AND PERSONALITY
To say that personality disorders
are not diseases like measles is not
to deny a physiological basis.
There is abundant evidence that
genetics and brain damage
contribute, as well as
environmental stresses.
“Responsibility” is not a
scientifically meaningful concept;
all behaviour (mad, sad & bad) has
its causes.
Phineas Gage (skull depicted)
famously became “irresponsible”
after accidental damage to his
frontal lobe.
BRAIN-DAMAGE IN PSYCHOPATHS
Research confirms that
psychopaths often have
structural and functional
impairments to the connections
between emotional areas (e.g.,
the amygdala) and brain areas
controlling decision-making
and conscience (prefrontal
cortex).
Diagram from Motzkin et al,
(2011) shows reduced
connectivity in psychopaths as
indexed by fMRI.
DIMENSIONAL ALTERNATIVES
The 3 main clusters of PD
correspond roughly to the lay
concepts of mad, bad and sad.
They also connect with
Eysenck’s 3 major personality
types (Psychoticism,
Extraversion & Neuroticism).
EPQ dimensions could replace
DSM categories, as could
Millon’s “multi-axial” system.
However, direct brain
measurements that cannot be
faked will ultimately be
needed for proper assessment.