One of the categories of Psychiatric illness is the Disorder of Adult Personality. ICD-10 features the Personality Disorder in Section F60-69 and the diagnostic features can be viewed online here. The Personality Disorders are complex and many professionals will spend their entire careers in the study of the Disorder of Personality as well as the clinical management of people who have received this diagnosis. The Personality Disorders are controversial for many reasons. These controversies range from consideration of whether a core feature of our identity can be medicalised through to the accuracy of these labels in describing such an identity across many settings. The overlap between many of the Personality Disorders also presents challenges. Many of these discussions are played out in the establishment of services such as the Dangerous Severe Personality Disorder services. A key feature of Personality Disorders though is that they are maladaptive. In other words in social groups, the Personality Disorder would causes difficulties for the person and others within the group. Looking at the conditions described in ICD-10 and selecting the Dissocial Personality Disorder, perhaps the most widely known of the Personality Disorders we can see a number of the features including a
‘Disregard for social obligations‘
This leads on to the subject of interest – how do values and illness interact? The Personality Disorders are the best example of this interaction. So why would those with a diagnosis of Dissocial Personality Disorder have a ‘disregard for social obligations’? The description of the Personality Disorders leaves a lot of scope for interpretation and the existence of these features is a key part of the diagnosis. Once this is acknowledged the Biological/Psychological/Social Models are invoked and explanations ranging from the immature Cerebral Cortex through to experienced trauma are invoked. However I would argue that there is a key step which is being missed in the movement from identification of features to explanatory models and that is the invocation of capacitious decision-making
A Role for the Will – Is there a Volitional Class of Disorders of Adult Personality?
I would argue that with regards to ‘disregard for social obligations’ a key question needs to be asked. Has the person made a conscious decision to hold these values with an understanding of the consequences. In other words are these capacitous values. By considering the will, the ability of a person to make capacitious decisions we can divide people showing a ‘disregard for social obligations’ into two groups – those that have made this out of choice and those that have not. For those that have made the explicit decision to hold these values they could be classed as a ‘Volitional’ Dissocial Personality Disorder. In this case, if the person is seeking help to relate with others their treatment approach would necessitate capacitious decision making with regards to treatment.
Are there Non-Volitional Disorders of Adult Personality?
There are two obvious reasons why a person might hold these values regarding social obligations
1. These values were learnt during a period when the person was non-capacitous – in early childhood for instance. The difficulty here is that disorders of emotion and attachment in Childhood do not necessarily lead to disorders of Adult Personality. Similarly not all people who develop disorders of Adult Personality have experienced difficulties in Childhood. A consideration of age and development issues does not necessarily fully address the subtleties of maladaptive Personality and perhaps would not be expected to given the many experiences we have which are able to shape our Personality. Nevertheless the issue of capacity with regards to values may be useful in areas of scientific enquiry investigating these conditions in more detail.
2. The person does not have the biological apparatus necessary to understand social meaning. Empathy is the construct most relevant to this possibility. If a person lacks the ability to understand another person’s mind then a ‘Disregard for social obligations’ moves away from being a choice to a Disorder of Understanding. Professor Simon Baron-Cohen’s ‘Zero Degrees of Empathy’ explores this subject in more detail. The most widely known disorders of Empathy are the ‘Autistic Spectrum Disorders’ and here there has been a large body of literature exploring underlying neurobiological explanations.
Whilst the above is merely speculation based on a consideration of the issues the subject of how we choose to hold the values we do has many profound implications which extend far beyond discussions of health and illness.
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