Professor Glenn Wilson, Gresham College, London

1. MAD, SAD OR BAD? Professor Glenn Wilson, Gresham College, London

2. NAMED AND SHAMED Last week a celebrity chef was caught shop-lifting from Tesco's. He cited overwork, stress and child abuse but still baffled by his motives and announced that he would enter therapy immediately. Was he slightly sad, slightly mad, or slightly bad? Perhaps a bit of each?

3. JUST A NAUGHTY BOY? Drug companies encourage diagnostic labels so that drugs can be sold to address the illness. ADHD is diagnosed in around 20% of US schoolboys and prescriptions for Ritalin are skyrocketing. Parents in the UK may receive disability allowance contingent on the diagnosis. Diet, lack of exercise, late nights, fast-moving images on TV and computer games may be real causes of distractibility.

4. WOMEN AND DEPRESSION Twice as many women as men are diagnosed as depressed and rates are increasing. In previous decades large amounts of Valium were prescribed for “anxiety”. Prozac seems to have taken over as “mother’s little helper”. Are women really under greater stress or is drug marketing contributing?

5. SEXUAL DYSFUNCTION Many “sexual disorders” would in the past have been regarded as normal variations. The “medical” take opens the door to marketing of drugs (e.g., testosterone therapy) and surgical procedures (e.g., radio frequency nerve ablation of pleasure signals).

6. SOME NEW DISORDERS Suggested new disorders for the DSM-5: Absexuality – exaggerated concern with stamping out obscenity. Hypersexuality – excessive libido. Hebephilia – attraction to adolescents Coercive paraphilic disorder – forcing people into sexual acts they find distasteful. Cognitive tempo disorder – laziness. Negativistic personality disorder – whinging. Nicotine use disorder – smoking. Intermittent explosive disorder – tantrums.

7. HOMOSEXUALITY IN THE DSM Classification of homosexuality in the DSM has followed changing social views: 1953 DSM-1 Sociopathic personality disturbance (SPD) 1973 DSM-2 Sexual orientation disturbance(SOD) 1980 DSM-3 Egodystonic homosexuality (EDH) 1987 DSM-3R Sexual disorder not otherwise specified (“persistent marked distress about one’s sexual orientation”). 2013 DSM-5 Homophobia?

8. PERSONALITY DISORDERS DSM-4 ICD-10 Paranoid }Odd-eccentric Paranoid Schizoid } Schizoid Schizotypal } Antisocial }Dramatic-erratic Dyssocial Borderline } Impulsive/Borderline Histrionic } Histrionic Narcissistic ) Avoidant )Anxious-fearful Anxious Dependent } Dependent Obsessive-compulsive} Anankastic

9. PROBLEMS WITH PD CATEGORIES Determined by consensus/committee rather than psychometric logic. Reliability of diagnosis is poor and there is much “co-morbidity” (overlap) among them. Continuity between normal and abnormal personality is not recognised. Diagnosis incorporates theories of aetiology (exclusions for stress, brain damage, drugs, neurosis & psychosis). Labels may be insulting and stigmatising.

10. BORDERLINE PERSONALITY An especially vague category, referring to a grab-bag of symptoms including black & white thinking, unstable mood and relationships, self-image and identity problems and tendency to self-harm/suicide. Unclear that that these traits cohere meaningfully or what border is between (neurosis and psychosis?)

11. MULTIPLE PERSONALTY? Multiple personality acquired great popularity with with publication of The Three Faces of Eve (1957) and Sybil (1973), who sported 16 personalities. Now called Dissociative Identity Disorder - classed as a “neurosis” rather than PD. A rare condition (mostly female, mostly American). Sometimes coerced by therapists (c.f., false memory syndrome)? Kenneth Bianchi (TheHillside Strangler) tried to fake it to prove his insanity.

12. THE CASE OF DAVID ICKE Difficulties of psychiatric diagnosis are illustrated by the case of David Icke. Claiming that the world is ruled by alien, shape-shifting lizards, Icke is handsome, intelligent, articulate, rich and attractive to women. Is he delusional (mad) or a conman (bad)? Certainly, he is not sad – he is a functional and highly successful writer and public speaker.

13. PSYCHOPATHY A term often used to describe people in the erratic-dramatic groups of PD (especially anti-social and narcissistic). Indexed by the Psychopathy Checklist of Robert Hare. Psychopaths have a disregard for the law and the rights of others, are grandiose and lacking in empathy or remorse. They may also be glib, charming and intelligent (like Ted Bundy, The Campus Killer).

14. THE PSYCHOPATHIC BOSS According to Babiak & Hare (2006) around 4% of bosses are clinical psychopaths (compared with 1% of the general population). They are attracted to the high-risk/ high-gain culture of the corporate world and rise up the ladder with charm and cunning. Their arrogance and grandiosity seem like leadership but they are poor team players and might have become serial killers were they not protected by positive experiences or high IQ.

15. MAD OR BAD? DOES IT MATTER? When psychopaths commit crimes who should take responsibility, medical or penal authorities? It should make little difference since dangerous people need containment anyway. We are confused about what prison is for – punishment, retribution, deterrence, rehabilitation or protection of the public? Only the latter is a good reason for incarcerating people.

16. BRAIN AND PERSONALITY To say that personality disorders are not diseases like measles is not to deny a physiological basis. There is abundant evidence that genetics and brain damage contribute, as well as environmental stresses. “Responsibility” is not a scientifically meaningful concept; all behaviour (mad, sad & bad) has its causes. Phineas Gage (skull depicted) famously became “irresponsible” after accidental damage to his frontal lobe.

17. BRAIN-DAMAGE IN PSYCHOPATHS Research confirms that psychopaths often have structural and functional impairments to the connections between emotional areas (e.g., the amygdala) and brain areas controlling decision-making and conscience (prefrontal cortex). Diagram from Motzkin et al, (2011) shows reduced connectivity in psychopaths as indexed by fMRI.

18. DIMENSIONAL ALTERNATIVES The 3 main clusters of PD correspond roughly to the lay concepts of mad, bad and sad. They also connect with Eysenck’s 3 major personality types (Psychoticism, Extraversion & Neuroticism). EPQ dimensions could replace DSM categories, as could Millon’s “multi-axial” system. However, direct brain measurements that cannot be faked will ultimately be needed for proper assessment.