Those with antisocial
personality disorder are not mentally ill. Discuss this statement.
Introduction
- perhaps the area of forensic psychiatry that has dominated the popular press in the last year or so is the area which deals with the question of how society should deal with those that it would rather not think about
- the subject of antisocial personality is where medicine and law collide and come up with the conclusions that the other one should be responsible from protecting ordinary Joe Public from those who present an unacceptable risk in this day and age
Definitions
- it would probably be helpful to actually define the terms that we will be using
- those with antisocial personality disorder, as defined by ICD-10, will firstly meet the general criteria for personality disorder, which are as follows:
- the individuals characteristic and enduring patterns of inner experience and behaviour deviate markedly from the normal range
- these deviations are manifest in the individual's cognitions, affectivity, control over impulses and gratification of needs, and the way in which they relate to others
- the behaviour is dysfunctional across a broad range of situations
- there is personal distress and/ or adverse impact upon the social environment
- the deviation is stable and of long duration
- the behaviour is not due to other mental disorders or organic brain disease
- to be diagnosed as antisocial personality disorder, the individual is characterized by:
- callous unconcern for the feelings of others
- disregard for social norms, rules and obligations
- difficulty maintaining enduring relationships, but with not difficulty in establishing them
- low tolerance to frustration and low threshold for violence
- inability to experience guilt, or profit from adverse experience such as punishment
- inability to accept responsibility for his/ her own actions
- psychopathic disorder is a legal term which is only valid in England and Wales - it has no validity at the current time in Scotland
- it refers to a 'persistent disorder or disability of mind (whether or not including significant impairment of intelligence), which results in abnormally aggressive or seriously irresponsible conduct'
The area of debate
- perhaps the reason why problems exist is that both camps refuse to accept responsibility for those individuals with antisocial personality disorder who fall under the criminal justice system
- why should this be?
- it may be helpful to look at the evidence for and against antisocial personality disorder being included within the rubric of medical illness
Antisocial personality disorder is a medical illness
- many studies have found a high MZ:DZ ratio when looking at offending rates among twins
- this suggests that there may be some shared genetic component contributing to antisocial behaviour
- EEG studies have, for a long time, reported abnormalities in those who have antisocial personality disorder or antisocial traits. These abnormalities are:
- a bilateral excess of slow waves (theta waves)
- right-sided abnormalities, particularly in the posterior temporal regions
- there is also evidence that links aggressive behaviour to serotonergic function within the brain:
- low levels of 5-HIAA (a metabolite of 5-HT) have been found in the CSF of those who have committed acts of unpremeditated violence
- a similar finding is found in those who have committed suicide, although it is difficult to tell whether this is cause or effect
- there is a negative correlation between levels of CSF 5-HIAA in rhesus monkeys and aggressive acts
Antisocial personality disorder is not a medical condition
- it is difficult however, to claim that some of the above findings are causative of antisocial behaviour and aggression
- there is much to suggest that antisocial behaviour in later life is linked to poor parenting and conduct problems in childhood:
- the famous Isle of Wight Study by Rutter in 1970 found a high correlation between childhood conduct disorder and offending in later life
- disharmony in the parental marriage was found to be linked with antisocial behaviour
- some of the links between offending in fathers and sons could be because of a shared environment rather than shared genes
- many of the factors which predispose to antisocial behaviour and those that are associated with it are political issues rather than medical ones:
- social deprivation
- educational difficulties
- failure to learn appropriate social rules
- drug and alcohol misuse
- solving some of these problems might go a long way in reducing antisocial behaviour in society
The problem on the doorstep of psychiatrists
- the argument above could go on forever, but it does not necessarily help us to manage the conundrums which are presented to psychiatrists by both society and politicians
- the issues seem to be a political 'hot potato' with no-one really wanting to accept responsibility
- the more cynical amongst us might say that psychiatrists are becoming agents of social control, under the direction of the state, much in the same way that doctors became puppets under the Nazi regime, and also in the way that political dissidents were labelled as 'mad' by the old Soviet state
- things were perhaps a little clearer, especially in Scotland, until recently when the Noel Ruddell case forced some clumsy, emergency legislation through the Scottish parliament
- until the end of 1999, it was clearly laid out in the Mental Health (Scotland) Act that for someone with antisocial personality disorder to be compulsorily detained, he (or she) had to be at risk to themselves or others, and treatment under the Act was likely to alleviate, or prevent a deterioration of the condition
- this meant that 'untreatable' 'psychopaths' should not, or were not' coming under the auspices of psychiatrists, who were saying that these people should be dealt with by the criminal justice system
- however, the threat of tens of untreatable psychopaths, who were dangerous to society (and to voters) could force the authorities to release them since they were not being treated, and were therefore not being detained under the rules of the Mental Health Act
- The Mental Health (and Appeals) (Scotland) Act 1999 for the first time made personality disorder a detainable condition under Section 17 of the Act
- it also created a statutory duty for sheriffs to refuse an appeal under the 1984 Act by a restricted patient if he or she were suffering from a mental disorder (which now includes personality disorder) and posed a risk to the general public
- this new Act created a number of problems:
- all patients transferred to a psychiatric hospital from prison become restricted patients, so someone who commits murder with no mental illness who then develops one during the course of his prison sentence would come under the new legislation, making it the psychiatrists responsibility to protect the public - it also makes it difficult to discharge someone back to prison once the illness is treated, should the person also have a personality disorder
- it removes the treatability element from the old Act, creating the very real possibility that someone who continues to pose a risk to the public due to their personality, rather than their psychiatric illness, could be detained indefinitely
- this raises a whole host of issues, which seem to impinge on someone's civil rights:
- Does the state have the power to detain someone forever, despite the fact that they may have served their sentence for their initial crime? - they may have committed no further crime, yet they are being incarcerated
- What should be held uppermost, the individual's civil rights, or those of the state?
- Are we now in fact punishing someone for developing a mental illness? What does this say about us as a civilized society?
Conclusions
- the difficult issue of how we can manage a civilized society, and both protect the rights of society and the human rights of those who live within it, is perhaps one which will continue to be a problem for many years yet
- we have seen that there is some evidence that antisocial personality disorder may have an underlying biological component, but of course, as animals there is ipso facto a biological basis to our very being
- this question raises the further problem of how we can 'treat' it, given that our usual definitions of illness being a state where the individual wants to 'get better' often do not apply
- Do we therefore have the right to treat someone for a condition that is not necessarily ego-dystonic? It seems more clear that we, as health professionals, are being asked to 'treat' antisocial personality disorder in order that the public are 'safer'
- If there is no clear treatment for this condition, where does that leave psychiatry? It is easy to understand the hostility to the idea of incarceration within a mental health framework that many psychiatrists have - many would also argue that if the state wants to remove these people from society, then the state should accept responsibility and use the criminal justice system to achieve its aims
- Perhaps then it is a review of the criminal justice legislation that is in need of review, rather than the mental health legislation
