The diagnosis of psychopathic personality disorder has salience for forensic clinical practice. It influences decisions regarding risk, treatability and sentencing, indeed, in certain jurisdictions it serves as an aggravating factor that increases the likelihood of a capital sentence. The concatenation of symptom that is associated with modern conceptions of the disorder can be discerned in early writings, including the book of Psalms. Despite its forensic clinical importance and historical pedigree the concept remains elusive and controverted. In this paper I (...) describe an attempt to map the concept of psychopathic personality disorder—the Comprehensive Assessment of Psychopathic Personality (CAPP). I outline the processes used to create the concept map; I summarise evidence in support of the content validity of the map and describe different operations designed to operationalise the construct. It is only when conceptual clarity is achieved that valid operations and measures can be created. I end with a plea for more carefully considered application of statistical methods; applications that better fit the theoretical questions being posed. (shrink)

'Cruel' simply ignores the supposed fact/value dichotomy and cheerfully allows itself to be used sometimes for a normative purpose and sometimes as a descriptive term.Personality disorders have always attracted considerable attention within the philosophy of psychiatry. It was not until two papers written by Louis Charland, however, that they simulated a wider and lively debate. The importance and, at least partly, the strength of Charland's analyses lie in the fact that they are relatively particular and focused in their...

Louis Charland’s claim that DSM Cluster B personality disorders are moral rather than clinical kinds has recently triggered a lively debate. In order to deliver a reliable report of the latter, both (1) Charland’s arguments concerning the impossibility of identifying and treating personality disorders without applying a morally laden conceptual framework and (2) some critical responses they provoked are discussed. Then, in turn, the conceptual history of the notion of personality disorder is traced, including not (...) only well-recognized contributions from (3) medical psychiatry, psychoanalysis, and DSM nosology, but also (4) an important, but often neglected, tradition of virtue and moral character. Finally, (5) the idea of a normatively neutral concept of personality disorder is scrutinized in the context of its logical dependence on the fact-value distinction. The latter dichotomy’s recent criticism, in particular, is employed to support Charland’s argument and to suggest that the normative character of personality disorders may go much deeper than this or that DSM formulation. (shrink)

Personality disorder symptomatology (PD-Sx) can result in personal distress and impaired interpersonal functioning, even in the absence of a clinical diagnosis, and is frequently comorbid with psychiatric disorders such as substance use, mood, and anxiety disorders; however, they often remain untreated, and are not taken into account in clinical studies. To investigate brain morphological correlates of PD-Sx, we measured subcortical volume and shape, and cortical thickness/surface area, based on structural magnetic resonance images. We investigated 37 subjects who (...) reported PD-Sx exceeding DSM-IV Axis-II screening thresholds, and 35 age, sex, and smoking status-matched control subjects. Subjects reporting PD-Sx were then grouped into symptom-based clusters: N = 20 into Cluster B (reporting Antisocial, Borderline, Histrionic, or Narcissistic PD-Sx) and N = 28 into Cluster C (reporting Obsessive–Compulsive, Avoidant, or Dependent PD-Sx); N = 11 subjects reported PD-Sx from both clusters, and none reported Cluster A (Paranoid, Schizoid, or Schizotypal) PD-Sx. Compared to control, Cluster C PD-Sx was associated with greater striatal surface area localized to the caudate tail, smaller ventral striatum volumes, and greater cortical thickness in right prefrontal cortex. Both Cluster B and C PD-Sx groups also showed trends toward greater posterior caudate volumes and orbitofrontal surface area anomalies, but these findings did not survive correction for multiple comparisons. The results point to morphological abnormalities that could contribute to Cluster C PD-Sx. In addition, the observations parallel those in substance use disorders, pointing to the importance of considering PD-Sx when interpreting findings in often-comorbid psychiatric disorders. (shrink)

It is concisely explained what Borderline Personality Disorder is and how it differs from psychopathy.

The traditional view that having a personality disorder, 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 personality disorder can render a person incompetent to refuse essential treatment, particularly because it can affect the doctor–patient relationship within which consent is given.

Individuals with conditions like borderline personality disorder experience chronic, pervasive impairments that interfere with moral functioning. Even in recovery these individuals are plagued by residual symptoms, requiring diligence and management. First, I stipulate that some individuals who recover from BPD act morally. I argue that by acting morally while managing residual symptoms these individuals expand the boundaries of traditional Aristotelian virtue. Individuals who recover from BPD are simultaneously virtuous and outside the boundaries of traditional Aristotelian virtue if they meet (...) the following conditions: they experience marked, unchangeable morally-relevant difference in moral faculties; act morally at approximately the same rate or better than other moral agents; and act morally for the right reasons. These individuals challenge the boundaries of traditional Aristotelian virtue by demonstrating that many views of temperance and virtue are too restrictive. I evaluate multiple interpretations of McDowell’s [1] silencing view and call for a more inclusive virtue ethics that embraces continence in the vein of Foot’s [2] corrective view. (shrink)

Whether treatment decision-making capacity can be meaningfully applied to patients with a diagnosis of “personality disorder” 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)

This paper seeks to determine the extent to which individuals with borderline personality disorders can be held morally responsible for a particular subset of their actions: disproportionate anger, aggressions and displays of temper. The rationale for focusing on these aspects lies in their widespread acknowledgment in the literature and their plausible primary association with blame directed at BPD patients. BPD individuals are indeed typically perceived as “difficult patients” (Sulzer 2015, Bodner et al. 2011), significantly more so than schizophrenic (...) or depressive patients (Markam 2003). The “responsibility question” for patients with BPD has already been raised (Martin 2010, Zachar & Potter 2009, Bray 2003), but this paper tackles it from a novel perspective. First, I narrow down the category of things for which the responsibility question is specific to individual with BPD. After that, I argue that some of the diagnosis criteria of BPD such as emotional instability or impulsivity might serve as excusing factors targeting the “control condition” on moral responsibility. Second, this paper also considers another widely accepted condition on moral responsibility: the epistemic condition. The view defended in the paper is that the answer to the responsibility question for individuals with BPD, concerning both the control condition and the epistemic condition, hinges on an understanding of their epistemic profile. (shrink)

The diagnostic category of borderline personality disorder (BPD) has come under increasing criticism in recent years. In this paper, we analyze the role and impact of epistemic injustice, specifically testimonial injustice, in relation to the diagnosis of BPD. We first offer a critical sociological and historical account, detailing and expanding a range of arguments that BPD is problematic nosologically. We then turn to explore the epistemic injustices that can result from a BPD diagnosis, showing how they can lead to (...) experiences of testimonial injustice which impede patient engagement in meaning-making activities, thereby undermining standard therapeutic goals. We conclude by showing how our arguments bolster ongoing efforts to replace the diagnostic category of BPD with alternatives such as complex post-traumatic stress disorder. (shrink)

Once common, therapeutic privilege—the practice whereby a physician withholds diagnostic or prognostic information from a patient intending to protect the patient—is now generally seen as unethical. However, instances of therapeutic privilege are common in some areas of clinical psychiatry. We describe therapeutic privilege in the context of borderline personality disorder, discuss the implications of diagnostic non-disclosure on integrated care and offer recommendations to promote diagnostic disclosure for this patient population. There are no data in this work.

This paper seeks to determine the extent to which individuals with borderline personality disorders can be held morally responsible for a particular subset of their actions: disproportionate anger, aggressions and displays of temper. The rationale for focusing on these aspects lies in their widespread acknowledgment in the literature and their plausible primary association with blame directed at BPD patients. BPD individuals are indeed typically perceived as “difficult patients” (Sulzer 2015:82; Bodner et al. 2011), significantly more so than schizophrenic (...) or depressive patients (Markam 2003). The “responsibility question” for patients with BPD has already been raised (Martin 2010; Zachar and Potter 2009; Bray 2003), but this paper tackles it from a novel perspective. First, I narrow down the category of things for which the responsibility question is specific to individual with BPD. After that, I argue that some of the diagnosis criteria of BPD such as emotional instability or impulsivity might serve as excusing factors targeting the “control condition” on moral responsibility. Second, this paper also considers another widely accepted condition on moral responsibility: the epistemic condition. The view defended in the paper is that the answer to the responsibility question for individuals with BPD, concerning both the control condition and the epistemic condition, hinges on an understanding of their epistemic profile. (shrink)

Several researchers point to disorganized attachment as a core feature of borderline personality disorder (BPD). However, recent studies suggest that specific internal working models (IWMs) of each parent combine to account for child outcomes and that a secure relationship with one parent can protect against the deleterious effects of an insecure relationship with the other parent. It was thus hypothesized that adolescents with BPD are more likely to be disorganized with both their parents, whereas non-clinical controls are more secure (...) with at least one of their caregivers. Thirty-six adolescents with BPD and 30 control participants (aged 13-19) were included. Psychiatrist diagnosis was verified with the SIDP-IV and comorbidity was assessed using the Kiddie-SADS. Reported trauma was assessed with the Childhood Trauma Questionnaire. Attachment IWMs of each parent were assessed with the Attachment Multiple Model Interview (AMMI), which enables separate coding for each attachment figure and in which disorganization is conceptualized as conflicting attachment strategies within a specific relationship. Results of a logistic regression analysis suggested that beyond insecure attachment, being disorganized not just with one but with both parents is particularly characteristic of adolescents with BPD. Conversely, belonging to the non-clinical group was predicted by higher security scores with the father and lower deactivation with the mother. Although higher levels of childhood abuse or neglect were reported by adolescents with BPD, the retained attachment dimensions predicted group membership over and above reported trauma. These findings have important implications for clinical intervention and highlight the protective role fathers may have. (shrink)

People with personality disorders should be treated fairly. Potential crime victims should be protected. That much is uncontroversial. The hard questions ask what is fair, when is protection adequate, and how should we achieve fairness and protection together. Peay outlines five main hurdles that the law must jump to reach these goals. All five raise serious challenges. To begin to address these challenges, we must first clarify what a personality disorder is. The notion of a personality (...) disorder is defined very broadly in DSM-IV-TR as any inflexible, pervasive, enduring, stable, and early-onset pattern of experience and behavior that deviates markedly from cultural expectations, leads to clinically .. (shrink)

This article critically examines Louis Charland’s claim that personality disorders are moral rather than medical kinds by exploring the relationship between personality disorders and virtue ethics. We propose that the conceptual resources of virtue theory can inform psychiatry’s thinking about personality disorders, but also that virtue theory as understood by Aristotle cannot be reduced to the narrow domain of ‘the moral’ in the modern sense of the term. Some overlap between the moral domain’s notion (...) of character-based ethics and the medical domain’s notion of character-based disorders is unavoidable. We also apply a modified version of John Sadler’s “moral wrongfulness test” to borderline and narcissistic personality disorders. With respect to both diagnoses, we argue that they involve negative moral evaluations, but may also have indispensable nonmoral features and, therefore, classify legitimate psychiatric disorders. (shrink)

Most clinicians and mental health practitioners are reluctant to work with people with dangerous and severe personality disorders because they believe there is nothing that mental health services can offer. Dangerous and severe personality disorder also signals a diagnosis which is problematic morally. Moral philosophy has not found an adequate way of dealing with personality disorders. This paper explores the question: What makes a person morally responsible for his actions and what is a legitimate mitigating (...) factor? How do psychiatric nurses working with this client group understand the awful things some clients do? What concepts do they need, if they are to know how to explain and how to react? It is suggested that dangerous and severe personality disorder is best regarded as a moral category, framed in terms of goodness, badness, obligation and other ethical concepts. It seems plausible that in important ways the dangerous and severe personality disordered client does not understand morality or understands it differently. The peculiar position of the dangerous and severe personality disordered individual in our system of moral responsibility stems from his apparent inability to see the importance of the interests of others. It might be more helpful to regard personality disordered clients as we do children: partially but not fully reasonable for their actions. We might regard the dangerous and severe personality disordered client responsible for those actions which he most clearly understands, such as causing others physical pain, but not for those with which he is only superficially engaged, such as causing emotional pain. The paper concludes by suggesting that the dangerous and severe personality disordered individual does not fit easily into any conventional moral category, be it criminal, patient, animal or child, and thus an assessment of his moral accountability must take into consideration his special circumstances. (shrink)

This book is the second volume of an interdisciplinary study, chiefly one of philosophy and psychology, which concerns personality, especially the abnormal in terms of states of aloneness, primarily that of the negative emotional isolation customarily known as loneliness. Other states of aloneness investigated include solitude, reclusiveness, seclusion, desolation, isolation, and what the author terms “aloneliness,” “alonism,” “lonism,” and “lonerism.”Insofar as this study most explicitly focuses on abnormal personalities, it employs the general and specific definitions of personality aberrations (...) as formulated by the American Psychiatric Association in its latest edition of theDiagnostic and Statistical Manual of Mental Disorders (DSM-IV). The author views personality as preeminently comprised of the individual's interpersonal relationships. Unlike theDSM-IV, he proposes that people with personality disorders not only possibly but necessarily manifest deviancy regarding interpersonal functioning via serious shortcomings in shared inwardness, paramountly reciprocated intimacy.This work also engages in an analysis of five social factors that are conducive to predisposing, precipitating, and maintaining negative kinds of personality and aloneness. The author has formed these factors into an acronym titledSCRAM since when they are present, intimacy scurries away and in its absence, loneliness and other sorts of unwanted aloneness scamper in and fill the person with unhappiness via, for instance, sadness and self-worthlessness. The constituents of SCRAM are the following social illnesses: Successitis (for example, the fixation on fame and fortune),Capitalitis (greed-driven, unfettered capitalism), Rivalitis (competitivitis),Atomitis (hyper-individualism), and Materialitis (for example, the anti-spirituality of consumeritis).In sum, this book provides a different perspective on personality via the lenses of various types of aloneness and their lack of public and private intimacy, especially love. (shrink)

Many feminist researchers have been critical of the psychiatric category of borderline personality disorder 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)

IntroductionBorderline personality disorder patients are often subjected to inpatient compulsory care due to suicidal behaviour. However, inpatient care is usually advised against as it can have detrimental effects, including increased suicidality.AimTo investigate what motives psychiatrists have for treating borderline personality disorder patients under compulsory care.Materials and MethodsA questionnaire survey was distributed to all psychiatrists and registrars in psychiatry working at mental health emergency units or inpatient wards in Sweden. The questionnaire contained questions with fixed response alternatives, with room (...) for comments, about the respondents’ motives for practising compulsory care of borderline personality disorder patients. The responses were analysed quantitatively with descriptive statistics, and comments were analysed with qualitative descriptive content analysis.ResultsThe psychiatrists’ views were divided on when it was justified to treat borderline personality disorder patients under compulsory care, as were their views on borderline personality disorder patients’ decision competence. When there was an assessed risk of harm, 53% were positive to compulsory care of decision-competent borderline personality disorder patients and another 31% because they considered the patients to be decision incompetent in such situations. Adding the risk of harm caused many respondents to alter their assessment of the patient from decision competent to decision incompetent.ConclusionThe large variations in doctors’ opinions indicate that the care of borderline personality disorder patients is arbitrary. Further, the assessed risk of harm increases the use of compulsory care, even though such care is advised against in clinical guidelines, has questionable legal support, and could lead to an increased suicide risk over time. (shrink)

The aim of this work is to contribute to the ecological and phenomenological understanding of people with borderline personality disorder by analyzing the relation to the “limit situations”, a concept that was formulated one century ago by Karl Jaspers. This study makes it possible to go beyond the nosographic debate in which the pathological entity is often confined, by defining it as a disorder “situated” between neurosis and psychosis. The five limit-situations (which have been described by Gabriel Marcel in (...) his introduction to Jaspers’ proposals) – namely, (1) historical situation, (2) love conflict, (3) suffering, (4) guilt, (5) and death – turn out to be crucial situations in which the limit-existence manifests itself in a specific way. In particular, we observe that the peculiarities of the experience characterizing the borderline individual’s limit situations rely on a temporality grounded on instantaneity and immediacy, and imply a specific relationship to others. Finally, the limit state seems to call into question this primordial tendency by suggesting that every man is bound to be part of time, to love, to feel guilty, to suffer and to flee this suffering, to die and to organize his life by considering such a condition of finitude. (shrink)

Personality disorders: illegitimate subject positions The diagnosis of personality disorder is common in mental health nurse settings and is a term often used without critical consideration. In clinical practice, the term personality disorder has pejorative connotations, which arise out of the way in which these behaviours are constructed as behavioural rather than psychiatric. The discursive construction of categories of personality disorder are inculcated into clinical practice and become taken‐for‐granted by those in practice culture. The construction (...) of some personalities as disordered and, therefore, illegitimate becomes natural. This paper provides a critical analysis of the diagnosis and suggests an approach to mental health nursing care that is more legitimising for those people who receive psychiatric diagnoses. (shrink)

This perspective paper aims at discussing theoretical principles that could explain how emotion regulation and physical diseases mutually influence each other in the context of borderline personality disorder (BPD). Furthermore, this paper discusses the clinical implications of the functional relationships between emotion regulation, BPD and medical conditions considering dialectical behavior therapy (DBT) as a well-validated therapeutic intervention, which encompasses these issues. The inflexible use of maladaptive emotion regulation strategies (e.g., suppression, experiential avoidance, and rumination) might directly increase the probability (...) of developing physical diseases through a physiological pathway, or indirectly through a behavioral pathway. Some metabolic and chronic medical conditions could significantly impact emotional functioning through biological alterations involved in emotion regulation. Several empirical studies have shown high co-occurrence rates between BPD and several chronic physical diseases, especially ones linked to emotion-based maladaptive behaviors. DBT addresses physical diseases reported by individuals with BPD reducing problematic behaviors functionally associated to emotion dysregulation and identifying physical health as a goal forBuilding a Life Worth Living. (shrink)

In “Personality Disorders: Moral or Medical Kinds—or Both?” Peter Zachar and Nancy Nyquist Potter (2010) reject any general dichotomy between morality and mental health, and specifically between character vices and personality disorders. In doing so, they provide a nuanced and illuminating discussion that connects Aristotelian virtue ethics to a multidimensional understanding of personality disorders. I share their conviction that dissolving morality–health dichotomies is the starting point for any plausible understanding of human beings (Martin 2006), (...) but I register some qualms about their discussion of responsibility. Zachar and Potter target the morality-health dichotomy as it appears in Louis C. .. (shrink)

Patients with borderline personality disorder are frequent users of inpatient mental health units, with inpatient crisis intervention often used based on the risk of suicide. However, this can present an ethical dilemma for nursing and medical staff, with these clinician responses shifting between the moral principles of beneficence and non-maleficence, dependent on the outcomes of the actions of containing or tolerating risk. This article examines the use of crisis intervention through moral duties, intentions and consequences, culminating in an action/consequence (...) model of risk management, used to explore potential outcomes. This model may be useful in measuring adherence and violation of the principles of beneficence and non-maleficence and therefore an aid to clinical decision making. (shrink)

Louis Charland has argued that the Cluster B personality disorders, including borderline personality disorder, are primarily moral rather than clinical conditions. Part of his argument stems from reflections on effective treatment of borderline personality disorder. 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 personality disorder. I suggest that both Dialectical Behaviour Therapy and Mentalization-Based Treatment indicate that borderline personality disorder 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 personality disorder requires primarily clinical intervention rather than moral edification. (shrink)

In this article, I argue for a reconsideration of the taxonomy of the Histrionic Personality Disorder. First, HPD does not carry the negative ethical implications of the other Cluster Bs, which are Anti-Social, Borderline, and Narcissistic. Using Aristotelian notions of character as a heuristic device, I argue that ontologically HPD is not a personality disorder, but instead a cultural disorder, a result of attitudes toward traditionally feminine styles of interaction. This explains the confusion in the research between HPD (...) and hysteria and also the curious paucity of literature on HPD itself in contrast to the other Cluster Bs. (shrink)

Personality-disordered individuals of certain types tend to exhibit behaviors that cause particular problems for the Ethics and Compliance (E&C) function inorganizations. This paper defines personality-disordered individuals and focuses on three types that might create such problems: the psychopath, the narcissist, and the obsessivecompulsive personality. We provide a working hypothesis about the problems that they may cause in organizations and then report the results of an exploratory study of E&C personnel. The paper concludes with recommendations for managers and (...) for future research. (shrink)

Individuals develop a narrative identity through constructing and internalizing an evolving life story composed of significant autobiographical memories. The ability to narrate these memories in a coherent manner has been related to well-being, identity functioning, and personality pathology. Previous studies have particularly focused on coherence of life story narratives, overlooking coherence of single event memories that make up the life story. The present study addressed this gap by examining associations between narrative coherence of single turning point memories and psychological (...) well-being, identity functioning, and personality disorder (PD) symptoms among 333 Belgian emerging adults (72.1% female;Mage= 22.56,SD= 3.13, age range = 18–30). In addition, the present study tested whether narrative coherence could predict unique variance in PD symptoms above and beyond identity and interpersonal functioning, both considered key components of personality pathology. The findings showed that narrative coherence was not significantly related to psychological well-being, but yielded significant negative associations with disturbed identity functioning and antisocial PD symptoms. Furthermore, narrative coherence predicted unique variance in antisocial PD symptoms above and beyond identity functioning, but did not predict unique variance in borderline and antisocial PD symptoms above and beyond both identity and interpersonal functioning. Collectively, these findings suggest that narrative incoherence within single event memories might be characteristic for disturbed identity functioning and antisocial personality pathology. (shrink)

Interpersonal sensitivity, particularly threat of potential exclusion, is a critical condition in borderline personality disorder (BPD) which impairs patients’ social adjustment. Current evidence-based treatments include group components, such as mentalization-based group therapy (MBT-G), in order to improve interpersonal functioning. These treatments additionally focus on the therapeutic alliance since it was discovered to be a robust predictor of treatment outcome. However, alliance is a multidimensional factor of group therapy, which includes the fellow patients, and may thus be negatively affected by (...) the exclusion-proneness of BPD patients. The aim of this pilot study was to examine the predictive value of threat of social exclusion for the therapeutic alliance in MBT-G. In the first part of the study, social exclusion was experimentally induced in 23 BPD inpatients and 28 healthy subjects using the Cyberball paradigm, a virtual ball tossing game. The evoked level of threat was measured with the Need-Threat Scale (NTS) which captures four dimensions of fundamental human needs, i. e. the need for belongingness, for self-esteem, for control, and for a meaningful existence. In the second part of the study, therapeutic alliance was measured on three dimensions, the therapists, the fellow patients and the group as a whole, using the Group-Questionnaire (GQ-D). BPD patients scored higher in their level of threat according to the NTS in both, the inclusion and the exclusion condition. The level of threat after exclusion predicted impairments of the therapeutic alliance in MBT-G. It was associated with more negative relationships, lower positive bonding and a lower positive working alliance with the fellow patients and lower positive bonding to the group as a whole whilst no negative prediction of the alliance to the therapists was found. Consequently, our translational study design has shown that Cyberball is an appropriate tool to use as an approach for clinical questions. We further conclude that exclusion-proneness in BPD is a critical feature with respect to alliance in group treatments. In order to neutralize BPD patients’ exclusion bias, therapists may be advised to provide an “inclusive stance”, especially in initial sessions. It is also recommendable to strengthen patient to patient relations. (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 personality disorder. 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 personality disorder. 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)

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 personality disorder, and acutely so for the extremes of personality disorder embraced by designations such as psychopathy or dangerous and severe personality disorder (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)

_Treating Dissociative and Personality Disorders_ draws on major theorists and the very latest research to help formulate and introduce the Relational/Multi-Motivational Therapeutic Approach, a new model for treating such patients within a clinical psychoanalytic setting. Supported by her fellow contributors, Antonella Ivaldi provides an overview of existing theories and evidence for their effectiveness in practice, sets out her own theory in detail and provides rich clinical detail to demonstrate the advantages of the REMOTA model as applied in a clinical (...) setting. The narratives in this book show how it is possible to integrate different contributions within a multidimensional aetiopathogenic treatment model, which considers the mind as a manifestation of the relationship between body and world. From a conceptual perspective, according to which consciousness emerges and develops in the interpersonal dimension, this book shows how it becomes possible to understand, in the therapeutic space, what stands in the way of sound personal functioning, and how to create the conditions for improving this. Treating Dissociative and Personality Disorders will be highly useful in addressing the particular clusters of symptoms presented by patients, stimulating therapists of different backgrounds to explore the complexity of human nature. On reading this book, it will become clear that theories can truly become useful instruments, if approached with a critical mind and with humbleness, in order to venture into what we do not know and will never know completely: the relationship with the other, unique and irreplaceable. Treating Dissociative and Personality Disorders provides an integrative and comparative new approach that will be indispensable for combining relational clinical knowing and motivational theories. It_ _will appeal to psychoanalysts and psychotherapists, especially those in training, clinicians of different backgrounds interested in comparative psychotherapy, as well as social workers and graduate and postgraduate students. (shrink)

The DSM-IV-TR (American Psychiatric Association 1994, 689) defines personality disorder (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 ..

Borderline Personality disorder 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 Personality Disorder. (shrink)

Patients with borderline personality disorder (BPD) sometimes request to be admitted to hospital under compulsory care, often under the argument that they cannot trust their suicidal impulses if treated voluntarily. Thus, compulsory care is practised as a form of Ulysses contract in such situations. In this normative study we scrutinize the arguments commonly used in favour of such Ulysses contracts: (1) the patient lacking free will, (2) Ulysses contracts as self-paternalism, (3) the patient lacking decision competence, (4) Ulysses contracts (...) as a defence of the authentic self, and (5) Ulysses contracts as a practical solution in emergency situations. In our study, we have accepted consequentialist considerations as well as considerations of autonomy. We conclude that compulsory care is not justified when there is a significant uncertainty of beneficial effects or uncertainty regarding the patient’s decision-making capacity. We have argued that such uncertainty is present regarding BPD patients. Hence, Ulysses contracts including compulsory care should not be used for this group of patients. (shrink)

The British prison estate is characterised by an elaborate mental health infrastructure, an edifice often rearranged to meet the near-permanent mental health ‘crisis’ in its walls. From ‘trauma-informed’ prisons to behaviour change programmes, care for mentally ‘vulnerable’ people in prison has sedimented into the backbone of penal strategy. Much of this is developed through appeals to inclusion: of the vulnerable, disadvantaged, and traumatised people who are increasingly recognised as comprising a disproportionate number of prisoners. One category around which this infrastructure (...) is organised is ‘personality disorder’. Since New Labour's demarcation of this ‘offender group’ in the early 2000s, they are now thought to comprise a majority of the prison population. This article, grounded in prison documents and interviews with former prisoners, looks at the disorder's operationalisation in prison. It shows the disorder to be a broad and malleable category that works to mediate between prisoners, as individual subjects, and an expanding, complex, and shifting prison structure. Prisoners are explained in terms of the diagnosis, as the category’s borders are wide and shifting enough to absorb all kinds of behaviour, beliefs, and experiences. We thus see how the diagnosis simultaneously works to dismiss prisoners’ inner lives at the very moment it claims to understand them—and how this move facilitates penal management. The article uses Althusser's work on subjects and interpellation to make sense of this situation, and prisoners’ tactical navigation of it. The material practices that make the diagnosis real are emphasised, and connected to the imperatives of prison management. (shrink)

Improving emotion regulation is central to borderline personality disorder (BPD) treatment, but little research indicates which emotion regulation strategies are optimally effective and when. Basic emotion science suggests that engagement emotion regulation strategies that process emotional content become less effective as emotional intensity increases, whereas disengagement strategies that disengage from it do not. This study examined whether emotional reactivity to emotional stimuli predicts the effectiveness of engagement and disengagement emotion regulation across self-report, general physiologic (heart rate), sympathetic (skin conductance (...) responses), and parasympathetic (respiratory sinus arrythmia) emotion in BPD, healthy, and clinical control (i.e. generalized anxiety disorder; GAD) groups. 120 participants (40 per group) were exposed to emotion inductions and then instructed to implement engagement (mindful awareness) and disengagement (distraction) strategies while self-report and physiological emotion measurements were taken. In the BPD and GAD groups, higher heart rate or respiratory sinus arrythmia reactivity, respectively, predicted improved mindful awareness effectiveness. Higher skin conductance reactivity predicted worsened distraction effectiveness in BPD. Higher reactivity may potentiate engagement emotion regulation, and exacerbate disengagement from emotional content, in BPD. Future research should examine other domains of emotion regulation that may be influenced by emotional intensity, and other forms of emotional intensity that may influence them. (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 personality disorder (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)

Dominic Murphy in several influential publications has formulated and defended what he calls the strong medical model of mental illness. At the core of this project is the objectivist requirement of classifying mental illness in terms of their aetiologies, preferably characterised by multilevel mechanistic explanations of dysfunctions in neurocomputational processes. We are sympathetic to this project and we devise an argument to support it based on a conception of psychiatric kinds. Murphy has, moreover, maintained that there are some open issues (...) concerning the applicability of his program to antisocial personality disorders and psychopathy. We argue that, as a matter of fact, there are already plausible and well-motivated classificatory proposals for these types of disorders that accommodate well within Murphy's strong medical model. (shrink)

Borderline Personality Disorder 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.

Borderline personality disorder (BPD) is characterized by severe disturbances in a subject’s sense of identity. Persons with BPD suffer from recurrent feelings of emptiness, a lack of self-feeling, and painful incoherence, especially regarding their own desires, how they see and feel about others, their life goals, or the roles to which they commit themselves. Over the past decade or so, clinical psychologists, psychotherapists, and psychiatrists have turned to philosophical conceptions of selfhood to better understand the borderline-specific ruptures in the (...) sense of identity, which are frequently associated with severe affective instability and turbulence in interpersonal relationships. Fuchs (2007) has suggested that these disturbances in self-experience can best be described and explained by using notions—widely discussed in philosophy and psychology—ofnarrativityandnarrative identity. On such a narrative view, key features of BPD present significant modifications of proto-narrative structures and inhibit the development of a narrative identity, resulting in a disturbed sense of identity. Although the role of narrativity in BPD has been acknowledged by many researchers, some have voiced dissatisfaction with what they take to be limitations of a narrativistic understanding of the disorders of identity characterizing BPD, and have proposed alternative, allegedly non-narrativistic, accounts. In this paper, we critically examine an example of the latter, viz. Gold and Kyratsous’ (2017) account ofthe person as an intrapersonal team reasoner. We defend a narrativistic understanding of BPD identity disorder against their objections. To this end, we propose a broader, and more finely-differentiated, concept of narrativity. On this account, four aspects of narrativity are distinguished, the disordering of which can affect those with BPD. As it turns out, our account implies that even Gold and Kyratsous—in order to ground their approach—must either make use of these aspects or propose an as-yet unarticulated alternative. This casts doubt upon whether their approach is non-narrativistic after all. (shrink)

The current study sought to examine emotional manipulation and its connection to symptoms of narcissistic personality disorder among couples, and whether there are statistically, significant differences based on the variables such as gender, age, duration of marriage, and educational level. The study involved a sample of 924 married couples, selected through the descriptive correlational approach. The findings revealed a moderate level of emotional manipulation and symptoms of narcissistic personality disorder among couples. They also showed statistically significant differences in (...) emotional manipulation and narcissistic personality disorder symptoms based on gender, favoring males; duration of marriage, favoring those married for less than (10) years; and educational level favoring those with secondary or less. No statistically significant differences were found based on age. Moreover, a positive and statistically significant relationship was identified between emotional manipulation and symptoms of narcissistic personality disorder in couples. Based on these findings, the researchers recommend organizing lectures and seminars to educate couples about the negative effects of emotional manipulation and various types of symptoms of narcissistic personality disorder appearing in the marital relationship. (shrink)

Self-harm is a potentially lethal symptom of borderline personality disorder (BPD) that often improves with dialectical behavior therapy (DBT). While DBT is effective for reducing self-harm in many patients with BPD, a small but significant number of patients either does not improve in treatment or ends treatment prematurely. Accordingly, it is crucial to identify factors that may prospectively predict which patients are most likely to benefit from and remain in treatment. In the present preliminary study, twenty-nine actively self-harming patients (...) with BPD completed brain-imaging procedures probing activation of the prefrontal cortex during impulse control prior to beginning DBT and after seven months of treatment. Patients that reduced their frequency of self-harm the most over treatment displayed lower levels of neural activation in the bilateral dorsolateral prefrontal cortex prior to beginning treatment, and they showed the greatest increases in activity within this region after seven months of treatment. Prior to starting DBT, treatment non-completers demonstrated greater activation than treatment-completers in the medial prefrontal cortex and right inferior frontal gyrus. Reductions in self-harm over the treatment period were associated with increases in activity in right dorsolateral prefrontal cortex even after accounting for improvements in depression, mania, and BPD symptom severity. These findings suggest that pre-treatment patterns of activation in the prefrontal cortex underlying impulse control may be prospectively associated with improvements in self-harm and treatment attrition for patients with BPD treated with DBT. (shrink)

When i was in graduate school, I inadvertently walked in on a fellow student taking his comprehensive exams. He was extremely frustrated because two of the questions asked about conceptual issues in personality and personality disorders. This student was not expecting such questions and considered them to be unfair. I knew other students in that same program who would have considered it a gift to get such “interesting” questions. Those clinical and counseling psychologists with theoretical–philosophical interests are (...) often attracted to the topics of personality and personality disorders. It has, therefore, puzzled me why these same topics are largely ignored by those philosophers who study the conceptual issues of .. (shrink)

Genetic and early environmental factors are interwoven in the etiology of Borderline Personality Disorder (BPD). Epigenetic mechanisms offer the molecular machinery to adapt to environmental conditions. There are gaps in the knowledge about how epigenetic mechanisms are involved in the effects of early affective environment, development of BPD, and psychotherapy response. We reviewed the available evidence of the effects of psychotherapy on changes in DNA methylation and conducted a pilot study in a sample of 11 female adolescents diagnosed with (...) BPD, exploring for changes in peripheral DNA methylation of FKBP5 gene, which encodes for a stress response protein, in relation to psychotherapy, on symptomatology and underlying psychological processes. For this purpose, measures of early trauma, borderline and depressive symptoms, psychotherapy outcome, mentalization, and emotional regulation were studied. A reduction in the average FKBP5 methylation levels was observed over time. Additionally, the decrease in FKBP5 methylation observed occurred only in those individuals who had early trauma and responded to psychotherapy. The results suggest an effect of psychotherapy on epigenetic mechanisms associated with the stress response. The finding that epigenetic changes were only observed in patients with early trauma suggests a specific molecular mechanism of recovery. The results should be taken with caution given the small sample size. Also, further research is needed to adjust for confounding factors and include endocrinological markers and therapeutic process variables. (shrink)