Personality problems and addictions

  Psychiatrists have always dealt with the consequences of drug and alcohol addictions. They have also always recognized that there are groups of individuals whose personalities are markedly abnormal and can cause endless problems. The degree of human misery associated with these problems is beyond dispute, and such

  DSM IV Diagnostic criteria for Oppositional Defiant Disorder

  A. A pattern of negativistic, hostile, and defiant behaviour lasting at least 6 months, during which four (or more) of the following are present:

often loses temper

  often argues with adults

  often actively defies or refuses to comply with adults’ requests or rules

  often deliberately annoys people

  often blames others for his or her mistakes or misbehaviour

  is often touchy or easily annoyed by others

  is often angry and resentful

  is often spiteful or vindictive

  Note: consider a criterion met only if the behaviour occurs more frequently than is typically observed in individuals of comparable age and developmental level.

  B. The disturbance in behaviour causes clinically significant impairment in social, academic, or occupational functioning.

C. The behaviours do not occur exclusively during the course of a Psychotic or Mood Disorder.

D. Criteria are not met for Conduct Disorder, and, if the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.

individuals are found in large numbers in mental health services. There are, however, strong arguments for and against whether these are primarily psychiatric disorders and whether psychiatrists should be responsible for treating them. This is no simple academic argument that could allow both sides to just make individual decisions that suit them. People with these problems may be, and are, treated against their wishes.

Coercion in psychiatry

  Compulsory treatment is permitted in psychiatry in every society – including Western societies whose very founding principles are respect for individual liberty before the law. This very striking exception stems from the observation that during periods of illness an individual’s judgement is impaired and they are not able to make rational decisions; mental illnesses often involve a ‘break’ with normal functioning and a change that estranges the patient from their normal self. Unlike, for instance, a learning disability where the individual may also not be able to make informed and rational decisions because they have never developed the capacity, the striking characteristic of mental illnesses is the change. Most societies have sanctioned a paternalistic provision for coercive treatment from a humane desire to protect an individual who is clearly ‘not themselves’. This resolve is strengthened by the repeated observation that patients recover and express the same concerns as the rest of us about their behaviour when unwell. Many are even grateful that they were forcibly treated.

  Lawyers find these areas difficult. The standard assessment of ‘capacity’ to make treatment decisions (the ability to understand the information, the ability to trust the individual giving the information, and the ability to retain and make a decision based on that information) works well for children, the learning disabled, and those with dementia. However, it doesn’t work well where the problem is one of judgement and mood rather than intellectual ability. Imposing treatment against a patient’s will rests ultimately on the psychiatrist’s conclusion that the patient is suffering from a mental illness such that their current decisions are not those they would usually express. Note that this involves the psychiatrist making a judgement on what he believes that the patient would usually do or want when well. Compulsion is also sometimes used as a brief safety measure with people who are ‘temporarily unbalanced’ – a terrified individual in a strange place or young people attempting to kill or harm themselves in despair after a relationship break-up.