Who’s Normal, Then?

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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Readers will be familiar with the old idea of distinct “categories of personality disorder,” which has been the approach used in the DSM system since 1980. This separates the idea of abnormal personality from formal mental disorder, commonly called “mental illness.” In my version of DSM-5, personality disorder is the 18^th chapter (p645-84) so obviously not very important. It lists ten distinct personality types and two unspecified, based on the concept that “…(individual) personality disorders are qualitatively distinct clinical syndromes” (p646). It presumes that the personality types are valid, i.e. that they exist as real things, and that we can reliably put people in the correct category.

The general criteria for personality disorder are “An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture.” This includes cognition (how people interpret events, etc.), emotion (including range, intensity and appropriateness), interpersonal functioning and impulsivity. Many of the names of the common personality disorders have entered common language: paranoid personality, schizoid, narcissistic, antisocial, and everybody’s favourite, borderline.

However, from the beginning, there has been argument over what should or shouldn’t be included and, indeed, what it all means. Part of the problem is the fact that, by definition, psychiatrists really aren’t interested in personality disorder. They’re interested in mental disorders, changes that come over previously normal people and are therefore presumed to be illnesses in the classic medical sense. The whole idea of personality is very much the province of psychologists, the sort of vague and ill-defined stuff that keeps them busy without interfering with the hard-headed work of psychiatry. In psychiatry training, very little time is given to learning about personality or about personality disorder, and practically nothing on actually managing personality disorder as a condition in itself.

The rest of psychiatry’s problem with personality disorder is that, as much as nobody wants to admit it, the psychologists appear to have the science on their side. To them, the idea that a person should have one personality type and no other is just a joke. Their research shows there are are no valild categories of personality, in the sense that we have a valid category of koalas and another of possums, and we can reliably sort small critters that live in trees into one pile or the other. Personality types don’t form readily-identifiable clusters since, on all traits, they vary dimensionally, i.e. they range smoothly from “very little” to “a great deal.” Take tidiness, for example. Some people are complete slobs, ignoring rules, dropping things where they use them and leaving chaos in their wake. Others are fusspots, insisting on a place for everything and everything in its place. Rules have to be followed just because they’re in the rulebook, not because they necessarily make sense or are the most efficient way of doing things. That’s called obsessionality, and a little bit goes a long way.

Similarly, we all need a “healthy” level of suspicion, otherwise we’d be robbed blind. I lock the house when we go out and at night, I keep my passwords safe and so on. If somebody drives slowly up and down our street a couple of times, I start to wonder why. That’s normal but some people are over-trusting and some don’t trust at all. For them, nothing occurs by chance, everything has a hidden purpose, people are always plotting behind the scenes. The paranoid personality is very important as a lot of them find their way into politics and then the trouble starts.

Clearly, all of this is very subjective. One person’s notion of an ordered kitchen or workshop is another person’s idea of hell; one person espies a conspiracy and the next yells “Conspiracy theorist”; one person’s joke is another’s cruel put-down. This is true of psychiatry, the diagnosis of a personality disorder depends very much on the psychiatrist, the worst example being the so-called bordeline personality. It’s a ridiculous term, not least because these days, nobody knows what it’s borderline to. It goes back 70 years or more to the era when psychoanalysis ruled. The patient was thought to be on the borderline between psychosis and neurosis but over the years, it has come to mean “severe personality disorder,” with the unstated rider “and we don’t like you.”

From the psychiatric point of view, there’s another problem with personality disorder: they can’t make any money from it. It’s personality, not an illness, therefore there’s no place for drugs and no role for the psychiatrist, so the patients are shunted off to see a psychologist. Now that’s not good for business and it’s not good for the self-esteem, treating psychologists as equals, everybody in psychiatry knows psychologists are cockroaches who are only trying to cause trouble. As a result, I have argued [1], psychiatry has taken on the very big and long-term project of reclassifying people with personality disorders as mentally ill, which means they can be given lots of drugs and need to see the psychiatrist for years. It also means that, as they don’t actually have a formal mental disorder, they’ll never get better but will probably develop lots of nasty side effects, which will lead to ever-more strenuous treatment, and so on. I set out my case over twelve years ago; so far, it seems to be correct.

That’s another story but what counts is that when DSM-5 was being prepared, the committee thought they’d better do something about the mess called personality disorder. They appointed a subcommittee who worked hard and produced an alternative model of personality disorder (AMPD). This was based on the psychological notion that there are no categories of disorder as all personality factors vary dimensionally. Their report was submitted with considerable fanfare but, at the last moment, the committee rejected it. We presume it was because the idea of dimensional factors would have thrown the rest of their categorical system into disarray. Since then, people have worked on it and it seems the powers-that-be have finally been convinced they need to do something. Accordingly, they appointed another subcommittee to review the matter.

Last week, the subcommittee published their first review of hundreds of research articles on the AMPD from the past dozen years [2]. They started with six polite criticisms of the present, categorical system, amounting to “It isn’t valid, it’s certainly not reliable and it’s no use anyway,” which is what psychologists have been saying forever. They then proposed a huge change: instead of a dozen categories, there should only be one, graded on severity, called Level of Personality Functioning (LPF). Each person is then given a score of five different personality traits but, this being DSM, they didn’t use the so-called Big Five factors that everybody else uses, they made up their own: Negative Affectivity, Detachment, Antagonism, Disinhibition and Psychoticism. Psychoticism doesn’t mean crazy or deluded, it’s what we would otherwise call psychopathic.

With all this in mind, they then assessed several hundred papers against a list of criteria that have to be satisfied before any major changes can be made to DSM (you see why nothing actually happens in psychiatry, everything gets bogged down in committees; at the back of DSM-5 is a list of all the people who had a say, thousands of names, all of whom got themselves elected because they have a barrow to push, an axe to grind or scores to settle). The paper is quite long but is largely incomprehensible to people who think mental disorder has something to do with humans. It is a huge statistical analysis of thousands of pages of statistics, all based on questionnaires which are themselves based in statistics and have to be assessed on scales of validity and so on. The jargon is mind-numbing:

Strong evidence is also available when using the STiP-5.1, with an average IRR of 0.89, and the SCID-5- AMPD Module I, with an average IRR of 0.87. At least one study has reported an excellent IRR estimate for the STIPO, at a value of 0.81. These data are consistent with a recent metaanalysis of seventeen IRR scores across fourteen studies using single-rater ICC or equivalent for total LPFS score. This resulted in a pooled ICC of 0.75, which is above the DSM-5 cutoff for acceptable IRR and indicates good reliability under ICC reporting guidelines (p329).

Got that? This is an important paper as it flags a significant change in a part of the DSM system that has the potential to bring the whole thing down, so they’re moving very cautiously. We could go through it line by line to find the many faults but I’ll go straight to the conclusion: this paper has no basis in science. At best, it’s bad science, at worst (which I believe is the case) it’s pseudoscience.

We can start with why it could be considered just a case of bad science, and here, the culprit is our old friend, positivism. Positivism is a philosophical movement aimed at standardising science and making it reliable by cleaning out all the subjective and just plain fanciful elements. Essentially, science is what can be reliably measured and then duplicated. If it can’t be measured, it ain’t science. Oh dear, we can’t measure the mind, does that mean the mind isn’t science? Yes, that is precisely what it means because that was the declared intent of the obsessional physicists and mathematicians and logicians who built the positivist movement [3]. How, then, can psychiatrists talk about mental matters and still remain in the field of science? For example, what about such overtly mentalist matters as personal identity, self-esteem and so on? Aren’t they important in any discussion on personality disorder? Indeed they are, and the committee finds a way around the roadblock: they translate “mentalist talk” into “physicalist talk.” Instead of talking about those ephemeral mental ideas, they switch to talking about brains and scans and chemicals:

A wealth of data is available on the neurobiological and pathophysiological correlates of components of LPF, including identity, self-esteem, self-appraisal, empathy, interpersonal functioning, social exclusion, rejection sensitivity, self-reflective capacity, and mentalizing ability. These constructs are most often studied in the Research Domain Criteria (RDoC) systems for social processes – specifically Affiliation and Attachment, Social Communication, Perception and Understanding of Self, and Perception and Understanding of Others, each demonstrating differential convergence of associated brain areas in a meta-analysis (p327).

That is, they assume that looking at brain scans and all that stuff will tell us all we need to know about the individual’s mental state. This is not a strong assumption. In fact, it’s a very bad assumption as nobody has ever shown a causative relationship between mental events and brain events, only a weak correlation. Self-esteem is one of the most important notions in personality but looking at brains will never tell us anything interesting about the person. That drops this whole project down to the level of science conducted by amateurs, but what converts it to pseudoscience is much more serious.

As the name says, pseudoscience is not science. It’s something that is put forward as science but doesn’t meet the criteria. Sometimes the people advancing the idea believe it’s true, and there are lots of examples in history where this year’s widely-accepted scientific theory is suddenly demoted to false science. All the theories about infections fell into disrepute when Louis Pasteur showed that it was all due to germs. The idea that immunisations or paracetamol cause autism is pseudoscience, it’s been shown repeatedly that they don’t (I would argue that the modern concept of “autism” is itself pseudoscience but we’ll leave that). Colonic irrigation is another favourite, the idea that the inner wall of the colon gets covered with a dense layer of hard faecal material which stops essential nutrients getting through and causes brain fog. This is crap. The entire wall of the colon is changed every few days, taking everything stuck to it as it goes. The people selling this have to know that, they can’t be so ignorant, which brings us to the next category.

It’s sometimes true that people advancing what sound like scientific ideas or theories don’t believe them, they’re charlatans and frauds who are just trying to make money from the gullible. There are so many examples we don’t know where to start but it all depends on people wanting to be told something pleasant, like “This will make you feel better.” This has been known forever, even the Romans had an expression for it: Mundus vult decipi, ergo decipiatur. The world wants to be deceived, so let it be deceived. Trying to distinguish genuine cases whose belief system just happens to be wrong (e.g. the geocentric universe before Copernicus), from the stupid and/or crackpots (like RFK Jr and his ilk) from the cheats is difficult, because if the cheats think somebody is on to them, they just change their story (see the link above, amazing she thought she could get away with it). This is the trouble: they think they’re smarter than everybody else. Look at Elizabeth Holmes, surely she knew that she couldn’t keep that story going for the rest of her life? Apparently, she thought her idea was so clever that they could just tweak a few dials and the machines would work. We won’t start on the stupid ideas that flow from the echoing spaces between Mr Trump’s ears, that will keep historians in business for decades (Australian universities are getting rid of their history departments; I think it’s a plot by politicians to conceal how stupid they’ve been, although the same universities are happy cuddling up with militarists).

Back to this rather painful paper on personality disorder which is about to set psychiatry’s course on personality disorder for the next few decades. I say it’s pseudoscience, for the very simple reason that they haven’t given any theory of personality as their starting point. Therefore they don’t have a model of personality disorder and, as a direct result, anything they say has no basis in science. It’s really that simple. The problem starts early. If you want to believe, as good positivists are required to believe, that all mental notions can be reduced to brain facts, then you have to provide a formal reductionist theory of mind. Take it from me, there isn’t one [4] but they still didn’t try, they just assumed somebody else had done it and everything they said was therefore valid. It’s not, but putting that aside, what did they say about personality that could be seen as interesting and worthwhile? Nothing, absolutely nothing. They assumed that everything important had been said, that they were on solid ground and, crucially, their audience knew all about it. It’s a case of the blind leading the blind. All of their statistical manipulations gives the impression that this is valid science but that’s like selling a truck with no engine. There is no way known to translate mentalist concepts such as personality traits into physicalist talk. Nobody has ever done it and, I argue, nobody ever will [4].

In order to talk meaningfully about personality disorder, and I believe we do need to, we have to start with a theory of mind. That will tell you what personality IS, how it is to be understood, how it relates to mental disorder and, most important, how it is to be managed. The biocognitive model for psychiatry says that mind is real but non-physical [5]. That is, it is a dualist model, which is enough to cause conniptions all round. However, as the biocognitive model proposes a mechanism by which mind emerges from brain and a means of interaction, it is a natural dualism, not magical. It says that personality is just the unique set of rules governing our behaviour that each of us acquires on our travels through life.

Because a lot of rules are acquired early in life, even preverbally, we often don’t know what they are, but they’re still effective. If my set of rules is internally consistent and meshes neatly with the rules of the larger society, my inner life is harmonious and I get a cap that says “Normal personality.” If my rules are internally inconsistent and produce inner conflict, or conflict with society, or both, I get a cap that says “PD.” What the DSM subcommittee calls “traits” are actually just clusters of rules that naturally fall together. For example, the trait of obsessionality means tidy, organised, rule-abiding, reliable etc. If I act like that because I see the world as a harsh and punitive place and I’m constantly scared of getting into trouble (anxious-obsessional), that’s different from the person who uses rules to control and dominate people (anankastic). All of this makes perfect sense but in their rush to be good little positivists, without knowing what that means or why they want it, the DSM people are obliterating these vital differences.

The final nail in the coffin is the actual data on which they based all their very expensive and time-consuming statistical analyses. It’s a case of GIGO, garbage in, garbage out. All of the material was based on questionnaires which, in turn, were based on the opinions of people that this symptom represents mental disorder while that one represents personality disorder, without having a model to guide their decisions. The whole process is circular. Thus, anxiety and depression are seen as categorically-distinct mental illnesses which are unrelated to personality, and the statistical analysis was designed to confirm this. So they would say of Mr J: “He’s anxious and BTW, he has a PD,” or of Ms K: “She’s depressed and BTW, she has a PD.” What they don’t understand is that J is anxious just because his perception of himself (weak and incompetent) and the world (a cruel, punitive place) makes him feel threatened and therefore produces the threat response, aka anxiety. The personality disorder precedes and explains the anxiety and should therefore be the focus of management. Treating the anxiety alone with drugs does nothing about the personality and therefore he never gets better, which is great for drug companies and the psychiatrist’s bottom line.

Similarly, poor Ms K constantly feels low and miserable because she believes she is a bad and worthless person whom nobody could possibly like, so she jumps into a bad marriage where she is constantly criticised and belittled by a man who needs somebody to put down each day so he can feel better about himself. Her early life experiences will explain her personality issues, which precede and explain the mental disorder. Treatment therefore consists of bringing to full awareness all her rules (beliefs) about herself and the world, sorting out where they came from and replacing them with a better set. That’s all. Minimal drugs and no ECT, just talking to her as a human and letting her see how each mental event causes the next. This is not rocket science but, for people raised in the positivist tradition who are forbidden to talk about minds, the thought of thoughts causing more thoughts is mystical mumbo-jumbo, the sort of stuff psychologists babble on about but not real science as practised by sensible psychiatrists.

There cannot be a proper understanding of personality disorder or a rational form of management without a theory of personality, which in turn depends on a theory of mind. The biocognitive model for psychiatry is the first such model for psychiatry. It gives a parsimonious and readily comprehensible account of how to recognise and manage personality disorder. Drugs only make it worse, harsh treatment definitely makes it worse, moralising is a waste of everybody’s time but running away from the problem or pretending it isn’t what is is equally destructive. The DSM committee is just swapping one pseudoscientific model for another.

Talking of personality disorder, there is now open discussion of the possibility that Trump is losing what little he had of his mind. Robert Reich, a very sensible observer, asked whether Trump is dementing. What a dumb question. Of course he’s dementing, Blind Freddy can see that, and as his condition progresses, his raw personality structure will become more and more obvious: grandiose, suspicious, brutally destructive, vengeful, seriously dishonest in his drive to be on top at all times, contemptuous of anybody beneath him, fearful of those above, and so on. Dementia dismantles the sufferer’s self-control, starting with the most recently-acquired and most subtle social rules, thereby exposing what the person has always believed but knew enough to keep quiet. Trump has now signed an order designating anybody who opposes him as evil and has to be punished. This is what he’s always wanted to do, hit people who look down on him, except now he’s been given the weapons to do it, so look out.

His niece, Mary, says that when she was about six and he was 29, they would play baseball in the garden. Baseballs are hard, and he threw it full strength at her; if it hit her, it hurt her greatly but he laughed and would do it again. He never did it to men, of course, only women, because he’s a coward who fears being flattened by an angry player. Now, he’s got an army to protect him so the real personality disorder shines through. The fact that he has a lot of money and great power doesn’t mitigate against personality disorder, in fact, it more or less guarantees it. What he does with that money and power is our real concern. Unfortunately, mainstream psychiatry won’t be any help for the next 30 years or so.

References:

1. McLaren N (2012). Chapters 14-16 in The Mind-Body Problem Explained: The Biocognitive Model for Psychiatry. Ann Arbor, MI: Future Psychiatry Press.

2. Sharp C et al (2025). The validity, reliability and clinical utility of the Alternative DSM-5 Model for Personality Disorders (AMPD) according to DSM-5 revision criteria. World Psychiatry 24:319–340. https://onlinelibrary.wiley.com/doi/full/10.1002/wps.21339

3. Hahn H, Neurath O, Carnap R (1929). The Scientific Conception of the World: The Vienna Circle. Ernst Mach Society, University of Vienna. http://rreece.github.io/philosophy-reading-list/docs/the-scientific-conception-of-the-world-the-vienna-circle.pdf

4. McLaren N (2024). Theories in Psychiatry: building a post-positivist psychiatry. Ann Arbor, MI: Future Psychiatry Press. Amazon.

5. McLaren N (2021): Natural Dualism and Mental Disorder: The biocognitive model for psychiatry. London: Routledge. Amazon

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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.