Professor Glenn Wilson, Gresham College, London

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MAD, SAD OR BAD?

• Professor Glenn Wilson, Gresham College, London

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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?

3
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.

4
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
  mothers little helper. Are women really under
  greater stress or is drug marketing contributing?

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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).

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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.

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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
  ones sexual orientation).
• 2013 DSM-5 Homophobia?

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PERSONALITY DISORDERS
DSM-4 ICD-10 Paranoid Odd-eccentric Paranoid
Schizoid Schizoid Schizotypal Antisocia
l Dramatic-erratic Dyssocial Borderline Impu
lsive/Borderline Histrionic Histrionic Narciss
istic ) Avoidant )Anxious-fearful Anxious Depend
ent Dependent Obsessive-compulsive Anankast
ic
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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.

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BORDERLINE PERSONALITY

• An especially vague category, referring to a
  grab-bag of symptoms including black white
  thinking, unstable mood and relationships,
  self-image and identity problems and tendency to
  self-harm/suicide.
• Unclear that that these traits cohere
  meaningfully or what border is between (neurosis
  and psychosis?)

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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.

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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.

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PSYCHOPATHY

• A term often used to describe people in the
  erratic-dramatic groups of PD (especially
  anti-social 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).

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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.
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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.

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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.

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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.

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DIMENSIONAL ALTERNATIVES

• The 3 main clusters of PD correspond roughly to
  the lay concepts of mad, bad and sad.
• They also connect with Eysencks 3 major
  personality types (Psychoticism, Extraversion
  Neuroticism).
• EPQ dimensions could replace DSM categories, as
  could Millons multi-axial system.
• However, direct brain measurements that cannot
  be faked will ultimately be needed for proper
  assessment.