Louis Charland has argued that the Cluster B personality disorders, including borderline personalitydisorder, are primarily moral rather than clinical conditions. Part of his argument stems from reflections on effective treatment of borderline personalitydisorder. In the argument from treatment, he claims that successful treatment of all Cluster B personality disorders requires a positive change in a patient’s moral character. Based on this claim, he concludes (1) that these disorders are, at root, deficits in (...) moral character, and (2) that effective treatment of these disorders requires a sort of moral education rather than clinical intervention. In this paper, I evaluate the argument from treatment through a critical analysis of two psychotherapeutic interventions that have shown recent effectiveness against borderline personalitydisorder. I suggest that both Dialectical Behaviour Therapy and Mentalization-Based Treatment indicate that borderline personalitydisorder is, at root, a deficit in non-moral cognitive and emotional capacities. I suggest that these non-moral deficits obscure the expression of an otherwise intact moral character. In light of this, I conclude that effective treatment of borderline personalitydisorder requires primarily clinical intervention rather than moral edification. (shrink)
The DSM-IV-TR (American Psychiatric Association 1994, 689) defines personalitydisorder (PD) as: An enduring pattern of experience and behavior that deviates markedly from the expectations of an individual’s culture. This pattern is manifested in two (or more) of the following areas: 1 Cognition (i.e., ways of perceiving and interpreting self, other people, and events); 2 Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response); 3 Interpersonal functioning; and 4 Impulse control. B The enduring ..
This paper outlines a multidimensional conception of Multiple PersonalityDisorder (MPD) that differs from the 'orthodox' conception in terms of the content of its commitment to the reality of the self. Unlike the orthodox conception it recognizes that selves are fuzzy entities. By appreciating the possibility that selves are fuzzy entities, it is possible to rebut a form of fictionalism about the self which appeals to clinical data from MPD. Realism about self can be preserved in the face (...) of multiple personalities. (shrink)
The purpose of this inquiry is to explore the experience of Borderline PersonalityDisorder with the aim of developing a more liberating approach to its diagnosis and treatment. Eight participants diagnosed with Borderline PersonalityDisorder were recruited from a psychiatric hospital operated by the Surrey and Borders NHS Trust and an outpatient daycentre based in London, United Kingdom. A narrative approach to methodology was employed to collect and analyse the participants’ life-stories. Themes to emerge from the (...) participant’s narratives were found to coincide with R.D. Laing’s concept of ontological insecurity. Ontological insecurity describes a number of aspects of the participant’s distress. To conclude, some general implications of this research for psychotherapy are briefly explored. (shrink)
Marya Schechtman argues that psychological continuity accounts of personal identity, as represented by Derek Parfit's account, fail to escape the circularity objection. She claims that Parfit's deployment of quasi-memory (and other quasi-psychological) states to escape circularity implicitly commit us to an implausible view of human psychology. Schechtman suggests that what is lacking here is a coherence condition, and that this is something essential in any account of personal identity. In response to this I argue first that circularity may be escaped (...) using quasi-psychological states even with the addition of the coherence condition. Second, I argue that there is something right about the coherence condition, and a major task of this paper is to identify its proper theoretical role. I do so by reflection on integration therapies for people with multiple personalitydisorder (MPD). The familiar distinction between the moral and the metaphysical concept of the person is developed alongside such reflection. Connecting these two issues I argue that coherence acts as a normative constraint on accounts of personal identity, but that the normative dimension of personhood is not essential to our notion of a person tout court. (shrink)
It is often emphasised that persons diagnosed with borderline personalitydisorder show difficulties in understanding their own psychological states. In this article, I argue that from a phenomenological perspective, BPD can be understood as an existential modality in which the embodied self is profoundly saturated by an alienness regarding the person’s own affects and responses. However, the balance of familiarity and alienness is not static, but can be cultivated through, e.g., psychotherapy. Following this line of thought, I present (...) the idea that narrativising experiences can play an important role in processes of appropriating such embodied self-alienness. Importantly, the notion of narrative used is that of a scalar conception of narrativity as a variable quality of experience that comes in degrees. From this perspective, narrative appropriation is a process of gradually attributing the quality of narrativity to experiences, thereby familiarising the moods, affects, and responses that otherwise govern ‘from behind’. Finally, I propose that the idea of a narrative appropriation of embodied self-alienness is also relevant to the much-debated question of personal responsibility in BPD, particularly as this question plays out in psychotherapeutic contexts where a narrative self-appropriation may facilitate an increase in sense of autonomy and reduce emotions of guilt and shame. (shrink)
The traditional view that having a personalitydisorder, unlike other mental disorders, is not usually reason enough to consider a person incompetent to make healthcare decisions is challenged. The example of a case in which a woman was treated for a physical disorder without her consent illustrates that personalitydisorder can render a person incompetent to refuse essential treatment, particularly because it can affect the doctor–patient relationship within which consent is given.
The British National Institute for Health and Clinical Excellence (NICE) has recently (28 January 2009) released new guidelines for the diagnosis, treatment and prevention of the psychiatric category antisocial personalitydisorder (ASPD). Evident in these recommendations is a broader ambiguity regarding the ontology of ASPD. Although, perhaps, a mundane feature of much of medicine, in this case, ontological uncertainty has significant ethical implications as a product of the profound consequences for an individual categorised with this disorder. This (...) paper argues that in refraining from emphasising uncertainty, NICE risks reifying a controversial category. This is particularly problematical given that the guidelines recommend the identification of individuals “at risk” of raising antisocial children. Although this paper does not argue that NICE is “wrong” in any of its recommendations, more emphasis should have been placed on discussions of the ethical implications of diagnosis and treatment, especially given the multiple uncertainties associated with ASPD. It is proposed that these important issues be examined in more detail in revisions of existing NICE recommendations, and be included in upcoming guidance. This paper thus raises key questions regarding the place and role of ethics within the current and future remit of NICE. (shrink)
This article argues in support of the proposition that “A PersonalityDisorder May Nullify Responsibility for a Criminal Act.” Building upon research in categorical and dimensional controversies in diagnosis, neurocognitive science and the behavioral genetics of mental disorders, and difficulties in differential diagnosis and co-morbidity with personality disorders, this article holds that a per se rule barring personality diagnosis as a basis for a defense of legal insanity is scientifically and conceptually indefensible. Rather, focus should be (...) upon the severity and impact in specific cases of any legally relevant functional deficits arising from a mental disorder (including personality disorders). Failure to do so risks potentially misleading “battles of the experts” about a defendant's diagnosis in criminal responsibility defenses and improper usurpation of the role of the legal finder of fact as mental health expert witnesses are inserted as gatekeepers indefensibly based upon diagnosis. Implications for practice and public policy are considered, including a “modest proposal” for post-trial management of defendants found not guilty by reason of insanity on the basis of functional deficits arising from personalitydisorder. (shrink)
Borderline Personalitydisorder is a severe personality dysfunction characterized by behavioural features such as impulsivity, identity disturbance, suicidal behaviour, emptiness, and intense and unstable relationships. Approximately 2% of the population are thought to meet the criteria for BPD. The authors of this volume - Anthony Bateman and Peter Fonagy - have developed a psychoanalytically oriented treatment to BPD known as mentalization treatment. With randomised controlled trials having shown this method to be effective, this book presents the first (...) account of mentalization treatment for BPD. The first section gives an overview of BPD, including discussion of nosology, epidemiology, natural history, and psychosocial aetiology. It additionally summarises the present state of our research knowledge about effective psychotherapeutic treatments and use of medication. The second section outlines the authors' theoretical approach and contrasts it with other well known methods, including DBT, CAT, and CBT. In the extensive final section, the authors outline their clinical approach starting with how treatment is organised. A detailed account of the transferable features of the model is provided along with the main strategies and techniques of treatment. Numerous clinical examples are given to illustrate the core techniques and detailed information provided about how to apply aspects of the mentalization based treatment approach in everyday practice. Aimed at mental health professionals, along with counsellors, psychotherapists, and psychoanalysts, the book will be a valuable tool, providing an effective means of treating those suffering from Borderline PersonalityDisorder. (shrink)
Mentalizing - the ability to understand oneself and others by inferring the mental states that lie behind overt behavior - develops during childhood within the context of a secure attachment relationship. It is crucial to self-regulation and constructive, intimate relationships. Failure to retain mentalizing, particularly in the midst of emotional interactions, is a core problem in borderline personalitydisorder and results in severe emotional fluctuations, impulsivity, and vulnerability to interpersonal and social interactions. Mentalization-based treatment for borderline personality (...)disorder is a 'How to Do It' book outlining a clinically proven treatment for Borderline PersonalityDisorder. Containing illustrative clinical examples, it details precisely how to develop and implement treatment and is a companion to the highly successful book Psychotherapy for Borderline PersonalityDisorder - mentalization based treatment. This practical guide explains how to treat borderline patients by helping them develop a more robust mentalizing capacity within the context of an attachment relationship. It provides the practitioner with everything they need to know about how to practise mentalizing treatment in day patient and out-patient settings. Enough theory is provided to orientate the clinician and there is step-by-step practical advice on the assessment of mentalizing and interpersonal relationships, how to structure treatment, the use of basic mentalizing interventions and how to apply them, as well as information on what not to do. In addition, it includes a check list to be used in the assessment of mentalizing and a self-rating exercise for practitioners to evaluate their adherence to mentalizing. (shrink)
Whether treatment decision-making capacity can be meaningfully applied to patients with a diagnosis of “personalitydisorder” is examined. Patients presenting to a psychiatric emergency clinic with threats of self-harm are considered, two having been assessed and reviewed in detail. It was found that capacity can be meaningfully assessed in such patients, although the process is more complex than in patients with diagnoses of a more conventional kind. The process of assessing capacity in such patients is very time-consuming and (...) may become, in itself, a therapeutic intervention. (shrink)
The determinative issue in applying the insanity defense is whether the defendant experienced a legally relevant functional impairment at the time of the offense. Categorical exclusion of personality disorders from the definition of mental disease is clinically and morally arbitrary because it may lead to unfair conviction of a defendant with a personalitydisorder who actually experienced severe, legally relevant impairments at the time of the crime. There is no need to consider such a drastic approach in (...) most states and in the federal courts, where the sole test of insanity is whether the defendant was “unable to appreciate the wrongfulness of his conduct at the time of the offense.” This is because the only symptoms that are legally relevant in such jurisdictions are those that impair reality-testing and thereby affect the person's capacity to understand the nature and consequences of her actions. However, if the test of insanity includes a “volitional prong” (inability to control one's behavior), some way must be found to limit the scope of the defense to the core cases (involving psychotic conditions) to which it has traditionally been applied, and to prevent a shift toward a deterministic account of criminal conduct — i.e., “people can't help being who they are and doing what they do.” The best way of accomplishing this is to limit the definition of mental disease to severe disorders characterized by gross disturbances of the person's capacity to understand reality. (shrink)
Disturbed identity is one of the defining characteristics of Borderline PersonalityDisorder manifested in a broad spectrum of dysfunctions related to the self, including disturbances in meaning-generating self-narratives. Autobiographical memories are memories of personal events that provide crucial building-blocks in our construction of a life-story, self-concept, and a meaning-generating narrative identity. The cultural life script represents culturally shared expectations as to the order and timing of life events in a prototypical life course within a given culture. It is (...) used to organize one’s autobiographical memories. Here, 17 BPD-patients, 14 OCD-patients, and 23 non-clinical controls generated three important autobiographical memories and their conceptions of the cultural life script. BPD-patients reported substantially more negative memories, fewer of their memories were of prototypical life script events, their memory narratives were less coherent and more disoriented, and the overall typicality of their life scripts was lower as compared with the other two groups. (shrink)
Popular and neurobiological accounts of addiction tend to treat it as a form of compulsion. This contrasts with personalitydisorder, where most problematic behaviours are treated as voluntary. But high levels of co-morbidity, overlapping diagnostic traits, and the effectiveness of a range of comparable clinical interventions for addiction and personalitydisorder suggest that this difference in treatment is unjustified. Drawing on this range of clinical interventions, we argue that addiction is not a form of compulsion. Rather, (...) the misuse of drugs and alcohol is like many of the problematic behaviours associated with personalitydisorder: it is typically a way of coping with psychological distress. We suggest that a satisfying explanation of why many addicts struggle to control their use can be given without departing from concepts employed in our basic folk psychological understanding of agency. In particular, we appeal to five rough-and-ready folk psychological factors to explain addiction: (i) strength of desire and habit; (ii) willpower; (iii) motivation; (iv) functional role; and (v) decision and resolve. (shrink)
Many feminist researchers have been critical of the psychiatric category of borderline personalitydisorder 1 and have emphasized the gendered nature of the diagnosis. It is estimated that people diagnosed with BPD comprise 1 to 2 percent of the general population in the United States in a given year, and that women represent 75 percent of those diagnosed.2 Critics have argued that the diagnosis reinforces double-binds for women and pathologizes traits associated with both conventional femininity, such as emotionality, (...) dependency, and self-destructiveness, and unconventional femininity, such as rebelliousness and sexual promiscuity (Lester 2013; Potter 2009; Shaw.. (shrink)
A striking feature of post-modernism is its distrust of the subject. If the modern period, beginning with Descartes, sought in the subject a source of certainty, an Archimedian point from which all else could be derived, post- modernism has taken the opposite tack. Rather than taking the self as a foundation, it has seen it as founded, as dependent on the accidents which situate consciousness in the world. The same holds for the unity of the subject. Modernity, in its search (...) for a single foundation, held the subject to be an indissoluble unity. Post-modernism’s position, by contrast, is announced by Nietzsche: “The assumption of one single subject is perhaps unnecessary; perhaps it is just as permissible to assume a multiplicity of subjects, whose interaction and struggle is the basis of our thought and our consciousness in general? ...My hypotheses: The subject as multiplicity.” Given this, there is a natural correspondence between the success of post- modernism and the current interest in multiple personalitydisorder. In the latter, we actually have the experience of a “multiplicity of subjects” in their interaction and struggle. The subject stands there before us “as multiplicity.” It gives us a concrete case, one which raises some of the pressing questions associated with the post-modern denial of the subject. Confronting it, we ask: how real are the personalities composing the multiplicity of this disordered self? What, in fact, does this multiplicity tell us about the self? about its genesis and status? What does it reveal about “our thought and consciousness in general”? I plan, in the short compass of this paper, to sketch some answers to these questions. §1. A brief description of MPD. The American Psychiatric Association gives two criteria for (MPD) multiple personalitydisorder. First, and most obviously, there is “the existence within the person of two or more distinct personalities or personality states (each with its own relatively enduring pattern. (shrink)
Long before i knew I had a personalitydisorder, I simply knew that my life felt unbearably difficult to live. For me, life has always been an uphill struggle, and at times I have just let myself tumble down the hill I have strived so hard to climb. Fortunately, I now understand how to keep going, and even to avoid falling down in the first place, but this learning process has taken the entire twenty-eight years of my life, (...) and I still feel I have a long way to go. It feels very difficult to describe the early years of my life. To me, it was like being stuck in a cage, gagged. I can remember feeling a great deal of fear, but being unable to express it. My dad would burst into anger very rapidly, and my .. (shrink)
All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood. (Article 1, Universal Declaration of Human Rights 1948) This resounding statement encapsulates a number of problematic themes for lawyers with respect to personalitydisorder, and acutely so for the extremes of personalitydisorder embraced by designations such as psychopathy or dangerous and severe personalitydisorder (...) (DSPD). These designations are in themselves contentious; they do not have commonly agreed definitions either across disciplines or across jurisdictions. Morse (2008), for example, argues in a fascinating account that .. (shrink)
Multiple PersonalityDisorder (MPD), now also known as Dissociative Iden- tity Disorder, raises many questions about the nature of persons, the goals of treatment, the suggestibility of patients, and the reliability of defendant reports of their own mental states. These issues become crucial when courts need to decide whether or not to punish a person with MPD who has committed a crime. This paper will explore that issue and propose a test of when people with MPD should (...) be held criminally responsible. (shrink)
The scene was pleasant on both sides. A cruder lover would have lost the view of her pretty ways and attitudes, and spoiled all by stupid attempts at caresses, utterly destructive of the drama. Grancourt preferred the drama. Gwendolen … found her spirits rising … as she played at reigning. Perhaps if Klesmer had seen more of her in this unconscious kind of acting, instead of when she was trying to be theatrical, he might have rated her chances [on stage] (...) higher.The histrionic personalitydisorder (HPD) stands at the intersection of ethics, ontology, and philosophy of psychiatry. Although HPD is a rarely probed diagnosis, it brings into relief the problems of gender and values in diagnosis, as well as nosological .. (shrink)
Background Previous research on informed consent for research in psychiatric patients has centered on disorders that affect comprehension and appreciation of risks. Little has been written about consent to research in those subjects with Borderline PersonalityDisorder, a prevalent and disabling condition. Discussion Despite apparently intact cognition and comprehension of risks, a borderline subject may deliberately choose self-harm in order to fulfill abnormal psychological needs, or due to suicidality. Alternatively, such a subject may refuse enrollment due to transference (...) or the desire to harm him or herself. Such phenomena could be precipitated or prevented by the interpersonal dynamics of the informed consent encounter. Summary Caution should be exercised in obtaining informed consent for research from subjects with Borderline PersonalityDisorder. A literature review and recommendations for future research are discussed. (shrink)
In the aftermath of the Port Arthur shootings, Dunblane or the schoolyard killings in America, communities try to come to terms with private and public trauma and there is a need to understand what kind of person can commit such terrible acts. The problem of how to understand dangerousness often centres on the role of the mental health and criminal justice systems and it is from the intersection of these two institutions that the categorisation of dangerous persons has emerged. This (...) 2001 book traces the history of the category of antisocial personalitydisorder and shows how it is linked to particular kinds of governing. It examines key legal and institutional developments in Australia, the UK and the US and also parallel developments within psychiatry and psychological medicine. Applying a social theoretical analysis to this material, McCallum challenges our assumptions about the formation and control concepts of dangerousness and personality. (shrink)
Borderline PersonalityDisorder is a diagnosis given to a significant number of people in the Western world. Yet many of the core concepts and symptoms that underlye this diagnosis are questionable. This book presents a compelling analysis of BPD, arguing that it needs to be approached in a new light- one that will benefit patients.