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

Should Behavior Harmful to Others Be a Sufficient Criterion of Mental Disorders? Conceptual Problems of the Diagnoses of Antisocial Personality Disorder and Pedophilic Disorder

Generally, diseases are primarily harmful to the individual herself; harm to others may or may not be a secondary effect of diseases (e.g., in case of infectious diseases). This is also true for mental disorders. However, both ICD-10 and DSM-5 contain two diagnoses which are primarily defined by behavior harmful to others, namely Paraphilic Disorder and Antisocial (or Dissocial) Personality Disorder (ASPD or DPD). Both diagnoses have severe conceptual problems in the light of general definitions of mental disorder, like the definition in DSM-5 or Wakefield’s “harmful dysfunction” model. We argue that in the diagnoses of Paraphilic Disorder and ASPD the criterion of harm to the individual is substituted by the criterion of harm to others. Furthermore, the application of the criterion of dysfunction to these two diagnoses is problematic because both heavily depend on cultural and social norms. Therefore, these two diagnoses fall outside the general disease concept and even outside the general concept of mental disorders. We discuss whether diagnoses which primarily or exclusively ground on morally wrong, socially inacceptable, or criminal behavior should be eliminated from ICD and DSM. On the one side, if harming others is a sufficient criterion of a mental disorder, the “evil” is pathologized. On the other side, there are practical reasons for keeping these diagnoses: first for having an official research frame, second for organizing and financing treatment and prevention.

Understandable, but if those reasons are the only reasons for keeping such diagnoses in the book, then it is also an acknowledgment that the diagnoses are inaccurate. Furthermore (see my arguments against PD abolition), I always prefer to advocate for the route which acknowledges the truth and accuracy first and foremost, and works around that when it comes to other secondary barriers such as stigma or insurance issues.

Generally, diseases are primarily harmful to the diseased individual herself either by being directly life-threatening or at least life-shortening, or by causing pain or suffering, or by impairing her ability to live in human symbiotic communities (1). Harm to others, however, may or may not be a secondary effect of diseases. A typical example are infectious diseases which harm the infected individual and possibly others as well. A mere infection, however, is not called a disease as long as it is not and will not be harmful to the infected individual herself, even if it poses a risk to others as a secondary effect. This is evident from the example of asymptomatic carriers of pathogens. Although they may transmit the pathogen to others and harm particularly vulnerable, e.g. immunosuppressed people, medicine does not regard them as ill.1 Therefore, such persons should be described as being ‘disease-causing’ for others, rather than as being ‘diseased’ themselves.

footnote: Contrary to medical mainstream opinion, Hucklenbroich regards asymptomatic carriers of infectious diseases as ill. According to his theory (see The general concept of disease), asymptomatic carriers fall within the scope of disease criterion 5 (2).

If this is true for diseases in general, that they are primarily harmful to the individual herself, it should also be true for mental disorders as long as they are viewed as a subset of diseases. This is reflected in frequently cited attempts to formulate a general definition of mental disorder, like the definition in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (3) or the “harmful dysfunction” model by Wakefield (4). Both definitions characterize a mental disorder by, broadly speaking, a dysfunction in mental processes that is associated with harm to the affected individual.

For some psychiatric diagnoses, however, it is questionable whether the presupposition of harm to the individual really applies. We will show that several diagnoses essentially rely on behavior that is harmful to others, but not necessarily to the individual herself. This is especially true for the diagnoses “Antisocial Personality Disorder” (ASPD) in DSM-5 (or “Dissocial Personality Disorder” in ICD-10) and “Paraphilic Disorder” in DSM-5 and ICD-11.2 Instead, as we will show, another disease criterion comes in here: the criterion of “harm to others”.

In the case of Paraphilic Disorder, harm to others is a sufficient criterion. In the case of ASPD, it is a necessary one and, as we will argue, practically also a sufficient one. In addition to the harm criterion, getting another meaning, we will argue that the criterion of a mental dysfunction is unclear in these diagnoses. Thus, the diagnoses of ASPD and Paraphilic Disorder fall out of the general concept of diseases and even out of the general concept of mental disorders. Are they accordingly rather “moral disorders” than clinical disorders?3 If this is true, psychiatry contributes to a “medicalization” of morally wrong behavior (6). The conceptual problems of ASPD and Paraphilic Disorder lead to the fundamental question which criteria define a mental disorder.

footnote: Charland (5) argues that only the personality disorders in Clusters A and C are genuine clinical disorders. In contrast, he considers the Cluster B disorders (which include antisocial, borderline, histrionic, and narcissistic personality disorder) as moral disorders since their definitions are “morally loaded” and they require “moral treatment”.

I disagree that the current criteria for Cluster B disorders are, if interpreted literally, always indicative of harm to others. All of the criteria for ASPD can be technically interpreted in a manner in which the antisocial individual is still in the right. However, regardless of technicality, it is true that once you read further in the text of the DSM, they make it clear what they actually meant by the criteria—and their interpretation is far less favorable.

The aim of this paper is to discuss whther behavior harmful to others should be a sufficient criterion of mental disorder as it is the case in the diagnoses of ASPD and Paraphilic Disorder. If we come to the conclusion that this should not be the case, the question arises whether ASPD and Paraphilic Disorder should be eliminated from the diagnostic manuals.

Mental Disorders and Their Diagnostic Manuals

In probably no other specialty of medicine has the concept of “disease” been as contested as in psychiatry. Even though in psychiatry the term “disorder” is predominantly used, it can be regarded as synonymous to “disease”, especially regarding the practical consequences. Apart from the fundamental question whether there’s such a thing as “mental disorders” at all (7), and hence, whether psychiatry is a part of medicine at all, the nature and definition of mental disorders in general have been discussed (4, 8, 9). Other controversies concern the disorder status of specific mental conditions, the most famous example probably being the removal of homosexuality from DSM in 1973 (10, 11). A still missing stringent scientific basis and the important role of values (12) bring psychiatry into a position to constantly question its own presumptions about the concept of mental disorder.

Mental disorders are classified in two classification systems: First, the International Classification of Diseases and Related Health Problems, 10th revision (ICD-10), by the World Health Organization (WHO) (13). Second, for mental disorders only, the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), published by the American Psychiatric Association (APA) (3). The latter is “viewed as representing the cutting-edge of the field” (14).

lol (while the DSM-V has its issues, such as the ones described in this paper, it is significantly better than the ICD)

Both manuals define the current state of the art in psychiatric diagnostics and thus have a huge impact on clinical use but also on public discussions about mental health and finally, through their use in forensic settings, even on court rulings. The practical implications of the diagnostic manuals thus range from the funding of treatments by the public health system to the assessment of someone’s capacity to work, and indirectly to the evaluation of diminished criminal responsibility.4

footnote: A psychiatric diagnosis per se is not a reason for assuming a lack of criminal responsibility or diminished responsibility but it is part of the forensic examination. According to German criminal law, “[a] person acts without guilt who, at the time the criminal act is committed, is incapable of understanding the wrongfulness of his or her action or is incapable of acting in accordance with this understanding due to mental illness, due to a profound disturbance of consciousness, or due to mental retardation or another serious mental abnormality” [Section 20, German Criminal Code, English translation cited from (15)]. Diminished responsibility is present in the case of a diminished capability of the offender to understand the wrongfulness of an action or to act in accordance with this understanding due to one of the reasons indicated in Section 20 and may lead to mitigated penalty (Section 21, German Criminal Code). Section 20 lists four mental conditions that are necessary prerequisites for assuming a lack of criminal responsibility. However, these mental conditions are not equivalent to specific psychiatric diagnoses. They are legal terms that refer to psychiatric diagnoses (16).

The diagnoses in both diagnostic manuals rely on polythetic criteria sets, of which a specified number of criteria needs to apply for a specified period of time. Since the neurobiological underpinnings and the etiology of many mental disorders are still scarcely understood, the diagnostic criteria sets consist of observable and subjective symptoms. Contrary to most cases in “somatic medicine”, there are only few additional objective tests in psychiatry to support a suspected diagnosis (e.g. for dementias or autoimmune encephalitis).

Given their importance in the diagnostic process, the selection and exact formulation of the criteria of mental disorders are crucial. Changes in these criteria sets have a huge impact on the prevalence of certain mental disorders and on the lives of many individuals. It is thus not surprising that every revision of the diagnostic manuals is accompanied by extended controversies about the inclusion or elimination of diagnoses and the formulation of the diagnostic criteria sets (17, 18). Frances (19), for example, sharply criticizes a “diagnostic inflation” in psychiatry which he thinks was intensified by DSM-5 by adding more diagnoses and expanding the existing ones.

Mental Disorders Harmful to Others

The most contested diagnoses in DSM and ICD are probably the [paras] (20) and Cluster B-personality disorders (5).5

footnote: The general concept of the personality disorders has been criticized fundamentally. Lieb criticizes the concept of personality disorder as contradictory in itself and as harmful to the patient and to the therapeutic relationship (21).

I’m a bit annoyed at this—it’s really frustrating how people keep jumping straight to PD abolition the moment any reasonable critique of the current conceptualization of PDs is brought up. Points two and three would be easily solved by destigmatizing PDs.

Especially Paraphilic Disorder and Antisocial Personality Disorder (ASPD) or Dissocial Personality Disorder (in ICD-10) are highly controversial diagnoses. Some authors question their status as clinical disorders [for ASPD, see Charland (5)] or even their place in the manuals [for Paraphilic Disorder, see Green (22)].

Paraphilic Disorder and ASPD are particularly contested because both diagnoses are highly linked to socially deviant or even criminal behavior. Persons with ASPD and pedophilic sexual offenders have a significantly increased risk of (re-)offending (23–25). Sadler (26) calls such diagnoses “vice-laden” disorders, vice being understood in a “technical sense—as simply criminal and/or immoral thought or conduct” (p. 452) by the legal and moral standards of the respective society. The notion of “vice-ladenness” indicates that those disorders imply thoughts and behaviors typically described and assessed in moral and/or legal rather than in medical terms.

Paraphilic Disorder and ASPD are not the only mental disorders associated with behaviors usually described in moral terms and potentially harmful to others, though. A person suffering from schizophrenia, for example, will presumably show in some way socially deviant behavior and may even cause harm to others when, for example, following the commands of imperative voices.

I would nitpick at this a bit though—following the commands of voices saying to cause harm is not an inherent feature of the disorder, nor does hearing voices cause any actual egosyntonic desire to obey them.

The crucial point, however, is that in the case of schizophrenia the symptoms described in the diagnostic criteria set are “relatively immune to misconstrual as vice” (6) (p. 9). Immoral or harmful behavior is not a defining criterion of the disorder, rather it may or may not be a secondary effect of it. In contrast, for ASPD and Paraphilic Disorder, behavior that is morally wrong and primarily harmful to others is a central part of the diagnosis: they are “vice-laden” at their core.

Antisocial Personality Disorder (ASPD)

In an attempt to define reliably measurable personality traits,

(tl;dr they didn't want to bother with actually listening to patients describe our own symptoms and suffering, and didn't trust us to assess ourselves accurately because we're too mentally ill and insane to have any level of insight whatsoever, and because we're evil psychos we'll lie at the first opportunity)

the DSM focused on behavior in the definition of ASPD, which was intended to be an equivalent of psychopathy (3, 42). Psychopathy, conceptualized by the Hare Psychopathy Checklist Revised (PCL-R) (24), contains much more interpersonal and affective symptoms than ASPD (25, 43) but is not a diagnosis in ICD-10 or DSM-5 (44).8

footnote: ASPD and psychopathy are largely overlapping concepts. According to Ogloff (25), 81% of persons diagnosed with psychopathy also meet the criteria of ASPD, whereas only 38% of the persons with ASPD receive a diagnosis of psychopathy. This indicates that the population of persons diagnosed with psychopathy can more or less be considered a subset of the population of persons diagnosed with ASPD. Exceptions are typically fraudulent personalities (or so-called “white collar offenders”) who are psychopaths but do not meet the criteria of dissocial or antisocial personality disorder (45).

A couple days ago on Twitter, I suggested that a useful hack for researching what we call ASPD is searching “psychopathy” when you’ve run out of options, since the psychopathy checklists typically mention more of the affective traits found in actual ASPD, rather than just the behaviors listed in ASPD’s DSM-V criteria.

Almost all criteria of ASPD in DSM-5 refer to behavior primarily harmful to others (Table 3). In accordance with the diagnostic criteria required for all personality disorders, the antisocial personality traits must be “inflexible, maladaptive, and persistent and cause significant functional impairment or subjective distress” (3).

The equivalent of ASPD in ICD-10, Dissocial Personality Disorder (DPD), refers less to behavioral and more to affective symptoms than ASPD in its criteria set (25) (Table 3). However, as Kröber and Lau (15) note, most of the criteria can still be “easily derived from the criminal behavior itself” (p. 681).

The general criteria of personality disorders in ICD-10 require that “the disorder leads to considerable personal distress but this may only become apparent late in its course” and “the disorder is usually, but not invariably, associated with significant problems in occupational and social performance” (13) (p. 202).9

Even when we don’t realize we are distressed, we are distressed, we are suffering, even if it’s not obvious to us yet. (same concept applies to pro-contact grooming victims who don't recognize themselves as feeling distressed from their abuse until they become anti-contact)

footnote: For the sake of clarity, we will mainly refer to Antisocial Personality Disorder in this paper, even though many of the points made equally apply to Dissocial Personality Disorder. However, because of the stronger focus on behavior in ASPD compared with Dissocial Personality Disorder, we consider the diagnosis of ASPD as more problematic.

However, Habermeyer states that persons with antisocial or dissocial personality traits subjectively do not suffer from their abnormalities and show little willingness to get treated (16). This is accentuated for inmates with high values on the Psychopathy Checklist (16). Many, if not the overwhelming majority of subjects with psychopathy are perfectly content with and identify with their traits; there is no subjective suffering involved in psychopathy (42). Because there is nothing painful or ego-dystonic in psychopathic symptoms, it is unlikely that a psychopath would seek or endure treatment (42). Also persons with ASPD rarely seek treatment (43, 46), indicating that they usually do not feel significantly distressed or impaired by their condition. This becomes evident from the description of the self-image of people with dissocial or antisocial personality traits by Müller-Isberner et al.: “These people generally see themselves as autonomous, strong loners. Some see themselves as exploited and mistreated by society and justify harming others by saying that they themselves are being harassed. Others see themselves as robbers in a world where the motto is ‘eat and be eaten’ or ‘the winner takes it all’ and where it is normal or even desirable and necessary to violate social rules.”10 (47) (p. 373).

And these are common traits in ASPD because we were raised in an environment where every interaction was a zero-sum game, thus we by default apply that mentality to every interaction even when we have escaped our abusers. We cause harm (especially throughout childhood and adolescence) more often than prosocials not because we lose control of overpowering impulses, nor because we are inherently cruel and malicious, but because we were never taught the value of altruism, because we automatically assume that if we act altruistically or refrain from preemptively only prioritizing ourselves, we will be harmed.

Throughout my childhood, I was exactly like the people this paragraph describes. I was frequently abusive, and took pride in not being weak like I believed others were. I believed that if I didn’t hurt others, I would be hurt myself. Now, though? I am finally surrounded by people whom I can relate to and who don’t mistreat me or stab me in the back at every turn. I have a partner and an FP I actively care about, whom I remember when I think about causing harm. Sometimes I come close to going back to the way I used to be, but as time goes on I am further and further away from that person.

This raises the question whether the diagnosis of ASPD could be made for anyone at all if the criteria of subjective distress and/or functional impairment were strictly applied. In clinical practice, distress can be presumed if someone seeks help voluntarily. The question is why this person seeks help and what distresses her. According to the literature on antisocial personality cited above, it is probably not her antisocial personality. However, subjective distress “in general” is not sufficient to make this specific diagnosis, even if all the other criteria of ASPD apply. According to DSM-5, the subjective distress must be caused by the antisocial personality traits.

I disagree with this paragraph, as it ignores the biggest glaring problem in PD diagnosis and treatment. PDs are sneaky little bitches that as part of their function try to hide themselves from us, make us believe the problem is the world around us rather than something in our own heads. They cause us to believe we are not suffering even when we are very obviously suffering. (Not to mention the stigma on ASPD making it harder for us to feel safe seeking treatment.)

It could be objected that a lack of personal distress in ASPD is precisely part of its psychopathology, in the sense that not recognizing one’s own problems is even more pathological than recognizing them.

> lack of personal distress
> problems

Pick one. Is it because we aren’t distressed, or because we don’t recognize our distress?

However, the general problem with this argument is that it allows the attribution of mental disorders to persons without personal distress from the outside. Even though there are cases in which this can be justified (e.g. in the case of severe psychosis/delusions where the individual doesn’t recognize her psychosis/delusions), there is a high risk of misusing psychiatric diagnoses for pathologizing socially deviant or nonconformist behavior.

Slippery slope argument. There are ways to identify our distress when we don’t personally believe we are distressed without slippery-sloping into assuming all antisocial/divergent thoughts/behaviors are distressing.

The questionable personal distress in ASPD is especially relevant in the forensic context where the prevalence of ASPD is much higher than in the general population. The base rate in the population is estimated at 2%, whereas the prevalence among male prisoners is estimated at between 47 and 80% (25, 48). Prisoners are certainly distressed. However, distress because of the legally justified consequences of antisocial behavior, like a loss of freedom, must not be confused with distress because of the antisocial personality traits themselves (49). Distress because of society’s negative reaction to deviant behavior is not a sign of a mental disorder. Rather, it is normal. We suspect that the criterion of subjective distress and/or impairment often is not considered correctly when the diagnosis of ASPD is made, especially not in forensic contexts. The great difference between the prevalence of ASPD in the general population and among male prisoners indicates a strong correlation between ASPD and imprisonments. This means that either most criminals have a mental disorder or that ASPD is a construct mainly depicting criminal behavior.

We conclude that, strictly speaking, many persons diagnosed with ASPD in fact only have antisocial personality traits, which are not a mental disorder according to DSM-5. This conclusion is supported by the observation of Herpertz that a lack of considering the general definition of personality disorder and instead a focus on the easily applicable specific criteria lists led to an “inflationary diagnosis frequency” of personality disorders (50). We suspect that, especially in the case of ASPD, many persons are mistakenly classified as “mentally ill” because of a wrongful interpretation or even neglect of the distress/impairment criterion.

So, ASPD likely overdiagnosed in prisoners, and others who receive negative consequences for causing harm. I’m not surprised.

ICD-10 and DSM-5 present a categorial classification of personality disorders with ASPD/Dissocial Personality Disorder being a distinct disorder-entity. This categorial approach to personality disorders, however, is broadly contested (50). DSM-5 already introduced an alternative “hybrid” model for personality disorders, mixing categorial and dimensional approaches.11

footnote: The alternative model for personality disorders in DSM-5 has been developed for further research (Section III). In the alternative model, personality disorders are generally characterized by impairments in personality functioning (Criterion A) and pathological personality traits (Criterion B). Personality functioning (Criterion A) involves self-functioning (identity and self-direction) and interpersonal functioning (empathy and intimacy). For each of these four elements, five levels of impairment (ranging from no impairment to extreme impairment) can be differentiated. Pathological personality traits (Criterion B) are organized in five broad domains, namely negative affectivity, detachment, antagonism, disinhibition, and psychoticism. The impairments in personality functioning and personality trait expression are relatively inflexible and pervasive across a broad range of personal and social situations (Criterion C). They are relatively stable with onset in at least adolescence or early adulthood (Criterion D), cannot be better explained by another mental disorder (Criterion E), are not attributable to the physiological effects of a substance or another medical condition (Criterion F), and not better understood as normal for an individual’s developmental stage or sociocultural environment (Criterion G) (3) (pp. 761–3).

I strongly disagree with the alternative model for PDs presented in the DSM-V because it differentiates between different conditions by surface-level traits, and ignore that the core of each PD is wildly different. Same effects =/= same causes.

According to the alternative model, the typical features of ASPD are “a failure to conform to lawful and ethical behavior, and an egocentric, callous lack of concern for others, accompanied by deceitfulness, irresponsibility, manipulative-ness, and/or risk taking” (p. 763). Psychopathy is described as a distinct variant that is “marked by a lack of anxiety or fear and by a bold interpersonal style that may mask maladaptive behaviors (e.g., fraudulence).” (3) (p. 765).

ICD-11 goes even further in replacing the categorial model by a dimensional one (50). According to this model, the diagnosis of a personality disorder comprises three steps. First, the general criteria of a personality disorder must be met (“problems in functioning of aspects of the self […], and/or interpersonal dysfunction […] that have persisted over an extended period of time (e.g., 2 years or more)”, “the disturbance is manifest in patterns of cognition, emotional experience, emotional expression, and behaviour that are maladaptive”, “the disturbance is associated with substantial distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning” (34)). Then, the severity of this general personality disorder must be determined (mild, moderate, severe).

Heavily problematic, as PD activists have repeatedly discussed. Am currently working on a post gathering opinions on why it’s a terrible idea.

Eventually, the specific underlying personality structure is assessed according to five personality domains (negative affectivity, detachment, dissociality, disinhibition, anakastia).

Hardly “underlying.” Most of these are effects, not causes.

Thus, in ICD-11, there will be no category “Dissocial Personality Disorder” anymore. Instead, dissocial and disinhibited traits and behaviors may be a specifier among others in a diagnosis of a (general) personality disorder.

Interim Conclusion

In both the definitions of ASPD and Paraphilic Disorder behavior harmful to others or even criminal behavior is a criterion for the diagnosis of a mental disorder. For Paraphilic Disorder, even though harming others (for a period of at least 6 months) is not a necessary criterion, it can be a sufficient one. For ASPD, repeated harming of others is a necessary criterion, and—not formally, but practically—also a sufficient one.

The key question is: Should criminal behavior/harm to others be a sufficient criterion of a mental disorder? Or does this lead to a “medicalization” of vice conditions, meaning that “all problematic deviance reflects human illness or injury, including criminality and ‘immoral’ conduct” (6) (p. 12)? The crucial point is: can behavior harmful to others alone indicate the presence of a mental disorder? Or is this rather an attempt to “pathologize the morally wrong”? We will come back to this question later.

The conceptual problems of Paraphilic Disorder and ASPD lead directly to a more fundamental question: which criteria define a mental disorder?

Since my whole review was too long to fit into one Dreamwidth post, I posted part two here.

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

(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.