Should harm to others be part of the ASPD criteria: a review (part two)

[anankastia]

(continued from Part One)

The Definition of Mental Disorder

The General Concept of Disease

If psychiatry claims to be a part of medicine, a general definition of disease should be the basis of a definition of mental disorders. Hucklenbroich developed a profound reconstruction of the general concept of disease (51). He distinguishes four levels of the concept of disease. The first level is the life-world and personal concept of disease (person X is ill). On the second level, a distinction can be made between healthy and pathological life processes (X is pathological). At the third level, reference is made to a standard model of the human organism (X is pathologically altered). At the fourth level, disease entities and categories are postulated (X is a disease). The basis of the determination of disease entities is an etiopathogenetic model that comprises an identification of primary causes and the typical clinical course.

According to this reconstruction, life processes that meet four criteria can be described as pathological: 1. They are states, processes, or procedures in individuals, 2. which are attributable to the organism, not the environment, 3. which take place independently of the will and knowledge of the affected individuals, and 4. for which there is at least one non-pathological alternative course.

To determine which processes are diseases, Hucklenbroich distinguishes positive and negative disease criteria. Positive criteria of a disease are: 1. lethality; 2. pain, discomfort, suffering; 3. disposition for 1 or 2; 4. inability to reproduce; 5. inability to live together. The two negative criteria of disease, which determine a condition as non-pathological, are 1. universal occurrence and inevitability, e.g. gender, intrauterine and ontogenetic phases, pregnancy, menopause, old age, natural death; 2. knowingly and intentionally self-induced behavior (as long as self-determination is not diminished), e.g. suicide, value judgements, risky behavior, abstinence, intentional lying.

Hucklenbroich argues that this general concept of disease also applies to mental disorders, even though an etiopathogenetic disease model like in “somatic” medicine is still missing in psychiatry (2). According to his model, especially the positive criteria 2 and 5 are relevant for mental disorders. Mental disorders are often associated with significant pain, discomfort or suffering. Additionally, they may impair the ability to live together with others in a community. However, Hucklenbroich notes that due to the lack of knowledge about the etiopathogenesis of mental disorders there are still diverging concepts of mental disorder (2).

The DSM-5 Definition of Mental Disorder

One of the mostly cited definitions of mental disorder is given in DSM-5. While conceding that “no definition can capture all aspects of all disorders in the range contained in DSM-5” (3) (p. 20), it is stated that the definition is rather meant to formulate elements required for considering something a mental disorder:

“A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g. political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.” (3) (p. 20, emphasis added)

The definition starts with 1. an observable symptom level (“clinically significant disturbance”) that is 2. caused by an underlying dysfunction in the “mental domain” of an individual, and that has 3. some expected consequences, namely distress or disability in important activities of daily life. The rest of the definition specifies circumstances under which certain conditions are not deemed mental disorders: Socially deviant behavior and conflicts between the individual and society, which are not the result of a dysfunction, are not considered mental disorders.

The last point seems to be crucial. Pedophilic Disorder and ASPD are, prima facie, conditions that are mainly based on a conflict between the individual and other individuals and/or society.12

footnote: As soon as a crime is committed against an individual person, the perpetrator comes into conflict not only with the victim but also with the society whose moral or legal norms have been violated.

A person with Pedophilic Disorder could argue [pro-contactism (see: fedi pro-c’s being assimilationist trash)].13 Or a person diagnosed with ASPD could argue that he does not feel bothered by his antisocial behavior because he has many advantages by it, although he might come into conflict with the law unless he is careful.

Another reason why ASPD should not be defined by behavior.

According to DSM-5, socially deviant behavior can be a sign of a mental disorder only if it results from a dysfunction in the individual’s “psychological, biological, or developmental processes underlying mental functioning”. However, the behavioral symptoms described in the diagnoses of ASPD and Pedophilic Disorder can have very different causes. Indeed, the lack of differentiation between the different causes of mental disorders is a fundamental problem of the nominalistic approach of DSM and ICD.

Also for antisocial behavior, there are associations between damage of the prefrontal cortex, be it due to a head injury or due to neurodegeneration like in Frontotemporal Dementia, and the occurrence of antisocial behavior in previously normal people (57). Cases of severe ventromedial prefrontal lobe epilepsy have been described that were associated with persistent antisocial behavior that was reversible after epilepsy surgery (58). In these cases, abnormal behavior is associated with a brain pathology which suggests a causal link between this pathology and the deviant behavior.

On the other hand, someone can behave in the same way for completely different reasons. For example, someone could live in a subculture where it is normal to behave in an antisocial or even criminal way to be “successful”. If it is normal in the social environment to make a living from, for example, drug dealing or criminal financial transactions, it could be reasonable to follow this tradition. Another example is someone who shows hypersexual behavior because he simply has no reason to confine himself due to money and power. In these cases, there is no reason to assume an underlying pathology. It is rather a morally questionable behavior.

The point here is: the fact that there are cases of brain pathologies leading to disinhibited or antisocial behavior doesn’t imply that all people behaving in the same way have a brain pathology.

Wakefield’s “Harmful Dysfunction” Model

The question of the underlying dysfunction in ASPD and Pedophilic Disorder seems to be crucial for defending their status as mental disorders. A frequently cited concept related to the DSM definition of mental disorder is Wakefield’s “harmful dysfunction” model (4). This model assumes that a mental condition can be classified as a mental disorder when two criteria apply: Firstly, it is the result of a dysfunction, understood in an evolutionary sense as the failure of a process to perform the function it was biologically designed for; secondly, it is harmful to the individual according to sociocultural standards (4). By this definition, Wakefield tries to escape definitional problems by combining, as he calls it, a “value term” (harm) and a “scientific and factual” term (dysfunction) (4). The idea is to evade two problems: On the one hand, a mere “scientific” concept of mental disorder leads to the problem that every deviation from a scientifically defined standard could be viewed as a mental disorder even though the affected individual is neither suffering nor impaired. On the other hand, a mere value-based concept of mental disorders entails the risk of pathologizing socially disvalued behavior. Thus, according to Wakefield, only a harmful dysfunction represents a mental disorder, not a dysfunction without any harm to the individual nor something evaluated as harmful (according to sociocultural standards) but without representing a dysfunction.

We will come back to the notion of dysfunction in Pedophilic Disorder and ASPD later. Regarding the harm criterion, ASPD and Pedophilic Disorder are special since most mental disorders are primarily harmful to the affected individual. For “vice-laden” disorders like ASPD and Pedophilic Disorder, however, the “harm-criterion” primarily concerns others.

Some persons with ASPD, however, may even enjoy real benefits through their special personality traits, both in terms of income and reproductive success.

Alternative Definitions of Mental Disorder

In the diagnoses of ASPD and Pedophilic Disorder, harm to the individual in the sense of personal distress or impairment is not necessarily implied. However, harm to the individual might be present even without the person concerned being aware of it. The philosopher Graham (59) states that having a mental disorder does not necessarily comprise the recognition of its harmfulness by the affected individual herself. According to Graham, a mental disorder is a disability, dysfunction or impairment in one or more basic mental or psychological faculties or capacities of a person that has harmful or potentially harmful consequences for the person concerned (59) (p. 28). It is a disorder because it is harmful in the sense that the person is worse off with the disorder than without the disorder, that she cannot control it, and that it cannot be removed by using additional psychological resources, e.g. by simply “pulling oneself together”.

In the case of ASPD, one could argue that the person is worse off with the disorder than without it because he is, for example, not able to have good relationships with other people. This, however, presupposes a certain model of good relationships and a “good life”, and therefore is value-laden and moralistic.

Heinz et al. (60, 61) argue for a differentiation between mental diseases in a narrow sense and states of suffering or disorders in a broader sense that do not meet the criteria of a disease. This differentiation, however, is not made by DSM and ICD where the notion of mental disorder is used for all diagnoses. Heinz et al. demand that the notion of mental disease should only be applied when life-relevant functional abilities are impaired and the affected person suffers from it or is impaired in her ability to cope with everyday life. Applying such a standard, many currently classifiable disorders are not diseases in this sense (60, 61). However, they are more or less easily classifiable states of suffering for which psychotherapeutic help and possibly drugs can be offered (60, 61). In this sense, Pedophilic Disorder and ASPD are not mental diseases.

What is a Mental Dysfunction?

The concept of mental dysfunction is central in most definitions of mental disorder. However, there is no consistent definition of this concept. For example, DSM-5 uses the notion of dysfunction without elucidating it.

Schramme (62) distinguishes four models of mental functions. The first model, for which Wakefield’s concept of dysfunction is the most prominent example, is based on evolutionary psychology. According to Wakefield, mental functions result from selection processes and thus enable individuals to solve problems of adaptation (4). Schramme rightly criticizes the historical orientation of this theory: Some processes may have been adaptive to past environments but not to our present environment. The second model of mental functions comes from cognitive psychology. Functions in this sense are best understood in formal terms as “input–output-relations”, not in any teleological sense. Schramme notes that this theory hardly applies to the concept of mental disorder, because it does not imply “normativity”, that means, it has no concept of how a mental function should work, and thus no concept of dysfunction. The third model supports a goal theory of function and is close to Boorse’s disease theory that identifies survival and reproduction as the highest goals of organisms (8). Mental functions are thus understood through their relation to these goals. In contrast to evolutionary psychology, this model does not refer to the evolutionary selection of these functions but evaluates them with regard to the present environment. Schramme, however, criticizes that this model lacks a plausible model of the “psychological species design” with regard to survival and reproduction. The fourth model is the ‘value-theory’, for which there is no established psychological account. This model determines functions according to their contribution to human welfare and the good human life. A mental function thus allows for the individual to live a good life. However, such a theory is always at risk of confounding a certain way of life with mental health.

Discussing the Disorder Status of Pedophilic Disorder and ASPD

As we have argued, in both the definitions of ASPD and Pedophilic Disorder behavior harmful to others or even criminal behavior is a criterion for the diagnosis of a mental disorder.

If we thus conclude that ASPD and Pedophilic Disorder are just a “medicalization” of vice conditions, we have to ask whether and, if so, how these diagnoses can still be justified within a medical model.

Neurobiological Findings in Pedophilic Disorder and ASPD

The most influential argument to justify the diagnoses of ASPD and Pedophilic Disorder within a medical model seems to be a “conservative” one. These diagnoses are well established, they have a long clinical tradition and some prognostic utility (18). This supports the argument that they should only be changed if there is strong empirical evidence that another nosological construct is more valid than the established ones.

The idea of a validation of the existing nosological constructs is pursued by researchers investigating underlying neurobiological and neuropsychological alterations in persons with ASPD or Pedophilic Disorder. There is a growing body of research indicating that there might be deviations in the brains of persons with ASPD and Pedophilic Disorder. However, the interpretation of these findings needs to be handled with care: Are the neurobiological deviations a sign of a pathology, or a sign of a vulnerability, or a consequence of a disease, or only a normal variant? And further, can these neurobiological differences causally explain the behavior (at least partly)?

For ASPD, studies show structural and functional deviations mainly in the areas of the amygdala, the striatum and the prefrontal cortex (43, 57, 63). Genetic etiological studies suggest an association of a gene x environment interaction of MAOA enzyme deficiency and childhood maltreatment with antisocial behavior (57, 63). Evidence for developmental factors in the etiology of ASPD comes from studies that suggest a link between prenatal factors, such as birth complications, maternal smoking and alcohol consumption during pregnancy, or prenatal nutritional deficiency, and the occurrence of antisocial and violent behavior (57, 64). Also, an association between maltreatment during childhood and maternal withdrawal in infancy and ASPD has been found (64). These findings suggest, that biological and social factors play a role in the development of ASPD, while “the presence of both factors exponentially increases the rates of antisocial and violent behavior” (64) (p. 4).

In the case of ASPD, the main methodological problem seems to be confounding variables, since most of the persons with ASPD show psychiatric comorbidities like substance use disorder or mood disorders (43). Another problem is the questionable homogeneity of persons that fulfill the criteria of ASPD. A study by Gregory et al. (71), for example, found significant differences in gray matter volume in the prefrontal cortex between offenders with ASPD and additional psychopathic traits and offenders with ASPD without psychopathic traits, but not between offenders with ASPD without psychopathic traits and non-offenders.

These findings show the need for better study designs to get more reliable results. However, even if we get better results, we still face the general problem of interpreting neurobiological differences as indicated above. The finding of a neurobiological difference is not equivalent to a dysfunction, understood in psychological terms. The question of dysfunction is superior to it. An atypical structure or function of the amygdala, for example, is not per se dysfunctional or pathological. The assessment of its dysfunctionality depends on its assumed effects on the psychological and behavioral level, and how these effects are evaluated. An atypical function of the amygdala could even be evaluated as advantageous because it is associated with less anxiety.

Dysfunction in Pedophilic Disorder and ASPD

A crucial point in any discussion about the disorder status of a mental condition is the question if there is a convincing model of dysfunction, understood in psychological terms. In the case of ASPD, one could argue that antisocial behavior represents a dysfunction in social functioning. This argument implicitly presupposes that prosocial behavior is normal human behavior. However, under an evolutionary account, in many or even most societies during human history antisocial behavior was probably “adaptive” because it was the “normal and efficient” way to success, both in terms of reproduction and material wealth. Only in civilized societies governed by the rule of law, antisocial behavior becomes less adaptive than prosocial behavior and is considered abnormal and dysfunctional.

Some authors suggested that psychopathy could also be understood in evolutionary terms due to frequency-based selection as “adaptive” behavior (49, 75). According to this idea, a society with a prosocial majority can tolerate a small number of psychopaths that pursue their goals without being restrained by “other-regarding norms”. Reimer (49) argues that the typical personality traits of psychopaths, like experiencing less anxiety and being able to resist attempts of “moral” social reinforcing, can also be understood as advantageous under a pro-individualist account of human existence. Maibom argues that psychopathy is not a disorder at all, but “from a certain perspective, what we call deficits are actually advantages” (75) (p. 34).

If there are certain traits (such as self-determined morality, lack of affective empathy, remorse, anxiety, etc.) present in an individual without other accompanying negative/distressing psychopathy/ASPD traits (chronic boredom, egodystonic impulses, etc.), then they are neurodivergent (not sure what exactly would be optimal to call it yet), but definitely not disordered, or at least not inherently disordered.

Practical Arguments for Considering Pedophilic Disorder and ASPD as Mental Disorders

Classifying something as a mental disorder is not only a theoretical question, but also has practical implications that need to be considered.

Most persons with Pedophilic Disorder and ASPD don’t seek help (11, 43). For ASPD, individuals presumably often don’t feel pain and thus have no motivation to change their condition (46).

In many countries, the diagnosis of a mental disorder justifies treatment within the publicly funded health system. For that reason, the diagnoses of ASPD and Pedophilic Disorder can serve a useful purpose for individuals who feel distressed by their condition. If the health system with its long clinical experience can offer help, then it should do so (72).

However, the question is whether we need the diagnoses of Pedophilic Disorder and ASPD so that these persons can get help. For social problems social institutions outside the health system could be conceivable that offer help. Even if these diagnoses were removed from the diagnostic manuals, people could get help within the health system for comorbid conditions like depression or anxiety disorder if these mainly cause their personal distress.

ASPD is also associated with anxiety disorders and substance use disorders. For the latter a prevalence of 80–85% among persons with ASPD was reported (43).

One could object that these comorbidities possibly are a consequence of the Pedophilic Disorder or ASPD and therefore the focus of treatment should be the Pedophilic Disorder or ASPD as the primary condition. However, the fact that there are almost no effective treatments for Pedophilic or ASPD yet indicates that what actually can be treated within the health system might rather be associated disorders like depression, anxiety, or substance use disorder and not ASPD or Pedophilic Disorder itself.

Both, ASPD and Pedophilic Disorder, are supposed to be associated, besides others, with neurodevelopmental factors (57, 66), which makes it difficult to therapeutically intervene as late as in adulthood. The goal of therapies is thus rather the prevention of future deviant behavior in order to avoid harm to others.

For ASPD, a meta-analysis by Wilson (83) shows no significant effects of treatments. A lack of high-quality studies and small sample sizes might contribute to these findings. Better designed studies with larger sample sizes are required for future research.

It seems necessary to classify ASPD and Pedophilic Disorder as mental disorders in order to facilitate further research on them, gain better insights into their etiology, and develop new therapies.

If those are your only reasons that’s kinda sad lmao

The example of the “psychopathy”-concept, however, shows that there can be a lot of research on a concept without being an official diagnosis in DSM and ICD (44). The psychopathy-checklist (PCL-R) is widely used in forensic contexts to reliably assess the risk potential of criminals with psychopathic traits (24). Since psychopathy does not need to be a diagnosis in DSM and ICD to be a broadly applied concept, it seems that ASPD and Pedophilic Disorder do not need it either.

Similar to psychopathy, ASPD and Pedophilic Disorder are most relevant in forensic contexts (25, 38). Apart from clinical utility, the forensic implications of these diagnoses need to be considered.

And this is a problem, because we cannot get a full picture of ASPD without studying how it presents outside of forensic contexts.

Conclusions 

“Vice-Laden Disorders” in Psychiatry

Diagnoses that primarily rely on behavior harmful to others, like Pedophilic Disorder and ASPD, fall out of the general disease concept. They even do not meet the general criteria of mental disorders as defined by DSM-5 or the “harmful dysfunction” model by Wakefield. Neither the criterion of harm to the individual himself, nor the criterion of a dysfunction are met in these two diagnoses.15

footnote: However, this conclusion is not equally applicable to definitions of mental disorder that do not require that the individual recognizes the harmful consequences of his condition, like the definition of Graham (59).

Instead, they rely on another disease criterion: the criterion of harm to others. Psychiatry brings itself into great conceptual difficulties by making behavior harmful to others/criminal behavior a central part of the definition of some mental disorders, while at the same time lacking a clear concept of dysfunction in these cases. When diagnoses are formulated in a way that makes it possible to apply them to mere antisocial and criminal behavior, psychiatry is at risk of confounding the medical and the moral.

Furthermore, the purely behavioral diagnoses do not reveal whether the behavior is based on a mental dysfunction or whether it was chosen voluntarily or for specific reasons.

Therefore, the formulation of the criteria sets of “vice-laden” disorders needs to be done very cautiously in order to avoid a confusion between criminal/immoral behavior and mental disorder. It should not be possible that harming others/criminal behavior defines a mental disorder. A psychiatric diagnosis should not only rely on observable behavior, but consider psychological, cognitive, or affective factors as well.

After considering the arguments for and against the disorder-status of Pedophilic Disorder and ASPD, we come to different conclusions regarding both diagnoses.

The Disorder-Status of ASPD

In the case of ASPD, however, we think that the arguments to remove it as a distinct diagnosis from the diagnostic manuals are stronger than the ones to keep it. Especially the presumed lack of personal distress of individuals with ASPD and the strong correlation with criminal behavior and incarceration indicate that this diagnosis is more of a social than a mere health-related problem.

We agree with Kröber and Lau (15) who said: “If those with antisocial personalities, like anyone else, are subject to social influences and learning processes, they act as rational and competent citizens; their decision against behaving in compliance with standards should not be considered as pathologic.” (p. 687).

Herpertz and Sass (90) warn of the consequences of confounding antisocial behavior with “real” disorders in forensic psychiatry: “If the forensic psychiatrist fails to distinguish clearly between simple antisocial behaviour and a profound disturbance in personality, psychiatry runs the risk of being charged with handling all kinds of recurrent social deviance and delinquency. This would greatly hamper our capacity to treat those offenders who show real and treatable mental disorders.” (90).

As Gert & Culver (41) put it: “If psychiatry is to take its place as a branch of medicine, mental disorders, like physical disorders, should be limited to conditions that cause harm to the person with the disorder.” (p. 489).We think that the implementation of a dimensional model of personality disorders, as introduced by ICD-11, will mitigate the problem of attributing a diagnosis of mental disorder to mere criminal behavior. The ICD-11 does not contain the diagnosis “Dissocial Personality Disorder” anymore. Antisocial or dissocial personality traits will then be a specifier among others in the diagnosis of a general personality disorder. Thus, with this new model, the focus will hopefully be more on the cognitive, affective and interpersonal dimensions of personality disorders while avoiding an overly focus on deviant behavior.

To summarize: We suggest removing ASPD from the DSM, and support the planned removal of the diagnosis DPD from the ICD-11.

*sigh*

stares in we can focus more on the cognitive and affective dimensions of personality disorders and ditch the parts about harmful/abusive behavior by editing categorical criteria, without shifting to a dimensional model which abolishes all the differentiations between each separate disorder and relies on surface-level effects rather than underlying causes

also while the current diagnostic conceptualization of ASPD is heavily flawed, it comes slightly close and its effects are often caused by an underlying set of causes which I and like-minded individuals in the community label “actual ASPD” and which are defined by divergence and/or distress to the individual, initially noticeable or not, and depriving us of language and terminology (already approved by the community) to describe our struggles is in fact counterproductive to your intended goal of destigmatization and support of the mentally ill

once more: reform > abolition when it comes to psych

However, it does correctly touch on a major point which we PD advocates frequently discuss: that anyone, regardless of neurotype, is capable of violence and abuse, and that prosocial egotypicals want to pathologize abusive/violent behaviors in large part because they wish to Other the individuals who commit such acts, rather than admit that they themselves are perfectly capable of doing harm, and addressing the structural issues within their own communities which enable such behavior.

Practical Implications

Our suggestion to remove or reformulate the “vice-laden” diagnoses does not imply the demand for stopping research on them—quite the contrary. Especially in the forensic context, it is important to find opportunities to effectively prevent their harmful consequences and develop treatment methods insofar this is possible. The concept of psychopathy shows that an official diagnosis is not necessary for research to be done on forensically relevant conditions.

Good point—psych isn’t just for mental illnesses, nonpathological abusive & offending behavior is researched by it too, & I think ppl forget that sometimes.

Regarding antisocial behavior, we think that it is much more of a social problem that has to be addressed more by other societal systems than the health system.

Feel free to ask more questions on my opinions regarding specific parts of the paper, but so far this is what I could come up with.