iness and tidiness.
Lists of personality disorder invite an obvious party game, seeing in which categories ourselves and our friends fit. And there is an equally obvious danger, that people whose personalities are unappealing to others will find themselves diagnosed as having a psychiatric disorder. That there is some subjectivity here is clear. The person diagnosed as having obsessional personality disorder on the basis of perfectionism, rigidity, being mean with money, and being obsessed with cleanliness may turn round and say that the psychiatrist who diagnosed her is a slapdash, unprincipled spendthrift who needs to take a shower more often.
Personality disorders are thought of in terms of two different models. There is the model based on the thought that some personalities dispose people to particular psychiatric illnesses, so that “schizoid personality disorder” might be thought of as a kind of incipient version of schizophrenia. The alternative model is based on the idea that there are dimensions of personality, with personality disorder being at an extreme of a continuum. Each of these models has its difficulties. The link between personality disorders and psychiatric illnesses such as schizophrenia is not clear. And it is hard to see why a personality at the extreme of some dimension should count as disordered. This is the part of psychiatry where scepticism about the “medical model” is most powerful. It is hard to make a case for treating “personality disorder” as a kind of illness.
One alternative to the medical model is to think of personality disorders in an Aristotelian way, invoking a species-specific idea of the good life for human beings. In the same way that caging a bird is cruel because the good life for birds includes freedom to fly, solitary confinement for people is cruel because the good life for human beings includes the ability to mix with other people and to make friends. If some such account can be given, it may be possible to apply it in explaining some of the personality disorders. The defective capacity for close relationships said to characterize “schizoid personality disorder” can be seen as deprivation of the means of realizing one aspect of the good human life.
On this model, psychiatrists need not necessarily confine themselves to treating psychiatric illnesses. The techniques psychiatrists have developed, whether using psychotherapy or pharmacology, might benefit people who seek help in freeing themselves from the constraints of a life-diminishing personality. Some thoughtful psychiatrists notice a tendency in themselves to prescribe Prozac at first to treat clinical depression but then to continue prescribing it, not to cure an illness but because of its enhancing effects on some patients’ personalities. They are right to be concerned about the boundaries of psychiatric intervention, but the Aristotelian model could provide a justification for their crossing the “medical” boundary. Of course, those they treat must be presented with a proposal that makes clear the non-medical “enhancement”, as well as any risks involved, and they must give their reflective and voluntary consent to it. Under these conditions, psychiatric intervention directed at enriching lives rather than at curing illness sometimes may be justified.
There are some dangers in this Aristotelian psychiatry. A lot of work needs to be done on the basis of the account of the good human life. And there is the danger of an Aristotelianism that underwrites prejudice. It is all too easy to think of a crude version that would again encourage interventions against the sexuality of gays and lesbians. At the very least, Aristotle needs to be combined with John Stuart Mill. Awareness of the open-endedness of our conception of the good life and the value of “experiments in living” is a necessary corrective here. But, despite these dangers, the Aristotelian alternative to the medical model may rescue something of value from the debatable diagnosis of personality disorder.
B. “Antisocial Personality Disorder”.
One of the most problema