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Philosophical Questions about Personality Disorders, part 1: Introduction

My previous three posts moved through a recent defense of dimensional approaches to personality disorder to a set of philosophical questions about selfhood, identity, character, and moral responsibility that arise from any serious reflection on the concept of personality disorder.

Going forward, I would like to turn to recent philosophical work on and around personality disorder. Right now, I plan to discuss the work of Nancy Nyquist Potter and Hanna Pickard, both of whom have their doctorates in philosophy but also have some direct practice experience working with people diagnosed with personality disorders. I will probably do some bibliography snowballing along the way and take some detours. If I am feeling up for it, I may also go back to Karl Jaspers’ classic book and try to make sense of what he has to say about personality.

For today, though, I thought I would get my bearings by looking at a recent textbook on philosophy of psychiatry by Sam Wilkinson. I read this book about a year ago, and I have found it immensely useful for orienting myself in that field. Wilkinson, however, has rather little to say about personality disorders. He discusses them briefly in a chapter on moral responsibility and mental illness. He then returns, again briefly, in the final chapter of his book, in a section on “overlooked phenomena” in the field. I take this as solid evidence that, in fact, personality disorders are overlooked phenomena in the field of philosophy of psychiatry. It would be interesting to speculate about why that is.

In any case, Wilkinson offers the following sketch of philosophical problems that arise around personality disorder:

[T]o say that someone has a disorder, on one attractive view, is precisely to say that it is not part of someone’s personality, that it is something outside of them, something that afflicts them and something that they want to be rid of. So how can something be both a disorder and part of [someone’s] personality…? [W]hat is personality in general? In what senses might a personality be disordered? And what are these different categories of personality disorder? Are they legitimate? Are they useful? These are all deep and difficult questions.... Where personality disorder differentiates itself from these other disorders [e.g., depression and schizophrenia] is that these problems are seen as, first, the kinds of problems that can be chalked up to personality… and, second, as ‘ego-syntonic,’ namely, part of, or in keeping with, the individual’s personality. As we’ve said, there is no different, underlying person afflicted by an external condition. The problematic behaviors, deemed disordered, pathological, are part of who this person is. (pp. 292-3)

The central point here is that there is an at least apparent contradiction in the concept of personality disorder. On the one hand, when we ascribe a disorder to someone, the implication is typically that the disorder is not them, is separable from them. On the other hand, when we ascribe a personality disorder to someone, we appear to be saying that the problem is that person, rather than something separable from them. So the proposition “Joe has a personality disorder” appears to mean both “Joe has a condition separable from himself” and “Joe has a condition inseparable from himself,” which is absurd.

I think Wilkinson gets something very right here about how the term “personality disorder” comes across when it is not actively reflected upon. If I were teaching an introductory philosophy of psychiatry class, I would probably start the lecture in much the same way as Wilkinson. But then I would ask whether the contradiction is real or merely apparent.

Here is the problem, I think: the entire framework rests on a series of obscure metaphors—outside, part of oneself, “ego-syntonic,” etc. (In a future post, by the way, I hope to write about why I find the ego-syntonic/ego-dystonic distinction problematic.) There is at this point a vast literature on how much of our thinking about illness and disorder rests on such metaphors. These metaphors function rather like loose theories, insofar as one thinks of theories as collections of inferentially-related propositions. So, when I say that labeling something a disorder is treating it as something “outside” of myself, I am really speaking telegraphically. I am trafficking in a dense network of implicit premises. Perhaps, for example, I am saying that the illness is outside of me in the way that the enemy laying siege is outside the city. And since it is the enemy, after all, at the gates, I am obliged to adopt all the old martial virtues and go into battle with courage and honor. The enemy and I are radically different. We hate each other. Peace is impossible. QED.

A similar problem occurs when we try to clarify what it means to say that a disorder is part of me. All sorts of attitudes are inferential networks are possible here. There are possibilities for what Ian Hacking calls looping effects—taking up psychiatric labels and reworking and reappropriating them while also identifying with them. As the existentialists pointed out, there are many ways to interpret the claim, “This is who I am.”

To close, consider a basic clinical point: some people really like to externalize their condition (“That’s just my OCD talking”). Other people do not like this. Similarly, there is a lively debate about person-first versus what usually gets called “identity-first” language. Is Jackie a person with autism or an autistic person? Advocates of the former contend that the latter reduces a person to autism; advocates of the latter contend that the former implicitly endorses the stigmatizing and shame-engendering attitude that there is something wrong with being autistic. They suggest that they do not aim to “transcend” their autism. Autism or being Deaf (the other area where I think identity-first language has been most robustly defended), it is argued, are integral to the person’s identity, but, crucially, what it means to be autistic or Deaf is not determined from the outside, and not determined once and for all. So too we might suspect that there could be something more complex at work in statement, "My personality disorder is a central part of me" than the idea that what everything I do is explained by personality disorder as understood in, say, DSM-5. 

In short, “personality disorder” is not a contradictio in adjecto, an internally-contradicting expression. There is, however, something that leads us to think it is. What leads us is, I think, altogether more historically- and culturally-specific than we might realize.

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