These posts examine modern psychiatry from a critical point of view. Unfortunately, mainstream psychiatrists usually react badly to any sort of critical analysis of their activities, labelling critics as “anti-psychiatry,” whatever that is. Regardless, criticism is an integral part of any scientific field and psychiatry is no different. As it emerges, there is a lot to be critical about.
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The subject matter of mainstream psychiatry is the mind and its discontents, yet it has no articulated and publicly available theory of mind and no model of mental disorder, nor a theory of personality or a model of personality disorder. Modern psychiatry therefore has no formal basis in science. At best, it is a protoscience; at worst, pseudoscience.
I have repeatedly said this but apparently need to keep saying because nobody with influence in psychiatry is listening. The caring people at Psychiatric Times are “people with influence,” and have just published an article, the first in two, on what used to be called psychopathic personality, so let’s see if they can prove me wrong. The title indicates their approach: Neurobiology of Aggression in Antisocial Behavior, Part 1: Foundations and Early-Life Risk [1]. They start by pointing out that the term “antisocial behaviour” covers a very wide range, from violence to theft, deceitfulness and general rule-breaking. Two types are immediately seen: the impulsive, explosive and violent type, previously known as the aggressive psychopath who typically ends up in prison, and the calm, emotionally-detached type, the creative psychopath who carefully plans crimes and thrives on cheating people. They have in common a disregard for the rules of society, emotional detachment from people, lack of remorse, a reluctance to admit wrong and an intense self-centredness. Traditionally, there was another type known as the inadequate psychopath who was a bit of both mixed with alcohol and drugs but fell to bits when anything went wrong and became a pathetic, weepy mess.
That classification worked well until the DSM-III committee was getting busy in the 1970s. As we know, they hoped to write a theory-free system of classification for psychiatry in which every mental patient could be slotted into a labelled box or category and everybody would know what the label meant. When it came to personality disorders, they ran into a couple of major problems. First, it had long been known that personality disorders don’t fit neatly into boxes, they sprawl untidily across the landscape. Their answer to this was to rephrase all the diagnostic criteria for each category so that they seemed separate and distinct, even though it was crystal clear to everybody that they weren’t. Thus, one group showed a reluctance to become emotionally involved with others while the next group were distant and detached from people. Same thing but it allowed them to get away with the fiction that personality disorders were unique categories [2].
Why would anybody bother, you ask. Indeed, and the answer was another subterfuge, another fudging of the basic idea of psychiatry: they were determined to write a classification that would set the scene for the biologisation of psychiatry. Each distinct surface syndrome would then map down to the genome with a unique genetic error for each mental disorder. In the fullness of time, their friends in the drug industry would then devise a specific drug to rectify that error and Bob’s your uncle, say goodbye to mental disorder. The categorical system of psychiatric diagnoses makes sense if and only if mental disorder is biological in nature. If it isn’t, it doesn’t. I say it isn’t but we’ll come back to that point.
The second big problem for the DSM-III committee came when they looked at the description of the creative psychopath. This was a person, traditionally seen as male although there’s never been a shortage of female psychopaths, who was charming, manipulative, lied as easily as he breathed, who planned crimes and carried them out in such a way that if a scheme failed, somebody else would get the blame. These people are remorseless, utterly self-centred, grandiose in their sense of entitlement and fixated on getting what they want by any means necessary. Other people’s interests or lives mean nothing to them, everything is transactional, as in: “What’s in it for me, what can I get out of this?” If they can win and at the same time humiliate their enemies, that’s even better.
Trouble is, that more or less describes about 90% of the American power elite: politics, finance, industry, military, academia, sport, entertainment and definitely religion, all these fields were colonised by psychopaths who, don’t ever forget, are always pleased to help each other in their machinations. Psychopaths are remarkably good at recognising each other, far better than ordinary people. And don’t think it’s restricted to the US, it’s everywhere although with neoliberal economics, they have perfected a system that selects for and benefits the charming, flint-hearted and remorseless marauder. That was all a bit embarrassing for the committee so they dumped the term psychopath and replaced it with sociopath, defined so as to exclude all their naughty friends. Sociopaths were people who used drugs and got into fights and had been to jail; only bad people from the wrong side of the track ended up in prison, so all the high class scoundrels now known as the Epstein class got a “get out of jail free” card. For life. And for their ghastly children. Anyway, nearly half a century later, psychopathy remains a problem, as the authors acknowledge:
... financial costs associated with the behavioral traits of psychopathic individuals in the United States have been estimated at approximately $400 billion annually, highlighting the urgent need for effective identification, management, and treatment strategies for this challenging population ...
Note that that figure doesn’t include the costs of all the pointless wars started by the psychopaths in government. Putting that aside, the idea of effective “treatment” runs into two major but entirely predictable problems. The first one is that the people doing the real damage aren’t out there in the suburbs causing mayhem or sitting sullenly in prisons waiting for the day they can get out and get even, no, they’re small bickies as we say, they hardly rate. The real psychopaths are the Jeffrey Epsteins and Ghislaine Maxwells and the Bernard Madoffs and the Peter Mandelsons and the Henry Kissingers and Elizabeth Holmes of this world (check that brief video that shows she has learned nothing; she makes my skin crawl and always has), not to overlook all the sharp crooks and dim-witted goons surrounding Trump, especially his son-in-law. These are the people who twist and manipulate entire financial systems, overthrow governments and start wars, just to serve their own purposes. US presidential advisor and ultraneocon Karl Rove put it precisely:
We’re an empire now, and when we act, we create our own reality. And while you’re studying that reality— judiciously, as you will—we’ll act again, creating other new realities, which you can study too, and that’s how things will sort out. We’re history’s actors... and you, all of you, will be left to just study what we do.
We do what we like and you just suck it up. That’s as psychopathic as it gets: the idea of history’s actors comes straight from Mein Kampf. So that’s problem No. 1: beware the charming, entirely plausible psychopath in Armani. Problem No. 2 is as the authors state is quite simple: When it comes to psychopathy, we don’t know what we’re doing: “... the underlying etiology and pathophysiology of antisocial behavior remain incompletely understood ...” (my emphasis). That’s a euphemism beloved of academic psychiatrists on the hunt for grants. It means “haven’t got an effing clue.” However, even in the absence of clues, they’re happy to steer research in a particular direction: “While environmental and social factors are influential, growing evidence points to the role of neurobiological contributors in the development and expression of antisocial traits.” In order to come to grips with it, they announce that there are two sorts of aggression, proactive and reactive:
Proactive aggression is deliberate, goal-oriented, and often used as a means to achieve personal gain. It is typically unemotional in nature and associated with low physiological arousal. In contrast, reactive aggression is impulsive and affectively driven, emerging in response to perceived provocation or threat. It is characterized by heightened anger and increased sympathetic nervous system activation ...
What they call proactive is the person calmly making illegal plans to disadvantage another person in order to gain a benefit for himself or his group. It may be one person deciding to cheat or harm another, or it may be two people conspiring together to plan a criminal outcome. Here is a brief but very clear description of soldiers acting in a wholly psychopathic manner without a hint of personal agitation or concern for the other person. It is critically important to understand that these people are not mentally disturbed or disordered in any way whatsoever. They are intelligent and well-educated, in full control, they are not affectively disturbed, with no hallucinations or delusions. The authors of the Psych Times article, however, have decided in advance that such people have biological disturbances of brain function: “Proactive aggression is associated with impairments in goal clarification, accessing appropriate responses, and decision-making...” That’s news to me: my understanding is that they’re very good at making decisions. We just don’t like the decisions they make.
What they call reactive aggression was the defining feature of the aggressive psychopath: Bill Smith is going about his day when something small goes wrong. Immediately, he flies into a rage, shouting and throwing tools and punches, then starts drinking, gets into a fight, jumps in his car and runs into a tree, gets pulled out but wants to fight the police and ambulance officers and so on. If he’s not doing that, he’s dominating his family, controlling them with constant threats and just enough violence to make them know not to step out of line. They drink and use drugs, they gamble, have endless affairs, cheat, steal and tell lies when it suits them and clearly don’t give a damn about the mental welfare of any other person, including their children: “reactive aggression,” say the authors, “is linked to difficulties in cue encoding and interpretation.” They then launch into biological speculation about the role of the amygdala and the prefrontal cortex in the different types, without once mentioning the defining feature: explosive high arousal.
How does personality disorder come about? Of course they invoke genetic factors even though the evidence is exceedingly weak, and mention other neurobiological factors such as the mother’s health and mental state during pregnancy. Maternal drug and alcohol use always gets a lot of air time and they bring in dietary deficiencies, maternal “stress” and lead poisoning before finally coming to what seems obvious: “... adverse childhood experiences (ACEs) have consistently been associated with increased risk of antisocial behaviors.” They point to violence, neglect and sexual abuse as major factors as “Early brain development is particularly sensitive to environmental stressors ...” Brain development? Do we have any proof of that? No, we don’t. So far as we know, the overwhelming majority of people with this personality disorder have absolutely nothing wrong with their brains. Indeed, some of them are very, very clever, so what’s going on? Tucked coyly in the second last paragraph is the clue, suitably disguised under biologisms:
Taken together, chronic exposure to childhood stress may lead to maladaptive neurobiological changes. Specifically, persistent stress may trigger a down-regulation of the stress response system as an adaptive mechanism to avoid chronic arousal, potentially disrupting neurobiological signaling and contributing to long-term pathophysiological outcomes associated with antisocial behavior.
That is, an adverse environment in early life may lead people to learn how to keep calm by ignoring all the madness going on around them. In that state, they quickly realise they can cheat people and get away with it. That is, after all their talk about brain centres, the authors offer a non-biological explanation: the creative psychopath is wholly a psychological phenomenon, a matter of personality but not of genes or neurotransmitters. Similarly, people who have had a violent or abusive childhood grow up hyper-alert to any sign of trouble or conflict. They react violently because that’s how everybody acted around them. They learned early that the world is a cruel and dangerous place, and humans will pounce on you at the drop of a hat so don’t trust them. That is, they never had the opportunity or need to learn otherwise. Treatment isn’t easy because they are deeply suspicious of the world, fully expecting somebody to hurt them every moment of the day, and ready to explode defensively.
Creative psychopaths are almost always the product of emotional deprivation but not of overt abuse. There is no better description than psychologist Mary Trump’s account of her uncle’s quite appalling childhood [3], although being a millionaire at eight probably made up for some of it. Donald Trump was not beaten or screwed until he became a psychopath, he was trained and he does it because he loves it. As were the soldiers mentioned above, who enjoy the killing as it allows them to get in touch with their inner Eichmann.
You cannot have an explanatory model of personality disorder until you have a theory of personality which, in turn, depends on a theory of mind. Thus, a project to explain psychopathy in biological terms ends up invoking psychology to complete the chain of causation. We find this all the time because it could not be otherwise: there are dozens of examples in philosophy where writers had to invent a non-biological “self” to complete their biological account of mind [4]. Why does this elementary mistake keep happening? Because biological psychiatry is not a science of mental disorder, it is an ideology, a belief firmly held and constantly reinforced in an echo chamber by a powerful group who have never done the groundwork of explaining just how mental matters can be explained by physics. If they tried, they would realise it can’t be done but that would be too threatening to their careers so they keep quiet and just keep parroting the party line: “The underlying etiology and pathophysiology of antisocial behavior remain incompletely understood but we’re convinced the answer lies in the neurobiology so we won’t look elsewhere.” This is entirely consistent with an observation by no less than the Lord Lister (1827-1912) from about 1876:
I remember at an early period of my own life showing to a man of high reputation as a teacher some matters which I happened to have observed. And I was very much struck and grieved to find that, while all the facts lay equally clear before him, only those that squared with his previous theories seemed to affect his organs of vision.
Nearly two hundred years ago, the French philosopher and “father” of sociology, Auguste Comte (1798-1857) provided the answer to their dilemma:
If it is true that every theory must be based upon observed facts, it is equally true that facts can not be observed without the guidance of some theories. Without such guidance, our facts would be desultory and fruitless; we could not retain them: for the most part, we could not even perceive them.
Mainstream psychiatry has no theory of personality and no model of personality disorder. Therefore, psychiatrists are unable to see facts when they stand clearly in front of them (I’ll send this to the authors of that article but they won’t respond).
(PS: an excellent article on suicide and antidepressants by Peter Gotzche in this week’s Mad in America. The mainstream gets away with their pseudoscience just because they make sure nobody questions their “biomedical model of mental disorder,” the same one they’ve never written. That’s pretty psychopathic).
References:
1. Neurobiology of Aggression in Antisocial Behavior, Part 1: Foundations and Early-Life Risk.https://www.psychiatrictimes.com/view/neurobiology-of-aggression-in-antisocial-behavior-part-1-foundations-and-early-life-risk.
2. McLaren N (2007). The categorical system of diagnosis: Personality Disorder. Chapter 8 in Humanizing Madness: Psychiatry and the Cognitive Neurosciences.; Ann Arbor, Mi.: Future Psychiatry Press.
3. Trump ML (2020). Too Much and Never Enough: How My Family Created the World’s Most Dangerous Man. London: Simon and Shuster.
4. McLaren N (2024). Theories in Psychiatry. See below.
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My critical works are best approached in this order:
The case against mainstream psychiatry:
McLaren N (2024). Theories in Psychiatry: building a post-positivist psychiatry. Ann Arbor, MI: Future Psychiatry Press. Amazon (this also covers a range of modern philosophers, showing that their work cannot be extended to account for mental disorder).
Development and justification of the biocognitive model:
McLaren N (2021): Natural Dualism and Mental Disorder: The biocognitive model for psychiatry. London, Routledge. At Amazon.
Clinical application of the biocognitive model:
McLaren N (2018). Anxiety: The Inside Story. Ann Arbor, MI: Future Psychiatry Press. At Amazon.
Testing the biocognitive model in an unrelated field:
McLaren N (2023): Narcisso-Fascism: The psychopathology of right wing extremism. Ann Arbor, MI: Future Psychiatry Press. At Amazon.
The whole of this work is copyright but may be copied or retransmitted provided the author is acknowledged.