Severe personality disorders

  Psychiatry’s attitude to psychopathic and antisocial personality disorder usually in men, and borderline personality disorder, usually in women, presents ethical and conceptual concerns. Psychopaths are cold, callous individuals who lack empathy for others and consequently can commit awful crimes. They give no thought to the consequences for others and show no remorse afterwards. They are often recognizable early on (death of pets, arson, etc.). Being self-centred and not caring about others’ feelings they can be extremely successful; it is jokingly proposed that mild psychopathy is an essential for being a successful politician. Psychopaths are often lumped together with explosive and violent individuals as antisocial personality disorder. This group is a massive problem for the prisons and criminal justice system.

  In some countries psychiatrists detain these individuals under the same conditions as the mentally ill and this has been criticized as an abuse of power. Compulsory treatment is justified mainly by the belief that the patient is not making the decisions that they would normally make and which they will make again after recovery. To warrant coercion the condition is usually time-limited and it is believed with some confidence that the treatment will speed recovery. None of these conditions are met for severe personality disorders. Their behaviour reflects their personality – their real identity; they are not aberrant or temporary, and to date there is no convincing evidence that forced treatments will significantly change them.

  Such people pose profound challenges for society. They have often committed serious sexual and violent crimes and it is obvious to prison staff that, as little has changed, they will offend again. In England they are labelled as having a dangerous severe personality disorder (DSPD) and highly staffed new units have been built to treat them. But is their potentially indefinite detention by psychiatrists (as opposed to a prison sentence when they break the law) any less an abuse than the detention of political prisoners in the Soviet system was? The humanitarian sentiments of those involved do not remove the ethical dilemma.

  The Western world has experienced an upsurge in chaotic selfdamaging behaviour in young women. Overdosing and cutting have become common features of female inmates of mental hospitals and prisons. Patients seem out of control, are clearly distressed, and damage themselves in what often seems like a mixture of anger and a desperate plea for help. Psychiatrists feel responsible but impotent and often try to ‘contain’ the situation by keeping the patient compulsorily on a ward offering supervision and support. Unfortunately things may go from bad to worse – the patient selfharms more and the psychiatrist increases the restrictions to control the situation. A vociferous pressure group argues that what these women do to their bodies is their own affair and psychiatry is overstepping the mark in treating them against their will. They point to the cultural precedents for self-mutilation (religious and ritual scarring are common in many societies) and underline how medicine, and psychiatry in particular, has consistently denied women’s self-determination over their own bodies.