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Antisocial Personalities and Tucson

January 20, 2011

This will be my one and only post on the Arizona shootings.  I only wrote this in response to a troublesome article I read in the Globe and Mail.  I shall send this as a letter to the editor.

Re: “Take Mental Illness out of the Arizona Debate,” The Globe and Mail, Wednesday, January 19th, 2011.

I appreciate Mr. Wilkerson’s contribution to the discussion on mental health stigma in the wake of the Tucson shooting.  While I am generally in agreement, I wish to note that some of its specifics demand correction and clarification.

First, while “Psychopath” and “Sociopath” are not clinical designations, the behaviour described by these terms is indeed covered in the DSM-IV under the category Antisocial Personality Disorder and in the ICD-10 under Dissocial (Antisocial) Personality Disorder.  As such, they are certainly part and parcel of psychiatry’s construct of mental and personality disorders.  I shall nonetheless maintain Mr. Wilkerson’s distinctions.

Next, in describing antisocial personalities, Mr. Wilkerson lists their characteristics and implies that such a tally does not an illness make.  Assuming that he is not trying to mislead, this is a significant gaffe for an expert advisor on mental health issues to commit.  The DSM and ICD-10 are emphatically rubrics of characteristics and descriptors.  Clinical psychiatry does not deal with etiology (causes or origins of an illness), but defines personality or mental health disorders based exclusively on their presenting symptoms.  If I arrive at a physician’s office complaining of chest pains, the doctor will parse these symptoms down to determine the underlying cause: heart condition, or bad congestion?  But with mental health conditions, there is no underlying cause to seek: behaviour and emotional/mental states are at once symptom and ailment, and the clinician merely needs to tick off boxes on a checklist of complaints.  If I present with 4 out of 7 symptoms (or personality characteristics, or behavioural traits), and these have been present over 6 months, that means I have X.  And that’s that, in all its brutal expediency.

The author is indeed correct in stating that antisocial types are thoroughly beyond the reach of science.  The extremely antisocial seem congenitally incapable of acknowledging any form of personal responsibility or culpability.  But he leaves out the fact that science is basically flummoxed by all mental and personality disorders.  As a bipolar person, the distant and proximate causes for my condition are no more understood than those of the antisocial type.  The reason why psychiatry does not deal with etiology is because no clinician can honestly or adequately describe what is going on in the brain of any mentally ill person—much less explain what is going on in the mind (the two are decidedly not synonymous).  Frontline clinical therapy for depressives, the bipolar and the schizophrenic—to take the ‘big three”—consists essentially of a haphazard mix of reasonably functional medications whose chemical properties are often completely misunderstood.  In the best of scenarios, these are supplemented by a scant handful of somewhat successful non-chemical therapies.  In all matters of the mind and the personality, then, science has very short arms.

Corollary to this, for Mr. Wilkerson it would seem that the major difference between the mentally ill and the dangerously antisocial is that the latter defy treatment.  This logic is faulty and nonsensical: a medical system which would define as ill only those whom it could treat would be vicious, wrong-headed, and would quickly run out of patients.  Rather, the fact that extreme antisocial personalities are indeed utterly resistant to any form of treatment tells us as much about them as it does about how medicine and society construct mental disorders, define “clinical deficits,” and categorize individuals.  The psychiatric system increasingly appears bent on pathologizing every possible personality quirk and eccentricity (the DSM-5 will be out in 2013 with a host of new and controversial additions), yet if we must go that route, would it not be more germane to deem someone pathological who is constitutionally lacking in remorse, guilt and an ethical centre?

I am most perplexed by Mr. Wilkerson’s statement that “these [antisocial] people are not mentally ill, they just are.”  How must we take this?  As a reason, or an excuse writ up as a reason?  If a reason, it begs some important questions on the one hand about individual responsibility and on the other about how we collectively interpret the actions of both the severely antisocial and of the mentally ill.  People like Mr. Wilkerson must take care, in their efforts to fight stigma, not to imply that society should look upon us who have mental conditions as somehow superior to the extremely antisocial simply because we have a notion of personal culpability and are capable of remediation.  Fighting stigma is not a battle for moral superiority, with the dangerously antisocial serving as convenient scapegoats because of their paltry numbers, the severity of their actions, and the likelihood of their indifference.  Such an understanding diverts us away from some important issues—how to deal with the horrid crimes of people who have not even the slightest comprehension of guilt—and toward pointless searches for “blame.”

Ultimately, as an advocate for mental health issues, I am as ardent in fighting blame as I am in combating stigma.  As a proud Mad person, I do not see myself as mentally “ill,” either.  I’m bipolar, and I just am.  In every possible human way, we all just “are.”

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